462 Congenital Intestinal Obstruction

Abstract

Vomiting, abdominal distension, and failure to pass meconium in the newborn period all suggest the possibility of intestinal obstruction. The cause of the obstruction can be mechanical or functional (> Table 418.1); but regardless of the final diagnosis, prompt assessment is essential in order to avoid treatment delays that can have catastrophic consequences for the infant. The initial management of neonatal bowel obstruction includes resuscitation with intravenous fluids and broad-spectrum antibiotics. Nasogastric suction is important in order to decompress the stomach, which can improve diaphragmatic excursion and ventilation while reducing the risk of pulmonary aspiration. Once resuscitation is underway, a detailed history and physical examination are essential. Based on the differential diagnosis thus generated, targeted imaging studies will usually lead to an accurate diagnosis. Occasionally, a plain radiograph may be the only study necessary prior to operative exploration in a critically ill child. Because of the time-sensitive nature of some causes of bowel obstruction, early consultation with a pediatric surgeon is important. The history should begin with the findings on prenatal ultrasound. The presence of dilated echogenic loops of bowel is suggestive of fetal intestinal obstruction. Polyhydramnios also occurs in bowel obstruction, especially in more proximal obstructions, like esophageal, duodenal, and jejunoileal atresia. Meconium peritonitis, diagnosed when intraperitoneal calcifications are identified on fetal ultrasound, indicates prenatal intestinal perforation and can be seen in association with intestinal atresias, volvulus, and meconium ileus. Nonintestinal anomalies seen on prenatal ultrasound are also important as they may direct the physician toward specific syndromes or associations. A maternal history, including a history of diabetes or drug use, is helpful, as is a thorough family history for cystic fibrosis, Hirschsprung’s disease, and any intestinal anomalies. The presence of prematurity is important as these infants often have delayed passage of meconium. Other