Intestinal obstruction in infants: signs, treatment

Intestinal obstruction in newborns is an acute surgical pathology, which, when untimely, has many complications. There are different types of this disease, but their symptoms are similar, which allows us to suspect the problem in advance even at the primary stage. Therefore, parents should know about the symptoms and manifestations of pathology in order to seek help in time.

[1], [2], [3], [4],

Epidemiology

Statistics of the spread suggests that intestinal obstruction is a common disease - about 10% in the structure of acute diseases of the abdominal cavity is precisely this pathology. In 0.1 - 1.6% complicates the course of the postoperative period in patients with children who underwent abdominal surgery in the neonatal period. The pathology is more common in boys. The mortality rate in this pathology varies from 5 to 30% and strongly depends on the gestation and age of the newborn. If there is acute intestinal obstruction in the early postoperative period reaches 16.2 - 60.3%, and depends on timely diagnosis, the timing of surgical treatment.

[5], [6], [7], [8], [9], [10], [11]

Causes of the intestinal obstruction in newborns

Intestinal obstruction is a syndrome that complicates the course of many diseases and conditions. Pathophysiological link is a violation of the movement of the chyme along the digestive canal, which in turn completely or partially disrupts the motor function of the intestine. The reasons for this can be very many, but it is the disruption of normal bowel function and is one of the most important factors.

To understand all the causes of the development of obstruction, you need to know some types of this pathology. There are strangulation, obturational, spastic and paralytic obstruction. Accordingly, and share different reasons.

Obturation obstruction occurs as a result of coprostasis or intestinal tumors, which is much less common in newborns. The cause of coprostasis is Hirschsprung's congenital disease, stenosis of the large intestine, which are accompanied by intestinal atony. This makes it difficult to reduce and intestinal motility from the very birth of the baby. This leads to the fact that these children suffer from constipation, and from the stool coprolits are formed (small feces). Such coprolits can completely enclose the lumen of the intestinal tube and cause intestinal obstruction.

Strangulation intestinal obstruction develops against the background of Meckel's diverticulum, internal hernias, especially clinically significant hernias of the diaphragm. Such pathologies often lead to increased motor activity of the intestine, and especially in newborns a very mobile mesentery of the intestine. This easily leads to constriction of the intestinal wall and there is some way external strangulation.

The most common causes of intestinal obstruction in newborns are diseases of other organs. They underlie the so-called paralytic obstruction. The reasons for it may be the following:

• medicines, especially narcotic drugs, that affect the muscular wall of the intestine;
• infection of the abdominal cavity weakens not only the motor skills, but also other functions of the intestine;
• Mesenteric ischemia on the background of congenital abnormalities of the vessels of the descending aorta or mesenteric arteries;
• complications of abdominal operations;
• diseases of the kidneys and organs of the chest cavity;
• metabolic disorders (hypokalemia);
• necrotizing enterocolitis in newborns;

Often such obstruction arises against the background of birth trauma, functional immaturity of the digestive tract, pneumonia, sepsis, with peritonitis. These pathologies cause the reaction of internal organs in the form of centralization of blood circulation, which causes ischemia of the intestinal wall. Also violated against the background of intoxication of the peristalsis, especially in newborns against the background of the immaturity of the mechanisms of coordination of this function. This leads to intestinal paresis and development of obstruction in the future.

Separately isolated intussusception, because with this version of obstruction there are elements of obturation and strangulation. Invagination is a special type of acquired obstruction in young children, the essence of which is that the proximal segment of the intestine wedges into the distal segment. In the future, blood supply to the intestine is impaired, which leads to its necrosis.

The cause of intussusception may be lymphadenopathy as a result of bacterial or parasitic disease. The mechanism of invagination in infants is explained by the discoordination of peristalsis, which is caused by the uneven development of the longitudinal and circular musculature of the intestine.

There are thin-intestinal intussusception, ileocecal appearance (90%), very rarely thick-colonic (1-3%) intussusception. In the area where the intussusception has come, a tumor-like formation is formed, which consists of three layers of the intestinal wall: the external, into which the invaginate is inserted, the middle and the inner. Between the walls of the invaginate, the mesentery of the intestine becomes entrapped. It is from the degree of pinching that the clinical course of the disease depends - with slight infringement, the symptoms of the obturation process predominate, the disease proceeds easily, the bowel necrosis does not occur. In cases of severe infringement, signs of strangulation intestinal obstruction predominate, bloody feces and necrosis of the invaginate quickly appear. Ileocecal intussusception proceeds more easily than thin-intestinal tract. After the phase of venous congestion, as a rule, swelling rapidly increases, stagnant bleeding occurs, a bloody effusion appears in the abdominal cavity. In connection with the progressive violation of the blood supply, necrosis of the invaginate occurs.

[12], [13], [14], [15], [16]

Risk factors

Given all the causes of obstruction, it is possible to identify the risk factors for this pathology:

• low birth weight and immaturity of the intestine due to this;
• birth trauma;
• abnormalities of intestinal development;
• severe infectious diseases of the intestine and other organs, sepsis.

[17], [18], [19], [20]

Pathogenesis

The pathogenesis of changes in obstruction does not depend on its type, but depends on the local stoppage of food movement through the intestine. This causes further changes that underlie the development of symptoms.

In the area of the pathological source in the intestine, the integrity and permeability of the blood vessels and the peritoneum, which ensure ultrafiltration of plasma and tissue fluid, is impaired. This leads to the fact that out of the vascular bed and the peritoneum the plasma proteins containing inactive components of the blood coagulation system emerge into the abdominal cavity. These substances, upon contact with the damaged peritoneum and tissues of the abdominal organs, are activated, a cascade coagulation reaction occurs, which results in the deposition of fibrin on the surface of the abdominal organs. This is facilitated by tissue coagulation factors contained in the cells of the tissues of the abdominal cavity organs and the peritoneal mesothelium. Fibrin, which fell on the surface of the abdominal organs, has adhesive properties and fixes adjacent organs. This leads to the fact that in the place where the food has stopped, there is even more gluing of the layers of the intestine, as well as mesentery. This completely disrupts the movement of chyme and is the main mechanism of the pathogenesis of intestinal obstruction in the newborn.

[21], [22]

Symptoms of the intestinal obstruction in newborns

Symptoms of intestinal obstruction in newborns do not depend on the species, since the pathogenetic features of the pathology pathway do not have any special differences. The stages of the development of disturbances in intestinal obstruction go in sequence from circulatory disturbances of a certain area of the intestine to its necrosis. Given that the newborn wall of the intestine is very thin, then the period of development of symptoms decreases. When there is necrosis of the intestine, the whole process ends with peritonitis.

The first signs of acute intestinal obstruction start suddenly and are characterized by a large polymorphism of clinical manifestations. The process quickly leads to severe intoxication, a change in homeostasis, causes various complications of the pathological process and worsens the patient's condition.

The classic clinical picture of intestinal obstruction in a newborn is characterized by a sudden onset against a background of complete health. Gradually, there is pain in the intestine, which is characterized by bouts of anxiety in newborns with the gradual addition of toxicosis.

Vomiting is one of the mandatory symptoms of this disease in newborns. With high intestinal obstruction, vomiting appears on the first day of life after birth. Depending on the level of damage, the nature of vomiting can vary.

So, in conditions of complete obstruction, vomitic masses will have the appearance of curdled milk without bile impurities. If the process is localized a little lower at the level of the distal parts of the small intestine, then vomiting will be digested milk.

The nature of the feces of the newborn also varies. With high obstruction, almost normal meconium will depart, in number and color normal. If the process of obstruction is slightly lower, then the meconium is not painted practical. There may also be bloody discharge from the rectum or blood veins in the feces of the child.

The general condition of the newborn from the onset of the disease is satisfactory, but quickly

Progression of exsicosis and hypotrophy on the background of repeated vomiting and diarrhea. Appears dry skin, eyesighting, fontanelle, a decrease in tissue turgor. Later, bloating of epigastrium is noted, which decreases after vomiting.

The clinical picture of paralytic obstruction of the intestine is characterized by a sharp swelling of the abdomen, intoxication phenomena, stool and gas retention. Since the paralytic focus is wider than with other types of obstruction, the swelling of the baby's tummy is strongly pronounced. This can disrupt the process of breathing, which in turn is a prerequisite for the development of hypoxia and hypostatic pneumonia.

Body temperature does not increase often, the effects of intoxication are often accompanied by dehydration and electrolyte disturbances.

Congenital obstruction of the intestine in the newborn has the same manifestations, but they appear immediately after the birth of the child. Vomiting, violation of meconium withdrawal, bloating - all these symptoms begin to manifest themselves within a few hours after birth.

Partial obstruction of the intestine in a newborn is characterized by disorders in which the intestinal cavity is only half closed. Therefore, the symptoms develop less acute and need to be carefully differentiated with functional disorders in newborns.

[23], [24]

Complications and consequences

Consequences and complications of intestinal obstruction can be very serious. Given the necrosis of the gut in the absence of timely treatment, then one of the most frequent consequences is peritonitis. More remote consequences can develop if surgical treatment has been performed. In this case, dense spikes are often formed, which can lead to repeated obstructions later on. Persistent functional disorders of the intestines in children in the future - this is one of the frequent consequences of the transferred intestinal obstruction. In the presence of newborns with obstruction of other concomitant pathologies, the risk of mortality increases, including lethal complications.

[25], [26], [27], [28], [29], [30]

Diagnostics of the intestinal obstruction in newborns

Diagnosis of intestinal obstruction in newborns must necessarily be based on a thorough examination of the baby. After all, vomiting and stool disorders are nonspecific symptoms that are peculiar not only to intestinal obstruction.

It is necessary to examine the abdomen of a newborn child with suspicion of any pathology of the intestine.

When intussusception against the background of intestinal manifestations, there are other local symptoms. Palpable tumor-like formation of the testate consistency, which when pressed can change its position. With paralytic obstruction, the abdomen looks sharply blown, with palpation soft. During percussion, high tympanitis is detected, auscultatory - peristaltic noises are not listened. The normal motor process is broken, so no noise is detected.

Analyzes that are necessary for the diagnosis of obstruction are not specific, therefore at the initial stages are limited only to general analyzes.

Instrumental diagnosis is the main and priority method for confirming the diagnosis of obstruction. X-ray examination allows you to determine the level of obstruction and degree, because above the level of obstruction accumulate gases and food, and below there are no signs of normal motor skills. X-ray examination helps verify the changes characteristic of high intestinal obstruction: a marked accumulation of air in the upper intestine and the determination of the level of fluid under these gases. The loops of the intestine are arranged in such a way that they form "arcades," which look like garlands filled with half-air, and half-liquid. The normal intestine has a clear distribution and location of the loops.

[31], [32],

Differential diagnosis

Differential diagnosis should be carried out with congenital abnormalities of the intestine, atresia of the esophagus, pyloric stenosis. All these pathologies are symptomatically very similar, but with a thorough examination you can determine the diagnosis.

Treatment of the intestinal obstruction in newborns

If the intestinal obstruction is suspected, the treatment of the child in the hospital is compulsory. Therefore, when there is a recurring vomiting, a disturbance of the stool, it is necessary to hospitalize the newborn if he was at home before. If a newborn immediately after birth starts similar problems, then it is necessary to consult a surgeon.

During the first 1,5-2 hours after hospitalization of the child in the hospital, complex conservative therapy is performed. Such treatment has a differential diagnostic significance and can be preoperative preparation in nature.

Therapy is aimed at preventing complications associated with pain shock, correction of homeostasis and at the same time is an attempt to eliminate intestinal obstruction by non-operative methods.

1. Measures to combat abdominal pain include: neuroleptanalgesia (droperidol, fentanyl), paranephric neocaine blockade and spasmolytics (baralgin, spasmoverin, salvafon, no-spa). In children, the use of certain drugs can be limited in the period of newborns, so treatment is conducted with the obligatory consultation of a pediatric anesthesiologist. Anesthesia is carried out after the diagnosis is established.
2. Elimination of hypovolemia with correction of electrolyte, carbohydrate and protein metabolism is achieved by the introduction of saline blood substitutes, 5-10% glucose solution, gelatin, albumin and blood plasma. All calculations are carried out taking into account the needs of the newborn baby's body in the liquid, and in addition take into account also the requirements for nutrients.
3. Correction of hemodynamic parameters, microcirculation and detoxification therapy is performed with the help of intravenous infusion of rheopolyglucin, reoglumane or neo-heme.
4. Decompressions of the gastrointestinal tract are carried out using a nasogastric tube. A child with a confirmed diagnosis of intestinal obstruction should be switched to full parenteral nutrition. It is forbidden to feed a child and all substances are calculated by body weight. At the time of the treatment, enteral food is banned completely, from the moment of recovery, breastfeeding is gradually introduced.
5. In the treatment of paralytic obstruction, treatment of the underlying disease, which caused the paresis, is necessary. In addition, drug stimulation of the peristalsis of the intestine with proserin, infusion solutions is carried out.

When there is obstruction, then necessarily in this area of the intestine there is a gradual necrosis with absorption of the products of decay and intoxication. This is always a prerequisite for the reproduction of bacteria, therefore, regardless of the method of treatment, if intestinal obstruction is used antibacterial therapy. Only spastic and paralytic obstruction is treated conservatively for several hours. All other types of obstruction should be treated promptly without delay. In this case, an initial antibiotic, infusion therapy is performed for two to three hours, which is preoperative preparation.

1. Sulbactomax is an antibiotic of a combined composition that consists of cephalosporin 3 generation ceftriaxone and sulbactam. Such a composition leads to the fact that the antibiotic becomes more resistant and is not destroyed by bacteria. This remedy is used for treatment in combination with other drugs. Method of application intravenous for more rapid action. The dosage of the drug is 100 milligrams per kilogram of body weight. Side effects are in the form of allergic reactions, renal dysfunction, effects on the liver.
2. Kanamycin is an antibiotic from the macrolide group, which is used for neonates in intestinal obstruction therapy as preoperative preparation, and in the postoperative period to prevent complications. Dosage preparation - 15 milligrams per kilogram of body weight per day for the first three days, then the dose can be reduced to 10 milligrams. The route of administration, intravenous or intramuscular, is divided into 2 divided doses. Side effects can be in the form of irreversible hearing impairment, as well as toxic effects on the kidneys.

When the child's condition is stabilized, mandatory surgical intervention is performed. Surgical treatment of obstruction of the intestine is mandatory for obturational and strangulation type. Since these species have a mechanical barrier, it will not be possible to restore the normal function of the intestine only with medicinal agents.

After a short preoperative preparation of the child, anesthesia is performed. In a newborn in such cases, general anesthesia is used.

The main task of surgical intervention is the elimination of obstruction, the restoration of normal bowel function, the elimination of bowel necrosis and the sanation of the abdominal cavity.

The technique of surgical intervention is as follows. The incision is made along the midline of the abdomen, along the balls, with simultaneous stopping of bleeding. After the incision, the peritoneums pass to the revision of the cavity and the determination of the site of obstruction. As a rule, the hearth is immediately visible from the altered color of the intestine. The affected intestine is inspected for the entire length and still receding several dozen centimeters from this center. If the perforation has not yet come, the gut may not suffer much, in that case simply remove the obstruction. It can be a curvature of the intestine, obturation with calculous stones. If there is necrosis of the gut area, then necessarily carry out a resection of this site. The vital activity of such an affected area of the intestine can be determined from the color, the reaction to irritation. After resection, the sections of the healthy intestine are stitched. After this, sanation of the abdominal cavity is carried out with solutions of antiseptics, and if there was necrosis of the intestine, drainages are put.

The early postoperative period is conducted with drug support by antibiotics, infusion solutions.

Invagination is a special type of obstruction and its treatment is slightly different. If the intussusception was diagnosed during the first 24 days after the onset, then conservative treatment is possible. For this purpose, insufflation of air through the rectum under pressure is used. Such a flow of air allows the invaginate to be spread without surgery.

Alternative methods for treating intestinal obstruction are not used in newborns.

Prevention

Prevention of obstruction consists in monitoring the risk group for the development of this pathology, as well as in the careful care of premature babies not only by staff, but also by parents. After all, parents first can notice any changes and symptoms in the child.

[33], [34], [35], [36], [37], [38], [39]

Forecast

Prognosis for survival is favorable in more than 80% of cases provided timely diagnosis without complications.

Intestinal obstruction in newborns is a pathology of disruption of the movement of food through the intestines, which is associated with a real obstruction, externally or internally located. Symptoms, as a rule, occur acute immediately after the first lesions of the intestine. Therefore, it is important that parents know the main manifestations of pathology and, in case of danger, they turn in time for help.

[40], [41], [42], [43],