Clinical Presentation and Management of Neonatal Intestinal Obstruction

Introduction 

Intestinal obstruction is a common surgical emergency in the neonates and occurs in approximately 1  in  2,000  live  births.1 Common aetiologies are intestinal atresia, meconium ileus, Hirschsprung disease and malrotation of gut with or without volvulus.^1,2

The diagnosis is suspected based on polyhydramnios in utero, bilious vomiting, failure to pass meconium in the first day of life, and abdominal distension.^1,2 An accurate history and physical examination corroborated by simple radiological studies usually leads the physician to correct diagnosis. Usually, a plain abdominal radiograph is all that is necessary to make a diagnosis, since gas pattern is distinctive and often will give a clue to the site of obstruction. Early diagnosis and treatment leads to better outcome. ailure to recognize neonatal bowel obstruction can result in aspiration of vomit, sepsis, midgut infarction or enterocolitis.³

With early intervention, morbidity and mortality of cases of intestinal obstruction is low. The outcome in part is dependent upon congenital comorbidities and delays in the diagnosis and management.⁴

This study was done to analyze the etiology, clinical presentation and outcome of neonatal intestinal obstruction at our institute.

Materials and Methods     

This prospective study was conducted over a period of 3 years from February 2016 to January 2019. 60 cases presented with neonatal intestinal obstruction were included in the study.

Neonates of Multiple anomalies, Necrotising enterocolitis, anorectal malformation and esophageal atresia were excluded from the study.

All neonates were admitted and their dehydration and electrolytes imbalance were corrected by administration of intravenous fluids and nasogastric tube aspiration. Vitamin K and prophylactic broad spectrum antibiotics were started

Plain x-ray abdomen was done in all cases in our study. Ultrasound scan was done in all cases to rule out renal and other anomalies. Contrast radiography performed in selected cases.

All cases underwent their respective operations depending upon the diagnoses. Cases of Duodenal atresia were treated with Kimura’s duodenoduodenostomy. Cases of Jejunal , ileal atresia, Meckel’s diverticulum were treated by resection and followed by anastomosis. Meconium ileus was treated with enterotomy, Hirshprung Disease (HD) were managed with initial colostomy; Malrotations were managed by Ladd procedure.

Results

Out of 60 cases 28 neonates had bowel atresia (Figure 1), 3 had meconium ileus(Figure 2), 9 had malrotation (Figure 3), 15 had HD(Figure 4) and 5 had Meckel’s diverticulum (Figure 5). There were 43 males and 17 females (M: F- 2.5:1). 

Among males, 18 had intestinal atresia, 2 had meconium ileus, 7 had malrotation, 9 had HD, 5 had malrotation, and 2 had Meckel’s diverticulum. Age of presentation varied from 1 day to 24 days. Median weight for patients with intestinal atresia and meconium ileus were 2 Kg (1.3-3 kg), Median weight was 2.5 kg for malrotation and Meckel’s diverticulum and for HD it was 2.5 kg (1.6-2.9 kg).

Intestinal atresia cases comprised of 5 cases (17.8%) of duodenal atresia (Figure 1), 9 (32.1%) cases of jejunal atresia, 14 (50%) patients of ileal atresia. Type I was the most common type of duodenal atresia. In contrast, type III was the most common type in patients with jejunal, ileal atresia. Out of five cases of duodenal atresia, 5 (100%) patients had type I atresia. Out of 14 cases of ileal atresia, 3 (21.4%) had type I, 9 (64.3%) had type III, and 2 (14%) had type IV atresia. Out of 9 cases of jejunal atresia, 7 (77.8%) had type III and 2 (22.2%) had type IV atresia.

Babies with atresia and meconium ileus presented earlier compared to those with HD and other causes of obstruction presented late (Table 1). Median age of presentation for intestinal atresia, malrotation and HD was 2 days, 10 days and 18 days respectively. Median age of presentation for Meckel’s diverticulum was 16 days. Most atresia patients 25 (89.3%) were premature as compared to only four premature patients in other group 31 (12.9%). 

Bilious vomiting, abdominal distention and failure to pass meconium or stool were the most prominent features of presentation in most cases (Table 2).

Septicaemia (53.3%) was most common complication followed by wound infection (16.6%), pneumonitis (8.3%) and anastomotic leak (5%) (Table3). 1 case of jejunal atresia and 2 cases of ileal atresia were reexplored due to anastomotic leak. 12 (20%) cases had mortality due to septicaemia and prematurity (Table 4).

Discussion        

There were 60 cases of neonatal intestinal obstruction over a period of 3 years, it was most common in males 43 than females 17 (M: F- 2.5:1). The male preponderance in this study similar with reports from other centres.^4,5,6

In our study, atresia was the most common cause for neonatal intestinal obstruction. This finding was similar to other studies conducted in India where intestinal atresia was the most common cause of neonatal intestinal obstruction followed by Hirschsprung disease (7, 8). Presentation of atresia is usually early. Early onset of symptoms and rapid deterioration of patient’s condition are commonly noted in intestinal atresia and meconium ileus was the probable cause of early presentation. Gestational age and birth weight which are also an important determinant in neonatal surgical outcome, were also comparable to that in other studies.^4,7,9

Among other causes, malrotation  was one of the important (15%) cause of neonatal intestinal obstruction. It was caused by a failure of normal bowel rotation. Incidence in our study was higher than its results of similar study from Bangladesh.¹⁰

According to literatures, neonates who do not pass meconium for more than 48 hours after birth are at moderate risk for having Hirschsprung’s disease (approximately 5–20 percent) and should be evaluated.¹¹ The diagnosis of Hirschsprung’s disease is being increasingly made in the neonatal period in the developed countries, while the the reverse situation is still prevalent in developing countries.^12,13

In our study, 29 (48.4%) neonates were preterm (less than 37 completed weeks) and 31 (51.7%) were full term. Gestational age was variable between 31 and 40 weeks. State of maturity was an important determinants in neonatal surgical outcome.^4,6,9

The mortality associated with neonatal intestinal obstruction ranged between 21 and 45%.^4,5,6 in developing countries, unlike Europe where it was less than 15% .14  Some of its factors attributing to the high mortality in developing countries included prematurity, late presentation, associated severe congenital anomalies and complications of surgery as well as lack of neonatal intensive care facilities.^4,5,6

In most developed countries, early diagnosis including prenatal diagnosis and planned delivery in a fully equipped pediatric surgical centre, has greatly improved the survival in neonates.⁹

Conclusion

Intestinal atresia was the most common cause of neonatal intestinal obstruction in our study and septicaemia was most common cause of morbidity and mortality. Early diagnosis including prenatal diagnosis and planned delivery in a fully equipped pediatric surgical centre is recommended for better outcome.