Approach Considerations
Children with small bowel obstructions are admitted to the hospital for close monitoring even if initial nonoperative management is chosen.
General principles in the treatment of small bowel obstruction include the following:
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Stabilize the patient and monitor ABCs (airway, breathing, circulation).
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Replace fluid losses with diligent intravenous (IV) resuscitation, using isotonic sodium chloride solution or lactated Ringer's solution.
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Administer nothing by mouth (NPO).
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Early gastric decompression with a nasogastric (NG) tube.
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Administer broad-spectrum antibiotics when necrosis or perforation is suspected.
Consultations
When small bowel obstruction is suspected in a pediatric patient, consult with a pediatric or general surgeon, depending on availability. Consider early transfer of care to a children’s center fully resourced to provide optimal care to children. [47]
Other considerations
Specific approaches to different causes of small bowel obstruction are discussed below.
Intussusception
Initial management of an ileocolic intussusception is a trial at reduction using an air or contrast enema, which is successful in approximately 90% of cases. [48, 49] Repeat enemas are useful and can be considered when the first enema is unsuccessful but did achieve some partial reduction. [41] Although some centers still elect to admit children for observation after a successful enema reduction, discharge from the emergency department after successful reduction has also been shown to be safe. [50]
Children who are systemically ill with signs of peritonitis are not candidates for enema reduction and should be expeditiously taken to surgery. Surgery is also indicated for patients whose intussusception cannot be reduced with enemas. See the image below.
Pediatric Small Bowel Obstruction. This is a surgical photograph of an 8-month-old patient with ileocolic intussusception.
Adhesive small bowel obstruction
A high level of concern for compromised bowel mandates operative exploration. In most patients with adhesive small bowel obstruction, however, such signs are not present, and a trial of nonoperative management with NPO, IV fluids, and NG decompression is appropriate. This management alone will result in resolution of many adhesive small bowel obstructions in children. [18]
The administration of a water-soluble contrast medium (such as Gastrografin) via NG tube, followed by abdominal radiography to assess the contrast progression, is useful in deciding early whether or not surgical intervention will be required. The passage of contrast material into the colon is predictive of resolution with nonoperative management, and administration of contrast medium may also decrease the need for surgery in some patients. This approach has been successfully used in children. [51]
Incarcerated hernia
In the absence of signs of strangulation, an attempt should be made to reduce the incarcerated hernia to relieve the associated obstruction. Sedation and placing the patient in a slight Trendelenburg position can be helpful. After reduction, semi-elective repair is typically performed 24-48 hours after reduction to allow the edema to subside. If reduction cannot be obtained or in the setting of strangulation, surgery is required.
Necrotizing enterocolitis
Treatment for early and uncomplicated necrotizing enterocolitis (NEC) is medical with broad-spectrum antibiotics, cessation of enteral feeds, and NG decompression. However, medical treatment may fail to improve the patient’s condition, or severe complications may develop that require surgical consultation. Infants who develop small bowel obstruction from NEC, either acutely from a necrotic portion of intestine or from a stricture that develops after a prior episode of NEC, generally fall into this group that requires surgical intervention.
Meconium ileus
The therapy of choice for uncomplicated meconium ileus is the administration of hyperosmolar contrast enema, which is both diagnostic and therapeutic in the majority of patients. In some cases, N -acetylcysteine can be added to the enema solution or can be administered using an NG tube from above to help loosen the meconium. Surgical intervention is required for complicated cases (volvulus, perforation, necrosis, associated atresia) and those obstructions that are not relieved with enemas.
Surgical Therapy
Intussusception
When reduction of intussusception via air or contrast enemas is unsuccessful, surgery is required. In addition, children with signs of compromised bowel should proceed directly to the operating room. The procedure can be performed safely via laparotomy or via laparoscopy. [52, 53] Surgery consists of reduction of the intussusception, followed by an evaluation of the viability of the bowel, with bowel resection and primary anastomosis as indicated.
Pediatric Small Bowel Obstruction. Necrotic bowel is shown after surgical reduction of an intussusception.
Incarcerated hernia
After reducing the hernia, elective repair is possible 24-48 hours after the edema subsides. For patients whose incarcerated hernias cannot be reduced or for patients with signs of strangulation, immediate surgery is required.
Malrotation of the bowel with midgut volvulus
Rapid diagnosis and surgery for malrotation with midgut volvulus is vital to preserve intestinal viability. [54] Clinical judgment trumps imaging, and there should be no delay in proceeding with emergent exploration to obtain confirmatory imaging when clinical findings suggest midgut volvulus.
Surgery consists of a Ladd procedure, which includes evisceration and inspection of the mesenteric root, derotation of the volvulus, lysis of Ladd bands, opening of the visceral peritoneum that covers the mesentery to maximally widen the mesenteric pedicle, and replacing the small bowel into the right side of the abdomen and the large bowel into the left side. It also typically includes an appendectomy, because the appendix will otherwise be located in an unusual place. The Ladd procedure can also be performed laparoscopically, although this is rarely used in the setting of acute volvulus. [55] 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. When large segments of bowel have questionable viability, temporary abdominal closure with a second look in 24-48 hours is advisable.
Postoperative adhesive small bowel obstruction
Signs of compromised bowel such as fever, tachycardia, and peritonitis mandate surgical exploration, as does failure of nonoperative management to relieve the obstruction. Adhesiolysis is the treatment of choice. In general, only the adhesion causing the obstruction needs to be resolved, as 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. Adhesiolysis can be achieved with laparotomy or laparoscopy. [56] Some patients will require bowel resection because of perforation or necrosis.
Duplication cysts
The treatment for enteric duplications is surgical excision, either via laparotomy or laparoscopy. Duplications of the small intestine often require resection and anastomosis. See the image below.
Pediatric Small Bowel Obstruction. The surgical photograph is that of a 3-year-old male patient with an obstructive, noncommunicating ileal duplication.
Necrotizing enterocolitis
Indications for surgery in necrotizing enterocolitis (NEC) include pneumoperitoneum (the only absolute indication); a fixed, dilated bowel loop; abdominal wall discoloration; and clinical deterioration or lack of improvement with nonoperative management. The presence of portal venous gas suggests advanced disease but does not by itself mandate surgical intervention, unless the child clinically requires it. See the image below.
Pediatric Small Bowel Obstruction. A plain abdominal film of a premature baby girl with necrotizing enterocolitis is shown. Note the air in the biliary tree and the grossly dilated bowel.
Surgical management of NEC that is causing small bowel obstruction consists of laparotomy with resection of any necrosed bowel, followed by primary anastomosis or creation of an ostomy. [32]
Mesocolic hernia
In symptomatic patients with mesocolic or other internal hernias, prompt surgical exploration to reduce the hernia and repair the defect is imperative. These patients often have a delayed diagnosis and present as a surgical emergency with acute bowel obstruction and intestinal ischemia. [35] See the image below.
Pediatric Small Bowel Obstruction. This is a 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.
Jejunoileal atresia and stenosis
Patients with jejunoileal atresia typically undergo surgical resection of the atretic segment, followed by an end-to-end anastomosis. The proximal, dilated bowel may need to be tapered to fit the smaller distal intestine. Surgeons should take care to preserve as much intestinal length as possible to prevent short-bowel syndrome, especially in patients with multiple atresias. Small intestinal atresias have classically been repaired through a transverse supraumbilical incision, although single jejunoileal atresias have also been successfully approached through a smaller periumbilical incision. [57]
Duodenal obstructions
The treatment for duodenal obstructions is a linear or diamond-shaped duodenoduodenostomy. Duodenojejunostomy is another option. A duodenal web, although less common, can be treated with duodenotomy and excision of the web, with or without duodenoplasty. [58]
Surgical management for annular pancreas is similar to that for duodenal atresia, with diamond-shaped duodenoduodenostomy being the preferred approach.
Meconium ileus
Surgical management is necessary for cases of complicated meconium ileus and when enemas are unsuccessful in relieving the obstruction. For uncomplicated cases, enterotomy and irrigation to remove the thickened meconium and meconium pellets may be sufficient. Catheter or tube enterostomy can be considered to allow for postoperative administration of N-acetylcysteine, which can also be provided via nasogastric tube postoperatively.
Complicated cases (volvulus, perforation, necrosis, associated atresia) require not only clearance of the meconium but also care of the associated complication, typically intestinal resection with primary anastomosis or stoma creation. [59]
Meckel diverticulum/band
Surgical resection of the diverticulum and lysis of any associated bands is the proper treatment in symptomatic patients. The minimally invasive approach is reasonable even in small children. [60, 61]
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Pediatric Small Bowel Obstruction. Small bowel obstruction is visible on a plain radiograph caused by intussusception in a 5-month-old patient.
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Pediatric Small Bowel Obstruction. This barium enema study reveals a coil spring appearance caused by the tracking of barium around the lumen of the edematous intestine in intussusception.
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Pediatric Small Bowel Obstruction. This image reveals 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.
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Pediatric Small Bowel Obstruction. This radiograph depicts the double-bubble sign characteristic of duodenal atresia.
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Pediatric Small Bowel Obstruction. An upper gastrointestinal contrast study demonstrates a jejunal atresia with a proximal dilated atretic bowel and lack of passage of contrast material into the distal small bowel.
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Pediatric Small Bowel Obstruction. This is a surgical photograph of the patient in the previous image, depicting the proximal dilated atretic jejunum.
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Pediatric Small Bowel Obstruction. An upper gastrointestinal contrast study shows a malrotation with lack of a normal C-shaped duodenum and the small bowel "hanging" on the right side of the abdomen.
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Pediatric Small Bowel Obstruction. This imaged is a contrast enema study showing an abnormally located cecum in a patient with malrotation.
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Pediatric Small Bowel Obstruction. The surgical photograph shows necrotic bowel in a patient with midgut volvulus.
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Pediatric Small Bowel Obstruction. Necrotic bowel is shown after surgical reduction of an intussusception.
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Pediatric Small Bowel Obstruction. The surgical photograph depicts a transition zone in a patient with small bowel obstruction.
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Pediatric Small Bowel Obstruction. An incarcerated left inguinal hernia is noted.
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Pediatric Small Bowel Obstruction. This photograph reveals a mesocolic hernia.
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Pediatric Small Bowel Obstruction. The surgical image depicts a laparotomy on a 7-month-old girl with ileocolic intussusception.
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Pediatric Small Bowel Obstruction. The surgical image depicts 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.
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Pediatric Small Bowel Obstruction. A barium enema study on a 1-year-old male patient depicts an ileocolic intussusception.
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Pediatric Small Bowel Obstruction. The clinical photograph of a 5-month-old male patient reveals characteristic currant-jelly stools due to intussusception.
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Pediatric Small Bowel Obstruction. The plain abdominal film on a 3-day-old newborn depicts the classic double-bubble sign for duodenal atresia.
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Pediatric Small Bowel Obstruction. This contrast-enhanced upper gastrointestinal film shows a duodenal atresia in a 2-day-old newborn.
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Pediatric Small Bowel Obstruction. The surgical photograph is that of a 3-year-old male patient with an obstructive, noncommunicating ileal duplication.
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Pediatric Small Bowel Obstruction. This plain abdominal film was obtained in a 6-year-old male patient with MRCP (mental retardation and cerebral palsy) and an organo-axial gastric volvulus. Note the grossly dilated and obstructed stomach. A gastrostomy feeding tube can be seen in place. Surgical staples from a previous laparoscopic fundoplication are seen near the diaphragmatic crura.
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Pediatric Small Bowel Obstruction. This is a surgical photograph of an 8-month-old patient with ileocolic intussusception.
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Pediatric Small Bowel Obstruction. The plain abdominal film of a premature baby born at 28 weeks of gestation reveals necrotizing enterocolitis. Note the "railroad sign" (pneumatosis intestinalis) in the hepatic flexure and "soap bubbles" in the descending colon.
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Pediatric Small Bowel Obstruction. This clinical image of a micro-premature baby boy shows discoloration on the right lower quadrant of the abdomen due to intestinal perforation secondary to necrotizing enterocolitis. An umbilical catheter is in place.
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Pediatric Small Bowel Obstruction. A plain abdominal film of a premature baby girl with necrotizing enterocolitis is shown. Note the air in the biliary tree and the grossly dilated bowel.
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Pediatric Small Bowel Obstruction. This is a 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.
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Pediatric Small Bowel Obstruction. This sonogram reveals intussusception in a 9-month-old male patient.
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Pediatric Small Bowel Obstruction. The surgical photograph was obtained in an 8-month-old boy with intussusception. The surgeon's finger is inserted into the intussusceptum, and the intussuscipiens is seen entering the distal bowel. No lead point was identified.
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Pediatric Small Bowel Obstruction. The surgical photograph depicts loops of bowel passing through a mesenteric defect. The bowel segment proximal to the obstruction is dilated, purplish, distended, and hypoperistaltic. The bowel distal to the obstruction is decompressed and normal-looking.
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Pediatric Small Bowel Obstruction. The surgical photograph was obtained in a newborn with a type IIIa jejunal atresia. Note the dilated proximal bowel pouch, the mesenteric V-shaped defect, and the thin, nondilated distal jejunum.
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Pediatric Small Bowel Obstruction. The surgical photograph depicts a Meckel diverticulum.
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Pediatric Small Bowel Obstruction. This surgical photograph was obtained from a newborn with type IIIb (“apple peel” or “Christmas tree”) atresia. Note the shortened distal small bowel coiled around its mesentery.
