Pediatric Small-Bowel Obstruction Treatment & Management
- Author: Jaime Shalkow, MD, FACS; Chief Editor: Carmen Cuffari, MD more...
General principles in the medical treatment of small-bowel obstruction include the following:
Stabilize the patient and monitor ABCs
Replace fluids with diligent intravenous (IV) resuscitation, using isotonic sodium chloride solution or lactated Ringer solution
Early bowel decompression with an NG tube decreases the chance of bowel necrosis and perforation
Administer broad-spectrum antibiotics when necrosis or perforation is suspected
Patients who do not respond to nonoperative treatment within 12-24 hours require surgical treatment.
Consult with a pediatric or general surgeon, depending on availability.
Administer nothing by mouth (NPO).
Patients with partial small-bowel obstructions can be nonoperatively treated with adequate fluid resuscitation and nasoenteric suctioning. However, close follow-up observation is mandatory for these patients after discharge.
Instruct parents that they must take their child immediately to an emergency department if the child's symptoms (eg, vomiting, pain) recur.
Stabilize the patient's ABCs and replace large fluid losses. Administer NPO to the child and place an NG tube to decompress the obstruction from above. The use of antibiotics is appropriate for management of bacterial translocation.
Barium, water, or air enema reduction is appropriate after surgical consultation if symptom duration is less than 24 hours and if the patient has no signs of peritonitis. Pneumatic reduction seems to be more effective and safer, and it could be considered an optimal first-line treatment. Enemas successfully reduce 80-95% of all intussusceptions, with better success rates in short-duration intussusceptions. Although the classic teaching is to admit any child with an intussusception that is successfully reduced with an enema for observation, in the thought that most recurrences occur during the first 24 hours, Whitehouse et al recently showed that recurrence rates do not differ between children observed as inpatients and those discharged home after successful hydrostatic reduction, suggesting it might be safe, in controlled circumstances, to discharge patients from the emergency department.[84, 85, 86]
Children whose symptoms persist longer than 24 hours, or have signs of peritonitis, should not be considered candidates for enema reduction. The risk of surgery is higher when the lapse between the onset of symptoms and the first attempt of conservative management is longer. Stabilize these children and immediately transport them to the operating room because untreated intussusception is almost always fatal. The recurrence rate is higher after radiographic than after surgical reduction. Surgery is also indicated for patients whose intussusception cannot be reduced after 2 enema attempts. See the image below.
Patients with postoperative intussusceptions require surgery for correction. In most cases, the intussusception can be reduced manually and strangulation is uncommon.
Adhesive Small-Bowel Obstruction
Only about 6-7% of children with adhesive small-bowel obstruction require immediate laparotomy. Approximately one half of these patients respond to medical treatment, which includes NPO, IV fluids, NG decompression, and antibiotics to suppress bacterial translocation and help prolong the viability of ischemic bowel. However, children younger than 1 year tend to respond poorly to conservative management. No single agent or treatment has proven effective in preventing adhesion formation after a laparotomy.
The use of water-soluble contrast via NG tube may decrease the need for surgery in some patients. Water-soluble contrast media (Gastrografin) cause redistribution of intravascular and extracellular fluid into the intestinal lumen because of their hyperosmolarity. As a result, these media decrease intestinal wall edema and act as a direct stimulant to intestinal peristalsis.
Stabilize the patient's ABCs and focus on replacing the large fluid losses. Nonoperative reduction of a nonstrangulated hernia is possible in approximately 95-98% of cases. Facilitate the reduction by sedating the patient and placing the patient in a mild Trendelenburg position. Gentle traction on the hernia and the contents of the sac usually suffices to reduce the volume and rapidly retract the contents of the sac into the abdominal cavity. After nonoperative hernia reduction, elective repair may be accomplished 24-48 hours after the edema subsides.
The only contraindication to nonoperative reduction is a long-standing incarceration with evidence of peritoneal irritation.
Antibiotic therapy is usually unwarranted, but critically ill infants with perforation and peritonitis require coverage for aerobic gram-negative organisms and anaerobic infections.
Treatment for NEC is initially medical with broad-spectrum antibiotics and cessation of enteral feeds. However, medical treatment may fail to improve the patients' condition or severe complications supervene and require surgical consultation. Roughly 30-50% of these neonates require surgery.
In the extremely low ̶ birth-weight infant, it is difficult to determine if free air in the abdominal cavity is due to a spontaneous perforation or NEC.
A vast array of surgical options have been described. Peritoneal drainage seems useful to decompress the abdominal compartment syndrome, improving cardiorespiratory status. However, randomized controlled trials have failed to demonstrate any survival or mortality differences between laparotomy and drainage groups, as well as long-term need for parenteral nutrition. However, 50% of infants in the peritoneal drainage groups were spared from further surgical intervention, and time to attain full enteral feeds in infants less than or equal to 1000 g was prolonged in this group.
Infants with advance NEC often require cardiopulmonary support, rendering them too unstable to be transferred to the operating room for surgical treatment. Transfer of patients from NICU to the OR presents the risk of physiological changes including hypothermia and clinical deterioration en route, as well as dislodgment of vital tubes or theater availability. Operating on babies at the NICU also poses constrains related to lighting, ergonomics, and equipment.
NEC management involves cessation of enteral feeds; gastric decompression on low, continuous suction with a sump-type tube; fluid management to correct hypovolemia; parenteral nutrition with a centrally located IV catheter once fluid resuscitation is complete; and antibiotic therapy.
Direct antimicrobial therapy is aimed at enteric bacteria (eg, Escherichia coli, Klebsiella species, Enterococcus species, anaerobic colonic flora [Clostridia species]).
Serial abdominal examinations should be performed, preferably by the same examiner.
Obtain radiographs of the abdomen, including cross-table lateral films, every 6-8 hours for the first 48 hours. Obtain blood, urine, sputum, and CSF cultures, if indicated.
Strong evidence shows breastfeeding to be a protective measure against NEC. A large Cochrane review supports the use of probiotics, especially in infants weighing more than 1000 g. This is slowly gaining popularity among neonatologists; however, more research is necessary to change this practice.[66, 90, 91]
Small studies have recently suggested that the use of pentoxifylline in adjunct with antibiotics for preterm babies with NEC and sepsis may decrease mortality without any adverse effects.
Treatment of meconium ileus requires evacuating the meconium. Nonsurgical methods relieve the obstructions of more than 50% of patients.
The therapy of choice for uncomplicated meconium ileus is nonoperative hyperosmolar enema (Gastrografin or Omnipaque), with enterotomy and irrigation reserved for enema failures. Dilute Gastrografin with N -acetylcysteine may also be administered using an NG tube from above to help loosen the meconium. Distal intestinal obstruction syndrome may be treated in the same way.
Complicated cases (meconium peritonitis, meconium pseudocyst, perforation, intestinal atresia) require exploration and bowel resection with primary anastomosis or stoma creation.
Meconium plug syndrome is usually relieved with rectal stimulation (suppositories, washouts, or contrast enemas).
Intussusception can be reduced by radiographic means in 80-95% of patients. Surgical reduction is indicated when symptoms have been present for more than 24 hours, in the presence of shock that cannot be corrected, when a lead point has been identified, when necrosis or perforation are present, or if the intussusception is irreducible by radiographic means. (See the image below.) The procedure can be performed safely via laparotomy or laparoscopy. Patients operated on laparoscopically have shorter hospital length of stay and a mildly higher incidence of recurrence, although this is not statistically significant.
After reducing the hernia, elective repair is possible 24-48 hours after the edema subsides. For patients whose hernias cannot be reduced and for patients with strangulation, immediate surgery is mandatory to prevent the incarceration from progressing to perforation and frank peritonitis.
Malrotation of the bowel with midgut volvulus
Preserving intestinal viability requires rapid diagnosis and surgery for malrotation with midgut volvulus. Initiate NG suction and IV hydration when entertaining the possibility of midgut volvulus. If abdominal plain radiographic findings confirm the diagnosis, defer contrast studies and take the child directly to the operating room.
A Ladd procedure is the preferred treatment. It includes evisceration and inspection of the mesenteric root, derotation of the volvulus (which has always been reported to occur in a clockwise direction), lysis of Ladd bands with kocherization of the duodenum along the right abdominal gutter, opening of the visceral peritoneum that covers the mesentery, and replacing the small bowel into the right side of the abdomen and the large bowel into the left side (in a position of nonrotation). It also includes an appendectomy (usually an inversion appendectomy), because the cecum and appendix are located in an unusual place. The procedure can also be laparoscopically performed.
Any frankly necrotic bowel should be resected and end-to-end anastomosis performed unless the peritoneal cavity is grossly contaminated or the condition of the patient does not allow it; in such cases, stomas should be created.
Postoperative adhesive small-bowel obstruction
A possible diagnosis of adhesive small-bowel obstruction requires prompt surgical consultation because delay can lead to intestinal necrosis. The most difficult part is to decide if and when the child is to undergo surgery. As a general rule, the presence of fever, tachycardia, leukocytosis, rebound tenderness, or complete obstruction warrants surgical exploration. Patients usually present with a single-point obstruction. The authors recommend entering the abdomen through a fresh extension of the original incision, to avoid damage to the bowel adhered to the old scar.
Adhesiolysis is the treatment of choice. Only the adhesion causing the obstruction needs to be resolved, since extensive unnecessary adhesiolysis increases the risk of serosal tears and bowel perforations, as well as an increased inflammatory response that may produce further adhesive obstruction. Careful sharp dissection of adhesions with gentle handling of the intestine is imperative. This can be achieved laparoscopically or with laparotomy. Some patients require bowel resection because of perforation or necrosis.
The treatment for duplications is surgical excision, even in an asymptomatic patient who is incidentally diagnosed. The prevalence of gastric mucosa suggests that the duplications should not be left indefinitely. The procedure may depend on the location of the cyst.
In esophageal duplications, the cyst is excised, and a mucosectomy is performed if the muscular layer shared with the esophagus is left behind. The entire muscular wall can be excised with the cyst, taking care not to penetrate the esophageal mucosa.
Duplications of the small intestine usually require resection and anastomosis. In rectal duplications, only the mucosal lining usually needs to be excised, because the duplication and normal rectum share the muscularis layer. If malignant degeneration is suspected, total excision, including excision of the normal rectum, may be necessary. Infected duplications may require initial drainage, followed by a staged resection. Laparoscopically assisted resection of ileocecal duplications is safe and effective. See the image below.
Surgical management is similar to that of duodenal atresia. Diamond-shaped duodenoduodenostomy is the preferred approach (Kimura procedure).
Indications for surgery include pneumoperitoneum, fixed dilated bowel loop, abdominal wall discoloration, or children whose conditions deteriorate or show no improvement with conservative therapy. Portal venous air suggests extensive intestinal necrosis but does not indicate that celiotomy is necessary. See the image below.
The options for surgical management include laparotomy with abdominal decompression, with or without resection of necrosed bowel followed by primary anastomosis or creation of an ostomy, versus peritoneal drainage alone.[50, 39] The surgical team must make the decision of whether a particular patient requires peritoneal drainage or laparotomy. Many surgeons place a peritoneal drain and wait until the patient is stable to take him or her to the operating suite for exploratory laparotomy. However, a meta-analysis showed a higher mortality rate (55%) in patients who underwent peritoneal drainage.
If the perforation is due to full-blown NEC, the bowel may continue to necrose and the patient may suffer later form short-bowel syndrome, which has catastrophic long-term complications. Although some studies have shown a higher mortality rate in patients undergoing surgery at the NICU instead of the operating room, those children were likely more critically ill, which motivated the surgeon to decide not to transfer the patient.
In symptomatic patients with internal hernias, prompt surgical exploration in order to reduce the hernia and repair the defect is imperative to improve survival. These patients usually have a delayed diagnosis and present as a surgical emergency with acute bowel obstruction and intestinal ischemia.
See the image below.
Surgical reduction of the cecal volvulus and pexy to the lateral peritoneal wall is usually required, in addition to fluid resuscitation, bowel decompression, and ABC monitoring.
Jejunoileal atresia and stenosis
Surgical resection of the atretic segment is followed by end-to-end anastomosis. The proximal, dilated bowel may need to be tapered to fit the smaller, distal intestine. Care should be taken to preserve as much intestinal length as possible in order to prevent short-bowel syndrome, mainly in patients with multiple atresias. These have classically been repaired through transverse supraumbilical incision, although single jejunoileal atresias have been successfully approached through a smaller periumbilical incision (as in the one described for hypertrophic pyloric stenosis).
Duodenal atresia and stenosis
The usual treatment for duodenal atresia is a linear or diamond-shaped duodenoduodenostomy (Kimura procedure). Duodenojejunostomy is another option. A duodenal web is much rarer and can be treated with duodenotomy and excision of the web, with or without duodenoplasty.
Surgical management by either primary resection and anastomosis or ileostomy is sometimes required.
Surgical resection of the diverticulum is the proper treatment in symptomatic patients. Some research has shown that minimal access surgery can be safely performed in pediatric and neonatal cases, providing both a diagnostic and therapeutic approach without concerns for safety.
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