Intestinal Obstruction in the Newborn Clinical Presentation

Updated: Feb 17, 2020
  • Author: James Goodwin Glasser, MD, MA, FACS; Chief Editor: Muhammad Aslam, MD  more...
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Presentation

History and Physical Examination

Infants with intestinal obstruction are unable to feed; hence, their problem is immediately apparent.

Infants with pyloric stenosis vomit gastric content: milk or mucus. If there is associated gastritis, the emesis may be rust colored.

Bilious (green) gastric aspirate or emesis indicates that the intestines are obstructed below the ampulla of Vater.

An infant who was eating well but who suddenly vomits bile (green fluid) has malrotation/volvulus until proven otherwise by upper gastrointestinal (GI) studies. [8]

Surprisingly, a survey of 175 knowledgeable people (pediatricians, neonatologists, nurses, midwives, and parents) determined that most respondants (75%) did not know that the color of "bilious emesis" is green. [18]

Important observations to make in examining an infant with intestinal obstruction include the following:

  • Is the baby's abdomen scaphoid or distended?
  • Is there a palpable mass (usually the obstructed loop of intestine)?
  • Does the abdomen have rippled appearance? Do the waves feel ropey (dilated intestine)?
  • Are bowel sounds present or absent or hyperactive?
  • Is the abdomen tender?

Peritonitis is an ominous sign, suggesting bowel ischemia or necrosis, sepsis, and multisystem organ failure. Closely monitor for the following signs:

  • Hypotension and tachycardia
  • Prolonged capillary filling and pallor
  • Hematochezia (intussusception, necrotizing enterocolitis)
  • Thrombocytopenia and Coagulopathy
  • Respiratory failure

Duodenal atresia/stenosis

Vomiting and right upper quadrant fullness complement the radiologic "double-bubble sign" in duodenal atresia. This fullness may disappear upon placement of an orogastric tube. In 85% of patients, the obstruction is distal to the ampulla of Vater, and these patients have bilious vomiting. Patients with duodenal atresia should be evaluated for trisomy 21.

Intestinal obstruction in the newborn. Partial duo Intestinal obstruction in the newborn. Partial duodenal obstruction: duodenal stenosis or malrotation/volvulus? Note the "double bubble" sign and narrowing of the second portion of the duodenum; however, the duodenum does cross the midline and it is not twisted.

Malrotation/volvulus

Babies with malrotation/volvulus present with sudden onset of bilious vomiting. Initially, the abdomen is scaphoid. Midgut volvulus begins as an incomplete closed-loop obstruction; however, with the passage of time, the obstruction becomes complete and the baby's abdomen becomes increasingly distended. Obtain an urgent upper GI onstrast study.

Intestinal obstruction in the newborn. Malrotation Intestinal obstruction in the newborn. Malrotation/volvulus. Note the spiral twist and the partial obstruction.

Jejunal atresia

Infants with jejunal atresia usually present with bilious vomiting. If the atretic proximal intestine is dilated and bulbous, the baby may also have abdominal distention and a palpable mass.

Ileal atresia

Infants with distal bowel obstruction present with abdominal distention, delayed passage of meconium, and absent transitional stools. Bowel sounds may be hypoactive or absent (fatigue in chronic obstructions).

Meconium ileus and plug syndrome

Meconium ileus usually presents with abdominal distention and obstipation.

Meconium plug syndrome is a relatively benign condition, usually occurring in healthy-appearing term infants. Abdominal distention and failure to pass meconium within the first 24 hours of life are the presenting signs.

Hirschsprung disease

Babies with Hirschsprung disease usually have distended abdomens and are intolerant of feedings; often, passage of meconium is delayed. A contrast enema study may be diagnostic (delay digital rectal examination until after the radiologic study) and therapeutic (initiating a bowel movement). Some neonates with Hirschsprung disease may be managed with rectal dilatation and irrigations and undergoing a primary pull-through procedure. Infants with enterocolitis, however, should be treated with diversion (a "leveling colostomy").

Strangely, some babies with Hirschsprung disease present later in life, perhaps because breast milk has so little residue. Later, when additional foods are added to the baby's diet, symptoms of constipation develop. [19]

Intestinal obstruction in the newborn. The contras Intestinal obstruction in the newborn. The contrast enema in a baby with Hirschsprung disease; the rectum is small and the sigmoid colon is dilated.

Imperforate anus

A diagnosis of imperforate anus is imediately obvious upon inspection of the newborn's perineum. Anorectal malformations range from anterior displacement of the anal opening to an absent patent anus. Infants with imperforate anus (see the following image) may have abnormalities of the sacrum; boys with high imperforate anus will have a rectourinary tract fistula, which may be demonstrated by the presence of meconium in the urine.

Intestinal obstruction in the newborn. Baby with a Intestinal obstruction in the newborn. Baby with a high imperforate anus; note the indistinct perineum ("rocker bottom"). Compare this photograph with the low imperforate anus photograph in the section "Surgical Relief of Obstruction," in which "pearls" of meconium along the scrotal raphe can be seen.