Intestinal diseases

Abstract

23.1 Accounts for 9 to 10 % of neonatal intestinal obstructions.The most common reason for meconium ileus is cystic fibrosis. Antenatal diagnosis is feasible.Diagnosis consists on abdominal plain X-rays demonstrating a soap bubble appearance, calcification and fluid levels in cases of perforation (rare). Retrograde hyper osmolar water-soluble enema is both diagnostic and therapeutic (80 % of cases). Operation is indicated if enemas fail to relieve obstruction. It consists on complete evacuation of meconium and unfrequently the need of segmental resection and ileostomy. Outcome depends on the severity of obstruction, the presence of perforation, birth weight, and the severity of initial disease if cystic fibrosis. 23.2 It is a therapeutic emergency affecting predominantly premature infants. Onset occurs during the first or second weeks of life after beginning oral feeding in low birth weight newborns (< 1500g). Outset is sudden and deterioration may be rapid. Diagnosis: clinical signs of intestinal obstruction then signs of peritonitis with severe shock and sepsis; abdominal X-rays (intestinal obstruction with pneumatosis) and ultra-sonography are helpful. Aggressive medical treatment must be started promptly: nasogastric tube, total parenteral nutrition, broad spectrum antibiotics. Surgery is indicated in cases of clinical deterioration and perforation. Operative goal is to perform the simplest and most effective procedure to save the child's life with the minimum of resection of non viable bowel. Overall survival rate is 70-80 %. 23.3 It is a remnant of the omphalo-mesenteric duct. It occurs in about 2 % of the population. The most common presentation is gastro intestinal bleeding due to ectopic gastric tissue (40%). It can be revealed by abdominal pain (diverticulitis), intussusception or chronic anaemia. Diagnostic procedures include essentially ultrasonograpy and technetium 99m-radioisotope scanning. Operative treatment consists of complete resection which can be performed either by laparoscopy or small transverse laparotomy through Mc Burney's point. Post operative morbidity is low. 23.4 It is the most common cause of intestinal obstruction in the first 2 years of life. It is an acute life threatening condition in which one segment of the intestine enfolds into an adjacent distal segment. In most cases it involves enfolding of the terminal ileum into the colon. It can lead to ischemia and bowel necrosis if non treated. Intermittent paroxysmal crampy abdominal pain is typical. Diagnosis is done by ultrasonography (target in transverse and pseudo kidney in longitudinal section). Reduction by retrograde enema (air or contrast) is the first therapeutic step. It is successful in 70 % of cases. In the other cases (failure of the enema reduction or too late diagnosis) surgery is needed. Recurrence rate is up to 15 %. Prognosis is good if the diagnosis is precocious. 23.5 It is a common cause of emergency abdominal surgery in children. Variability in clinical finding often lead to mis diagnosis. Interpretation of signs requires a large clinical experience. The younger the child, more difficult the diagnosis is. Repeated clinical examination is crucial to determine the evolution of signs. Blood tests and ultrasonography (CT scan if fatty) can add to the diagnosis but the clinical status remains the most important key. Treatment is surgical either by laparoscopy or open surgery (mac Burney point). Antibiotic therapy is included as part of the treatment in case of perforation or special situations. The mortality rate is low in paediatric centers but morbidity rate continues to be high: residual abscess, late post operative occlusion by adherence and sterility due to tube dysfunction in girls. © 2009 Springer-Verlag.