Pediatric Small-Bowel Obstruction Workup

  • Author: Jaime Shalkow, MD; Chief Editor: Carmen Cuffari, MD   more...
 
Updated: Feb 16, 2012
 

Approach Considerations

Signs and symptoms of bowel obstruction, especially in newborns, may be subtle; physicians should maintain a high index of suspicion. Moreover, rapid decisions about the need for surgical intervention can mean the difference between full recovery and massive bowel loss.

Bilious vomiting in a newborn should immediately lead physicians to suspect a bowel obstruction and to initiate an immediate workup and a surgical consultation. Admit any child with suspected small-bowel obstruction for observation, even if the diagnosis of obstruction is unclear.

The following laboratory tests may be useful in patients with small-bowel obstruction:

  • Serum electrolyte level
  • Blood urea nitrogen (BUN) level
  • Creatinine level
  • Glucose level
  • Complete blood count (CBC)
  • Urinalysis
  • Arterial blood gas (ABG) level
  • Stool for occult blood

Results can include the following:

  • Malrotation with midgut volvulus - Routine laboratory studies usually do not help to establish a diagnosis of malrotation with midgut volvulus, although leukocytosis with a left shift may develop late in the disease process.
  • Incarcerated hernia - Potassium is an intracellular ion; thus, patients with incarcerated hernias or other conditions that lead to ischemic bowel may present with hyperkalemia
  • NEC - Neonates with NEC typically present with low platelet counts and metabolic acidosis, especially if areas of the bowel are already affected; a more than 30% drop in platelet count is associated with increased morbidity and mortality, as well as length of hospital stay[40]
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Imaging Studies

Obtain flat decubitus and upright radiographs of the abdomen. Study radiographs for signs of dilated small-bowel loops and air-fluid levels produced by the layering of air and intestinal content. Absent colonic or rectal gas also indicates a complete bowel obstruction.

The pattern of bowel gas on plain radiography can help to differentiate between proximal and distal bowel obstructions. Drawing an imaginary line from the right upper quadrant to the left lower one is helpful in establishing the level of the obstruction. The jejunum corresponds to the left upper three fifths of the small bowel, whereas the right lower two fifths of it represents the ileum.

When intestinal perforation is suspected and the child cannot be placed in an upright position, a left lateral decubitus film with horizontal beam is helpful in diagnosing free intraperitoneal air because it facilitates identification of free air around the hepatic density.

Contrast studies such as upper GI series and contrast enemas can help to determine obstruction location. Contrast studies also reveal whether the obstruction is intrinsic or extrinsic to the bowel. Remember to always use hydrosoluble contrast to avoid severe barium peritonitis in patients with a perforation.

Abdominal computed tomography (CT) scanning should not be obtained when the diagnosis is evident on radiography because this would only delay treatment and subject the child to unnecessary radiation. CT scanning helps to identify causes of chronic partial obstructions, as well as abscesses, tumors, and other causes of acute abdominal pain.

Ultrasonographic examinations reveal many intestinal abnormalities, including tumors, mesenteric cysts, and intussusceptions.

Intussusception

In approximately 60% of intussusception cases, plain abdominal radiography reveals the head of the intussusceptum projecting into the air-filled colon. Abdominal radiography may also reveal scattered air-fluid levels that suggest an ileus or partial obstruction. A left lateral decubitus film aids in the initial diagnosis of intussusception by revealing air or stool in the cecum and ascending colon.[41, 42] See the image below.

A barium enema on a 1-year-old male patient depictA barium enema on a 1-year-old male patient depicts an ileocolic intussusception.

Contrast radiography using a barium enema can be therapeutic, as well as diagnostic. A classic sign is a coil spring appearance caused by the tracking of barium around the lumen of the edematous intestine. Air and water enemas have been used to reduce intussusception. Pneumatic reduction under fluoroscopic guidance and hydrostatic reduction under ultrasonographic monitoring are the preferred techniques. The aim should be a success rate of at least 90% in idiopathic intussusception. (See the image below.)

Barium enema revealing a coil spring appearance caBarium enema revealing a coil spring appearance caused by the tracking of barium around the lumen of the edematous intestine in intussusception.

Ultrasonography is useful in some cases and may have high sensitivity in as many as 75% of patients. The characteristic finding is a target or bull's eye configuration, consisting of 2 rings of low echogenicity that are separated by an intermediate hyperechoic ring visible on a cross-sectional image of intussuscepted bowel. See the image below.

Image of intussusception by ultrasound on a 9-montImage of intussusception by ultrasound on a 9-month-old male patient.

Intussusception has been recently identified by capsule endoscopy.[43]

Incarcerated hernia

In complete bowel obstruction, air-fluid levels are visible on plain radiography. The bowel may be visible within the inguinal canal and scrotum. Ultrasonography may reveal the incarcerated viscera in the inguinal canal or the umbilical ring and can be useful in difficult cases. (See the image below.)

Small-bowel obstruction caused by an incarcerated Small-bowel obstruction caused by an incarcerated inguinal hernia in a 2-month-old infant with bilateral inguinal hernias as well as an umbilical hernia.

A careful physical examination is more helpful than imaging studies for the diagnosis of incarcerated inguinal or umbilical hernias. Incarcerated hernias are diagnosed clinically, and no imaging studies are required. Determining the level of the obstruction is not that important because the treatment does depend on this finding.

Malrotation of the bowel with midgut volvulus

Plain abdominal radiography sometimes reveals a double-bubble sign that depicts air-fluid levels in the stomach and in the distended duodenum (see the image below). The abdomen often appears gasless on abdominal plain radiography. Distended loops of small bowel are only occasionally visible, because the point of obstruction is proximal, in the third portion of the duodenum.

Radiograph depicting the double-bubble sign characRadiograph depicting the double-bubble sign characteristic of duodenal atresia.

Definitive diagnosis of midgut volvulus requires contrast studies. Barium enema findings may provide indirect evidence by revealing an ectopically placed right colon and cecum, but a high or mobile cecum is common in many asymptomatic infants. In fact, 10-15% of patients with malrotation have barium enema findings that appear normal.

An upper GI series is a quicker and more direct approach, with high sensitivity and accuracy, making it the criterion standard study for malrotation with or without volvulus. The duodenum usually has a "C" shape, and the duodenojejunal junction is localized to the left of the midline.[44]

In malrotation, the duodenum lacks its normal shape and does not cross the midline. Duodenal obstructions due to volvulus, Ladd bands, or angulation are evident. The classic patterns of volvulus are the "bird beak," in cases involving complete duodenal obstruction, or the "corkscrew,” in cases involving incomplete obstruction.

Postoperative adhesive small-bowel obstruction

Supine and upright abdominal radiography reveals dilated, gas-filled loops of small intestine, with multiple air-fluid levels scattered throughout the abdomen above the obstruction site. Air in the colon usually indicates a partial obstruction, although determining whether a gas-filled loop is the colon or small bowel is difficult in infants. Demonstrating gas in the rectum is the only way to be certain of gas in the colon.

Oral administration of water-soluble contrast media (Gastrografin) with subsequent abdominal radiography is useful in deciding whether to perform early surgery in cases in which the obstruction cannot be determined to be partial or complete.[45, 46] If the contrast is found in the large bowel 6-8 hours after administration, the obstruction is presumed to be partial, and the patient can be conservatively managed without an immediate operation. The technique has been successfully used in children.[47]

Duplication cysts

Plain radiography usually reveals a soft-tissue mass within the abdomen that displaces the adjacent bowel and causes the obstruction. An upper GI contrast series may reveal stenosis or extrinsic compression by a mass. Technetium scanning can be used to image duplications that contain ectopic gastric mucosa.

For most abdominal duplications, ultrasonography is more expedient and provides greater detail than does conventional contrast radiography. Ultrasonography reveals either a sonolucent mass with good wave transmission because of its clear fluid content, or an echogenic mass secondary to hemorrhage that has inspissated material within the duplication. Intra-abdominal enteric duplication cysts are increasingly likely to be prenatally detected.[48]

Annular pancreas

Although an annular pancreas is often not diagnosed until surgery, plain abdominal radiography may reveal the double-bubble sign characteristic of duodenal obstruction. An upper GI series reveals a diminished duodenal lumen.

Ultrasonography provides a reliable method to help diagnose duodenal obstruction, even prenatally in pregnancies complicated by polyhydramnios in the third trimester. It is also a good study to rule out hypertrophic pyloric stenosis as a differential diagnosis.

Necrotizing enterocolitis

Abdominal radiography initially reveals multiple gas-filled loops of intestine and air-fluid levels. Straightening of the bowel wall and bowel wall thickening with intramural air suggest mural edema (railroad sign). A gasless abdomen, a fixed bowel loop, or a ground-glass appearance, which suggests free intraperitoneal fluid, is sometimes encountered.[49] See the images below.

Plain abdominal film of a premature baby born at 2Plain abdominal film of a premature baby born at 28 weeks of gestation with necrotizing enterocolitis. Note the "railroad sign" (neumatosis intestinalis) in the hepatic flexure and soap-bubbles in the descending colon. Plain abdominal film on a premature baby girl withPlain abdominal film on a premature baby girl with necrotizing enterocolitis. Note the air in the biliary tree and the grossly dilated bowel.

Pneumatosis intestinalis is the radiographic hallmark; its presence indicates gas in the bowel wall. Portal venous gas is an ominous sign, and pneumoperitoneum indicates a bowel perforation. Pneumatosis intestinalis and portal venous gas (pylephlebitis) are easily detected using ultrasonography.

A review from Toronto considers color Doppler ultrasonography to be a more accurate method of diagnosing bowel necrosis than plain abdominal radiography.[50]

Mesocolic hernia

An upper GI study with small bowel follow-through during a hernia episode can support the diagnosis. This study usually reveals the intestines bunched together as if enveloped by a sac. Abdominal CT scanning may reveal a mesocolic hernia during nonherniating periods.

Cecal volvulus

Plain abdominal radiography may reveal a large, air-filled loop of colon that occupies the right lower quadrant, in addition to depicting a typical small-bowel obstruction. The characteristic barium enema finding is a bird-beak–shaped deformity, coupled with nonvisualization of the cecum.

Jejunoileal atresia and stenosis

Radiographic findings often reveal thumb-sized intestinal loops and air-fluid levels. A loop of small bowel proximal to the atresia may become grossly distended and filled with fluid, producing the appearance of a mass.

A contrast enema is usually indicated to confirm the diagnosis. The preferred methodology is a water-soluble enema, which aids in distinguishing between small- and large-bowel distention, determining the presence or absence of a microcolon, and locating the position of the cecum relative to possible abnormalities of intestinal rotation and fixation. (See the image below.)

Upper GI contrast study demonstrating a jejunal atUpper GI contrast study demonstrating a jejunal atresia with a proximal dilated atretic bowel and lack of passage of contrast into the distal small bowel.

An upper GI series reveals the level of obstruction with a grossly distended proximal bowel. Care must be taken to avoid contrast aspiration.

Duodenal atresia and stenosis

Abdominal radiography usually confirms a duodenal atresia diagnosis. Gas and air-fluid levels are present in the stomach and the dilated duodenal bulb (ie, the double-bubble sign), but no air is present in the distal GI tract. These radiographic findings confirm a diagnosis of duodenal obstruction, making further studies unnecessary. See the image below.

Plain abdominal film on a 3-day-old newborn depictPlain abdominal film on a 3-day-old newborn depicting the classic double-bubble sign for duodenal atresia.

An upper GI series adds no information and creates the potential hazard of vomiting with barium aspiration. If the patient has vomited or has been decompressed using a nasogastric (NG) tube prior to abdominal radiography, the stomach and duodenum may be collapsed, making the correct diagnosis difficult. In such cases, a small amount of air (ie, 10-15 mL) may be injected into the stomach through the NG tube, and radiography may be repeated. (Upper GI studies are useful in the late diagnosis of duodenal web and stenosis.) See the image below.

Contrast-enhanced upper gastrointestinal film showContrast-enhanced upper gastrointestinal film showing a duodenal atresia on a 2-day-old newborn.

Meconium disease

Abdominal radiographic studies reveal multiple air-fluid levels consistent with small-bowel obstruction. The presence of calcifications throughout the peritoneum suggests a prenatal perforation and meconium peritonitis or meconium pseudocyst.

The inspissated meconium often has a ground-glass appearance on radiography. A "soap-bubble" image in the right lower quadrant is characteristic.

A contrast enema is diagnostic and, in many cases, therapeutic for meconium ileus and meconium plug syndrome. In most cases, the contrast enema reveals a microcolon (nonused colon) and meconium pellets in either the terminal ileum (meconium ileus) or the colon (meconium plug syndrome). Gastrografin is the agent of choice. Its osmotic properties pull water into the lumen, which may unplug the intestine.

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Contributor Information and Disclosures
Author

Jaime Shalkow, MD  Head of Surgical Oncology, Division of Surgery, National Institute of Pediatrics, Mexico; Head-Professor of Pediatric Surgical Oncology, Universidad Nacional Autonoma de Mexico

Jaime Shalkow, MD is a member of the following medical societies: American College of Surgeons, International Society of Pediatric Surgical Oncology, Mexican Association of Pediatric Surgery, Mexican Association of Pediatrics, Mexican Society of Oncology, and Pacific Association of Pediatric Surgery

Disclosure: Nothing to disclose.

Coauthor(s)

Jose Asz, MD  Professor of Embryology, Assistant Professor of Surgery and Pediatrics, Faculty of Medicine, Universidad Nacional Autonoma de Mexico; Consulting Staff, Department of General Surgery, National Institute of Pediatrics, Mexico

Disclosure: Nothing to disclose.

Adrian Florens, MD, FAAP  Attending Faculty Staff, Department of Pediatrics, Division of Neonatology, John H Stroger Hospital of Cook County

Adrian Florens, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Nicholas A Shorter, MD  Professor of Clinical Surgery and Clinical Pediatrics, State University of New York Downstate University; Division Chief, Department of Surgery, Division of Pediatric Surgery, State University of New York Downstate Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Carmen Cuffari, MD  Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Additional Contributors

B UK Li, MD Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Director, Pediatric Fellowships and Gastroenterology Fellowship, Medical Director, Functional Gastrointestinal Disorders and Cyclic Vomiting Program, Medical College of Wisconsin; Attending Gastroenterologist, Children's Hospital of Wisconsin

B UK Li, MD is a member of the following medical societies: Alpha Omega Alpha, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Jorge H Vargas, MD Professor of Pediatrics and Clinical Professor of Pediatric Gastroenterology, David Geffen School of Medicine, University of California at Los Angeles; Consulting Physician, Department of Pediatrics, University of California at Los Angeles Health System

Jorge H Vargas, MD is a member of the following medical societies: American Liver Foundation, American Society for Gastrointestinal Endoscopy, American Society for Parenteral and Enteral Nutrition, Latin American Society of Pediatric Gastroenterology, Hepatology & Nutrition, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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Small-bowel obstruction visible on plain radiograph caused by intussusception in a 5-month-old patient.
Barium enema revealing a coil spring appearance caused by the tracking of barium around the lumen of the edematous intestine in intussusception.
Small-bowel obstruction caused by an incarcerated inguinal hernia in a 2-month-old infant with bilateral inguinal hernias as well as an umbilical hernia.
Radiograph depicting the double-bubble sign characteristic of duodenal atresia.
Upper GI contrast study demonstrating a jejunal atresia with a proximal dilated atretic bowel and lack of passage of contrast into the distal small bowel.
Surgical photograph of the patient in the previous image depicting the proximal dilated atretic jejunum.
Upper GI contrast study showing a malrotation with lack of normal C-shaped duodenum and the small bowel "hanging" on the right side of the abdomen.
Contrast enema with an abnormally located cecum in a patient with malrotation.
Surgical photograph of necrotic bowel in a patient with midgut volvulus.
Necrotic bowel after surgical reduction of an intussusception.
Surgical photograph of a transition zone in an infant with small bowel obstruction.
Incarcerated left inguinal hernia.
Mesocolic hernia.
Surgical image of a laparotomy on a 7-month-old girl with ileocolic intussusception. An edematous and erythematous cecal appendix was found to be acting as a lead point.
Surgical image of a laparotomy on a 2-day-old female patient with congenital small bowel obstruction. A type I jejunal atresia without mesenteric gap and a grossly dilated proximal intestine is seen.
A barium enema on a 1-year-old male patient depicts an ileocolic intussusception.
Clinical photograph of a 5-month-old male patient with characteristic currant-jelly stools due to intussusception.
Plain abdominal film on a 3-day-old newborn depicting the classic double-bubble sign for duodenal atresia.
Contrast-enhanced upper gastrointestinal film showing a duodenal atresia on a 2-day-old newborn.
Surgical photograph of a 3-year-old male patient with an obstructive, noncommunicating ileal duplication.
Plain abdominal film of a 6-year-old male patient with MRCP (mental retardation and cerebral palsy), with organo-axial gastric volvulus. Note the grossly dilated and obstructed stomach. A gastrostomy feeding tube can be seen in place. Surgical staplers from a previous laparoscopic funduplication are seen near the diaphragmatic crura.
Surgical photograph of an 8-month-old patient with ileocolic intussusception.
Plain abdominal film of a premature baby born at 28 weeks of gestation with necrotizing enterocolitis. Note the "railroad sign" (neumatosis intestinalis) in the hepatic flexure and soap-bubbles in the descending colon.
Clinical image of a micro-premature baby boy with discoloration on the right lower quadrant of the abdomen, due to intestinal perforation secondary to necrotizing enterocolitis. An umbilical catheter is in place.
Plain abdominal film on a premature baby girl with necrotizing enterocolitis. Note the air in the biliary tree and the grossly dilated bowel.
Surgical photograph of a 1-year-old male patient who previously underwent a right radical nephrectomy for Wilms tumor. He presented to the emergency department with signs of a mechanical small bowel obstruction. A transition zone is clearly seen at the point where the small bowel is trapped on an internal hernia through a mesenteric gap.
Image of intussusception by ultrasound on a 9-month-old male patient.
 
 
 
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