Pediatric Small-Bowel Obstruction Workup
- Author: Jaime Shalkow, MD, FACS; Chief Editor: Carmen Cuffari, MD more...
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
Complete blood count (CBC)
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 
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.
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.[71, 72] See the image below.
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.)
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.
Intussusception has been recently identified by capsule endoscopy.
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.)
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.
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.
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.
Ultrasonographic findings suggestive of malrotation include the following:
Third part of the duodenum not in the normal retromesenteric position (ie, located between the mesenteric artery and the aorta in the retroperitoneal space)
Abnormal position of the superior mesenteric vein (either anterior or to the left of the superior mesenteric artery [SMA]): The superior mesenteric vein is normally located to the right of the SMA.
The "whirlpool" sign of volvulus: This is caused by the vessels twisting around the base of the mesenteric pedicle.
Dilated duodenum (indicating duodenal obstruction by Ladd bands)
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.[75, 76] 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.
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.
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.
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. See the images below.
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.
An upper GI study with small bowel follow-through during a hernia episode can support the diagnosis. This study has a good detection rate for paraduodenal hernia. This hernia can be diagnosed when a cluster of bowel loops is associated with loss of the usual interdigitation between the loops. Transmesenteric hernias can occasionally be seen as a cluster of bowel loops on GI studies. Abdominal CT scanning is the diagnostic imaging study of choice for both paraduodenal and transmesenteric hernias because of its high accuracy and use for estimating severity.
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.)
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.
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.
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.
The criterion standard for diagnosis of MD is the technetium-99-pertechnetate scintigraphy, which is effective in 60-80% of patients, thus requiring a high index of clinical suspicion as well.
Wyllie Robert. Intestinal atresia, stenosis and malrotation. Nelson Textbook of Pediatrics. 18. Saunders; 327.
Kitagawa S., Miqdady M. Intussusception in children. UpToDate. 2014; Accessed: October 2015.
Mansour AM, El Koutby M, El Barbary MM, Mohamed W, Shehata S, El Mohammady H. Enteric viral infections as potential risk factors for intussusception. J Infect Dev Ctries. 2013 Jan. 7(1):28-35. [Medline].
Nylund CM, Denson LA, Noel JM. Bacterial enteritis as a risk factor for childhood intussusception: a retrospective cohort study. J Pediatr. 2010 May. 156(5):761-5. [Medline].
Weintraub ES, Baggs J, Duffy J, Vellozzi C, Belongia EA, Irving S, et al. Risk of intussusception after monovalent rotavirus vaccination. N Engl J Med. 2014 Feb 6. 370(6):513-9. [Medline].
Patel MM, López-Collada VR, Bulhões MM, De Oliveira LH, Bautista Márquez A, Flannery B. Intussusception risk and health benefits of rotavirus vaccination in Mexico and Brazil. N Engl J Med. 2011 Jun 16. 364(24):2283-92. [Medline].
Manish M. Et al. Intussusception risk and healt benefits of rotavirus vaccination in Mexico and Brazil. The New England Journal of Medicine. Jun 2011. 364 (24):
Okimoto S, Hyodo S, Yamamoto M, Nakamura K, Kobayashi M. Association of viral isolates from stool samples with intussusception in children. Int J Infect Dis. 2011 Sep. 15(9):e641-5. [Medline].
Ruscher KA, Fisher JN, Hughes CD, Neff S, Lerer TJ, Hight DW, et al. National trends in the surgical management of Meckel's diverticulum. J Pediatr Surg. 2011 May. 46(5):893-6. [Medline].
Nikolic H, Palcevski G, Saina G, Peršic M. Chronic intussusception in children caused by Ascaris lumbricoides. Wien Klin Wochenschr. 2011 May. 123(9-10):294-6. [Medline].
Vestergaard H, Westergaard T, Wohlfahrt J, et al. Association between intussusception and tonsil disease in childhood. Epidemiology. 2008 Jan. 19(1):71-4. [Medline].
Wang SM, Huang FC, Wu CH, Ko SF, Lee SY, Hsiao CC. Ileocecal Burkitt's lymphoma presenting as ileocolic intussusception with appendiceal invagination and acute appendicitis. J Formos Med Assoc. 2010 Jun. 109(6):476-9. [Medline].
van Lier MG, Mathus-Vliegen EM, Wagner A, van Leerdam ME, Kuipers EJ. High cumulative risk of intussusception in patients with Peutz-Jeghers syndrome: time to update surveillance guidelines?. Am J Gastroenterol. 2011 May. 106(5):940-5. [Medline].
Laje P, Stanley CA, Adzick NS. Intussusception after pancreatic surgery in children: a case series. J Pediatr Surg. 2010 Jul. 45(7):1496-9. [Medline].
Abbo O, Pinnagoda K, Micol LA, Beck-Popovic M, Joseph JM. Osteosarcoma metastasis causing ileo-ileal intussusception. World J Surg Oncol. 2013. 11(1):188. [Medline].
Abbo O, Pinnagoda K, Micol LA, Beck-Popovic M, Joseph JM. Osteosarcoma metastasis causing ileo-ileal intussusception. World J Surg Oncol. 2013 Aug 12. 11 (1):188. [Medline].
Fraser JD, Aguayo P, Ho B, Sharp SW, Ostlie DJ, Holcomb GW 3rd. Laparoscopic management of intussusception in pediatric patients. J Laparoendosc Adv Surg Tech A. 2009 Aug. 19(4):563-5. [Medline].
Esposito F, et al:. Flouroscopy-guided hydrostatic reduction in infancy: role of pharmacological premedication. Radiol Med. June 2015. 120(6):549-56.
Rajput A, Gauderer MW, Hack M. Inguinal hernias in very low birth weight infants: incidence and timing of repair. J Pediatr Surg. 1992 Oct. 27(10):1322-4. [Medline].
de Goede B, Verhelst J, van Kempen BJ, Baartmans MG, Langeveld HR, Halm JA, et al. Very low birth weight is an independent risk factor for emergency surgery in premature infants with inguinal hernia. J Am Coll Surg. 2015 Mar. 220 (3):347-52. [Medline].
Ikossi DG, Shaheen R, Mallory B. Laparoscopic femoral hernia repair using umbilical ligament as plug. J Laparoendosc Adv Surg Tech A. 2005 Apr. 15(2):197-200. [Medline].
Chan KL, Hui WC, Tam PK. Prospective randomized single-center, single-blind comparison of laparoscopic vs open repair of pediatric inguinal hernia. Surg Endosc. 2005 Jul. 19(7):927-32. [Medline].
Boley SJ, Cahn D, Lauer T, Weinberg G, Kleinhaus S. The irreducible ovary: a true emergency. J Pediatr Surg. 1991 Sep. 26(9):1035-8. [Medline].
Mboyo A, Goura E, Massicot R, et al. An exceptional cause of intestinal obstruction in a 2-year-old boy: strangulated hernia of the ileum through Winslow's foramen. J Pediatr Surg. 2008 Jan. 43(1):e1-3. [Medline].
Gingalewski C, Lalikos J. An unusual cause of small bowel obstruction: herniation through a defect in the falciform ligament. J Pediatr Surg. 2008 Feb. 43(2):398-400. [Medline].
Lee N, Kim SG, Lee YJ, Park JH, Son SK, Kim SH, et al. Congenital internal hernia presented with life threatening extensive small bowel strangulation. Pediatr Gastroenterol Hepatol Nutr. 2013 Sep. 16(3):190-4. [Medline]. [Full Text].
El-Gohary Y, Alagtal M, Gillick J. Long-term complications following operative intervention for intestinal malrotation: a 10-year review. Pediatr Surg Int. 2010 Feb. 26(2):203-6. [Medline].
Brandt M. Intestinal Malrotation. UpToDate. 2014; Accessed: October 2015.
Chesley PM, Melzer L, Bradford MC, Avansino JR. Association of anorectal malformation and intestinal malrotation. Am J Surg. 2015 May. 209 (5):907-11; discussion 912. [Medline].
Kargl S, Wagner O, Pumberger W. Volvulus without malposition--a single-center experience. J Surg Res. 2015 Jan. 193 (1):295-9. [Medline].
Lakshminarayanan B, Hughes-Thomas AO, Grant HW. Epidemiology of adhesions in infants and children following open surgery. Semin Pediatr Surg. 2014 Dec. 23 (6):344-8. [Medline].
Prasad A, Chadha R. Intestinal Obstruction. Gupta D, Ed. Pediatric Surgery: Diagnosis and Management. New Delhi, India: Jaypee Import; 2009.
Nasir AA, Abdur-Rahman LO, Bamigbola KT, Oyinloye AO, Abdulraheem NT, Adeniran JO. Is non-operative management still justified in the treatment of adhesive small bowel obstruction in children?. Afr J Paediatr Surg. 2013 Jul-Sep. 10(3):259-64. [Medline].
Li M, Ren J, Zhu W, Li Y, Zhao Y, Jiang J, et al. Long intestinal tube splinting really prevents recurrence of postoperative adhesive small bowel obstruction: a study of 1,071 cases. Am J Surg. 2015 Feb. 209 (2):289-96. [Medline].
Tsao KJ, St Peter SD, Valusek PA, et al. Adhesive small bowel obstruction after appendectomy in children: comparison between the laparoscopic and open approach. J Pediatr Surg. 2007 Jun. 42(6):939-42; discussion 942. [Medline].
Ohno Y, Kanematsu T. Annular pancreas causing localized recurrent pancreatitis in a child: report of a case. Surg Today. 2008. 38(11):1052-5. [Medline].
Kihne M, Ramanujam TM, Sithasanan N. Mesocolic hernia: a rare cause of intestinal obstruction in childhood. Med J Malaysia. 2006 Jun. 61(2):251-3. [Medline].
Villalona GA, Diefenbach KA, Touloukian RJ. Congenital and acquired mesocolic hernias presenting with small bowel obstruction in childhood and adolescence. J Pediatr Surg. 2010 Feb. 45(2):438-42. [Medline].
Wright NJ, Thyoka M, Kiely EM, Pierro A, De Coppi P, Cross KM. The outcome of critically ill neonates undergoing laparotomy for necrotising enterocolitis in the neonatal intensive care unit: a 10-year review. J Pediatr Surg. 2014 Aug. 49(8):1210-4. [Medline].
Neu J, Walker WA. Necrotizing enterocolitis. N Engl J Med. 2011 Jan 20. 364(3):255-64. [Medline].
Morgan JA, Young L, McGuire W. Pathogenesis and prevention of necrotizing enterocolitis. Curr Opin Infect Dis. 2011 Jun. 24(3):183-9. [Medline].
Henry MC, Moss RL. Neonatal Necrotizing Enterocolitis. Seminars in Pediatric Surgery. May 72008. 17:98-109.
Fisher JG, Bairdain S, Sparks EA, Khan FA, Archer JM, Kenny M, et al. Serious congenital heart disease and necrotizing enterocolitis in very low birth weight neonates. J Am Coll Surg. 2015 Jun. 220 (6):1018-1026.e14. [Medline].
Dilli D, Aydin B, Fettah ND, Özyazıcı E, Beken S, Zenciroğlu A, et al. The propre-save study: effects of probiotics and prebiotics alone or combined on necrotizing enterocolitis in very low birth weight infants. J Pediatr. 2015 Mar. 166 (3):545-51.e1. [Medline].
Lau CS, Chamberlain RS. Probiotic administration can prevent necrotizing enterocolitis in preterm infants: A meta-analysis. J Pediatr Surg. 2015 Aug. 50 (8):1405-12. [Medline].
Tayman C, Tonbul A, Kahveci H, et al. C5a, a complement activation product, is a useful marker in predicting the severity of necrotizing enterocolitis. Tohoku J Exp Med. 2011. 224(2):143-50. [Medline].
Young CM, Kingma SD, Neu J. Ischemia-reperfusion and neonatal intestinal injury. J Pediatr. 2011 Feb. 158(2 Suppl):e25-8. [Medline].
Autmizguine J, Hornik CP, Benjamin DK Jr, Laughon MM, Clark RH, Cotten CM, et al. Anaerobic antimicrobial therapy after necrotizing enterocolitis in VLBW infants. Pediatrics. 2015 Jan. 135 (1):e117-25. [Medline].
Heida FH, Hulscher JB, Schurink M, Timmer A, Kooi EM, Bos AF, et al. Intestinal fatty acid-binding protein levels in Necrotizing Enterocolitis correlate with extent of necrotic bowel: results from a multicenter study. J Pediatr Surg. 2015 Jul. 50 (7):1115-8. [Medline].
Zhang Y, Ortega G, Camp M, Osen H, Chang DC, Abdullah F. Necrotizing enterocolitis requiring surgery: outcomes by intestinal location of disease in 4371 infants. J Pediatr Surg. 2011 Aug. 46(8):1475-81. [Medline].
Sharma S, Gupta D. Gastric Volvulus. Gupta D, Ed. Pediatric Surgery: Diagnosis and Management. New Delhi, India: Jaypee Import; 2009.
Kumar KJ, Kumar MG, Shyamala P, Kumar MP. Meckel's diverticulitis causing intestinal obstruction in a 3 month old infant. J Res Med Sci. 2013 Sep. 18(9):826. [Medline].
Javid P, Pauli E. Meckel’s diverticulum. UpToDate. Jan 2014; Accessed: October 2015.
Kin Wai Edwin Chan. Et al. Laparoscopic excision of Meckel's diverticulum in children: what is the current evidence?. World J Gastroenterol. Nov 2014. 20(41):15158-62.
Herndon CD, Rink RC, Cain MP, et al. In situ Malone antegrade continence enema in 127 patients: a 6-year experience. J Urol. 2004 Oct. 172(4 Pt 2):1689-91. [Medline].
Foley PT, Sithasanan N, McEwing R, et al. Enteric duplications presenting as antenatally detected abdominal cysts: is delayed resection appropriate?. J Pediatr Surg. 2003 Dec. 38(12):1810-3. [Medline].
Ladd W, Gross RE. Surgical treatment of duplication of the alimentary tract: Enterogenous cysts, enteric cysts, or ileum duplex. Surg Gynecol Obstet. 1940. 70:295-307.
Ksia A, Zitouni H, Zrig A, Laamiri R, Chioukh F, Ayari E, et al. Pyloric atresia: A report of ten patients. Afr J Paediatr Surg. 2013 Apr-Jun. 10(2):192-4. [Medline].
Karrer FM, Potter DD, Calkins CM. Pediatic Duodenal Atresia. Medscape Reference. Available at http://emedicine.medscape.com/article/932917-overview. Accessed: January 9, 2012.
Lewis N, Glick P. Pediatric Duodenal Atresia and Stenosis Surgery. Medscape Reference. Available at http://emedicine.medscape.com/article/935748-overview. Accessed: January 9, 2012.
Ksia A, Zitouni H, Zrig A, Laamiri R, Chioukh F, Ayari E, et al. Pyloric atresia: A report of ten patients. Afr J Paediatr Surg. 2013 Apr-Jun. 10 (2):192-4. [Medline].
Wetherill C, Sutcliffe J. Hirschsprung disease and anorectal malformation. Early Hum Dev. 2014 Dec. 90 (12):927-32. [Medline].
Moss RL, Kalish LA, Duggan C, et al. Clinical parameters do not adequately predict outcome in necrotizing enterocolitis: a multi-institutional study. J Perinatol. 2008 Oct. 28(10):665-74. [Medline].
Berman L, Moss RL. Necrotizing enterocolitis: an update. Semin Fetal Neonatal Med. 2011 Jun. 16(3):145-50. [Medline].
Duro D, Kalish LA, Johnston P, et al. Risk factors for intestinal failure in infants with necrotizing enterocolitis: a Glaser Pediatric Research Network study. J Pediatr. 2010 Aug. 157(2):203-208.e1. [Medline]. [Full Text].
Mark I, Richard M. Emergent evaluation of the child with acute abdominal pain. UpToDate. 2014; Accessed: October 2015.
Bell MJ, Ternberg JL, Feigin RD, Keating JP, Marshall R, Barton L. Neonatal necrotizing enterocolitis. Therapeutic decisions based upon clinical staging. Ann Surg. 1978 Jan. 187(1):1-7. [Medline].
Rastogi S, Olmez I, Bhutada A, Rastogi D. Drop in platelet counts in extremely preterm neonates and its association with clinical outcomes. J Pediatr Hematol Oncol. 2011 Dec. 33(8):580-4. [Medline].
Roskind CG, Ruzal-Shapiro CB, Dowd EK, et al. Test characteristics of the 3-view abdominal radiograph series in the diagnosis of intussusception. Pediatr Emerg Care. 2007 Nov. 23(11):785-9. [Medline].
Rosenbaum J, Alex G, Simpson D, Catto-Smith A. Luminal view of an intussusception captured by capsule endoscopy. J Pediatr Gastroenterol Nutr. 2011 Aug. 53(2):127. [Medline].
Sizemore AW, Rabbani KZ, Ladd A, et al. Diagnostic performance of the upper gastrointestinal series in the evaluation of children with clinically suspected malrotation. Pediatr Radiol. 2008 May. 38(5):518-28. [Medline].
Fazio VW, Cohen Z, Fleshman JW, et al. Reduction in adhesive small-bowel obstruction by Seprafilm adhesion barrier after intestinal resection. Dis Colon Rectum. 2006 Jan. 49(1):1-11. [Medline].
Shah U, Shafiq Y, Khan MA. Gastrograffin use in distal intestinal obstruction syndrome of cystic fibrosis. J Ayub Med Coll Abbottabad. 2007 Jan-Mar. 19(1):58-60. [Medline].
Yagci G, Kaymakcioglu N, Can MF, et al. Comparison of Urografin versus standard therapy in postoperative small bowel obstruction. J Invest Surg. 2005 Nov-Dec. 18(6):315-20. [Medline].
Gul A, Tekoglu G, Aslan H, et al. Prenatal sonographic features of esophageal and ileal duplications at 18 weeks of gestation. Prenat Diagn. 2004 Dec 15. 24(12):969-71. [Medline].
Dordelmann M, Rau G, Bartels D, et al. Evaluation of portal venous gas detected by ultrasound examination for diagnosis of NEC. Arch Dis Child Fetal Neonatal Ed. 2008 Sep 11. [Epub ahead of print].
Faingold R, Daneman A, Tomlinson G, Babyn PS, Manson DE, Mohanta A. Necrotizing enterocolitis: assessment of bowel viability with color doppler US. Radiology. 2005 May. 235(2):587-94. [Medline].
Kandpal DK, Siddharth S, Balan S, Chowdhary SK. Intestinal obstruction in a premature baby: Endoscopic diagnosis and management by minimal access surgery. J Indian Assoc Pediatr Surg. 2013 Jul. 18(3):118-20. [Medline]. [Full Text].
Ekenze SO, Mgbor SO. Childhood intussusception: the implications of delayed presentation. Afr J Paediatr Surg. 2011 Jan-Apr. 8(1):15-8. [Medline].
Tareen F, Ryan S, Avanzini S, Pena V, Mc Laughlin D, Puri P. Does the length of the history influence the outcome of pneumatic reduction of intussusception in children?. Pediatr Surg Int. 2011 Jun. 27(6):587-9. [Medline].
Whitehouse JS, Gourlay DM, Winthrop AL, Cassidy LD, Arca MJ. Is it safe to discharge intussusception patients after successful hydrostatic reduction?. J Pediatr Surg. 2010 Jun. 45(6):1182-6. [Medline].
Kaiser AD, Applegate KE, Ladd AP. Current success in the treatment of intussusception in children. Surgery. 2007 Oct. 142(4):469-75; discussion 475-7. [Medline].
Ramachandran P, Gupta A, Vincent P, et al. Air enema for intussusception: is predicting the outcome important?. Pediatr Surg Int. 2008 Mar. 24(3):311-3. [Medline].
Abbas S, Bissett IP, Parry BR. Oral water soluble contrast for the management of adhesive small bowel obstruction. Cochrane Database Syst Rev. 2007 Jul 18. CD004651. [Medline].
Rao SC, Basani L, Simmer K, Samnakay N, Deshpande G. Peritoneal drainage versus laparotomy as initial surgical treatment for perforated necrotizing enterocolitis or spontaneous intestinal perforation in preterm low birth weight infants. Cochrane Database Syst Rev. 2011 Jun 15. CD006182. [Medline].
James DC, Lessen R. Position of the American Dietetic Association: promoting and supporting breastfeeding. J Am Diet Assoc. 2009 Nov. 109(11):1926-42. [Medline].
Probiotics for prevention of necrotizing enterocolitis in preterm infants. 2008;
Alfaleh K, Anabrees J, Bassler D, Al-Kharfi T. Probiotics for prevention of necrotizing enterocolitis in preterm infants. Cochrane Database Syst Rev. 2011 Mar 16. CD005496. [Medline].
Haque KN, Pammi M. Pentoxifylline for treatment of sepsis and necrotizing enterocolitis in neonates. Cochrane Database Syst Rev. 2011 Oct 5. CD004205. [Medline].
Kao C, Tseng SH, Chen Y. Laparoscopic reduction of intussusception in children by a single surgeon in comparison with open surgery. Minim Invasive Ther Allied Technol. 2011 May. 20(3):141-5. [Medline].
Draus JM Jr, Foley DS, Bond SJ. Laparoscopic Ladd procedure: a minimally invasive approach to malrotation without midgut volvulus. Am Surg. 2007 Jul. 73(7):693-6. [Medline].
Tsumura H, Ichikawa T, Murakami Y, et al. Laparoscopic adhesiolysis for recurrent postoperative small bowel obstruction. Hepatogastroenterology. 2004 Jul-Aug. 51(58):1058-61. [Medline].
Sola JE, Tepas JJ 3rd, Koniaris LG. Peritoneal Drainage versus Laparotomy for Necrotizing Enterocolitis and Intestinal Perforation: A Meta-Analysis. J Surg Res. 2009 Jun 6. [Medline].
Banieghbal B, Beale PG. Minimal access approach to jejunal atresia. J Pediatr Surg. 2007 Aug. 42(8):1362-4. [Medline].
Kozlov Y, Novogilov V, Yurkov P, Podkamenev A, Weber I, Sirkin N. Keyhole approach for repair of congenital duodenal obstruction. Eur J Pediatr Surg. 2011 Mar. 21(2):124-7. [Medline].
Jawaheer J, Khalil B, Plummer T, et al. Primary resection and anastomosis for complicated meconium ileus: a safe procedure?. Pediatr Surg Int. 2007 Nov. 23(11):1091-3. [Medline].
Stevenson DK, Kerner JA, Malachowski N. Late morbidity among survivors of necrotizing enterocolitis. Pediatrics. 1980. 66:925-7.
Minney-Smith CA, Levy A, Hodge M, Jacoby P, Williams SH, Carcione D, et al. Intussusception is associated with the detection of adenovirus C, enterovirus B and rotavirus in a rotavirus vaccinated population. J Clin Virol. 2014 Dec. 61 (4):579-84. [Medline].
Pammi M, Abrams SA. Oral lactoferrin for the prevention of sepsis and necrotizing enterocolitis in preterm infants. Cochrane Database Syst Rev. 2015 Feb 20. 2:CD007137. [Medline].