Congenital intestinal obstruction

Congenital intestinal obstruction is a condition in which the passage of intestinal matter through the digestive tract is disrupted.

The article describes in detail the causes and mechanisms of development, clinical picture and diagnostic methods, surgical treatment and prognosis of intestinal obstruction in newborn children.

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Epidemiology

The incidence of various forms of intestinal obstruction is 1 in 2,000–20,000 newborns.

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Causes congenital intestinal obstruction

The causes of congenital intestinal obstruction are a whole group of diseases and malformations of the abdominal organs:

• intestinal atresia or stenosis,
• compression of the intestinal tube (annular pancreas, enterocystoma),
• malformations of the intestinal wall (Hirschsprung's disease),
• cystic fibrosis,
• violation of rotation and fixation of the mesentery (Ledd's syndrome, volvulus of the midgut).

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Pathogenesis

Most intestinal tube defects occur in the early stages of intrauterine development (4-10 weeks) and are associated with impaired formation of the intestinal wall, intestinal lumen, intestinal growth and rotation. From the 18th to 20th week of intrauterine development, the fetus begins to make swallowing movements, and the swallowed amniotic fluid accumulates above the obstruction, causing intestinal expansion. Developmental abnormalities of the posterior pancreas in the 5th to 7th week of intrauterine development can cause complete obstruction of the duodenum. Genetically determined cystic fibrosis of the pancreas in cystic fibrosis leads to the formation of dense and thick meconium - the cause of obstruction of the ileum at the level of the terminal section. The genesis of Hirschsprung's disease is based on a delay in the migration of ganglion cells from the neural crests to the intestinal mucosa, resulting in an aperistaltic zone through which the movement of intestinal contents becomes impossible. When the intestine twists, the blood supply to the intestinal wall is disrupted, which can lead to necrosis and perforation of the intestine.

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Symptoms congenital intestinal obstruction

After the birth of a child, the timing of the appearance of clinical signs and their severity depend not so much on the type of defect as on the level of obstruction. Congenital intestinal obstruction should be assumed if more than 20 ml of contents are obtained during aspiration from the child's stomach immediately after birth. There are two main characteristic symptoms: vomiting with pathological impurities (bile, blood, intestinal contents) and the absence of stool for more than 24 hours after birth. The more distal the level of obstruction, the later the clinical symptoms appear and the more pronounced the abdominal distension in the child. Strangulation (intestinal volvulus) causes pain syndrome, which is characterized by bouts of anxiety and crying.

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Forms

There is high and low intestinal obstruction, the division level is the duodenum.

In 40-62% of cases, duodenal obstruction is characterized by chromosomal diseases and combined developmental anomalies:

• heart defects,
• defects of the hepatobiliary system,
• Down syndrome,
• Fanconi anemia

In 50% of children with small intestinal atresia, intrauterine intestinal volvulus is detected, combined anomalies occur in 38-55% of cases, chromosomal aberrations are rare.

Congenital colonic obstruction is often combined with congenital heart defects (20-24%), musculoskeletal system (20%) and genitourinary system (20%); chromosomal diseases are rare.

With meconium ileus, respiratory problems may appear immediately after birth, or lung damage may occur later (mixed form of cystic fibrosis).

In Hirschsprung's disease, a combination with defects of the central nervous system, musculoskeletal system and genetic syndromes is possible.

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Complications and consequences

Complications of the early postoperative period:

• sepsis,
• PON,
• intestinal bleeding,
• intestinal obstruction,
• peritonitis.

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Diagnostics congenital intestinal obstruction

Radiographs of the abdominal organs (plain and with contrast agent) can detect fluid levels in low obstruction, the "double bubble" symptom in duodenal obstruction, calcifications in meconium ileus or antenatal intestinal perforation. The diagnosis of Hirschsprung's disease is confirmed by intestinal biopsy and irrigography.

Prenatal diagnosis

Congenital intestinal obstruction can be suspected starting from the 16th-18th week of intrauterine development, by the expansion of the intestinal or stomach area of the fetus. The average time for diagnosing small intestinal obstruction is 24-30 weeks, the accuracy is 57-89%. Polyhydramnios appears early and occurs in 85-95% of cases, its occurrence is associated with a violation of the mechanisms of utilization of amniotic fluid in the fetus. Congenital intestinal obstruction of the colon is not diagnosed in most cases, since the fluid is absorbed by the intestinal mucosa, as a result of which the intestine does not expand. An important criterion is the absence of haustra and an increase in the size of the abdomen.

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Treatment congenital intestinal obstruction

Detection of signs of intestinal obstruction requires urgent transfer of the child to a surgical hospital. In the maternity hospital, a nasogastric tube is inserted to decompress the stomach and constant evacuation of gastric contents is established. Significant fluid losses with vomiting and into the "third space", often accompanying intestinal obstruction, quickly lead to severe dehydration, up to hypovolemic shock. This is why infusion therapy should be started in the maternity hospital by catheterizing the peripheral vein.

The duration of preoperative preparation depends on the type and level of congenital intestinal obstruction.

Preoperative preparation

If a child is suspected of having a volvulus, the operation is performed urgently. In this case, preoperative preparation is limited to 0.5-1 hour, infusion therapy is performed at 10-15 ml/(kgxh) and acid-base balance is corrected, hemostatic drugs are prescribed, pain relief [trimeperidine at a dose of 0.5 mg/kg], and, if necessary, artificial ventilation is administered. Diagnostic measures include determining:

• blood groups and Rh factor,
• KOS,
• hemoglobin level,
• hematocrit,
• blood clotting time.

All children with intestinal obstruction undergo central venous catheterization, as long-term infusion therapy is expected in the postoperative period.

In case of low congenital intestinal obstruction, the operation is not so urgent. Preoperative preparation can take 6-24 hours, which allows for additional examination of the child to identify developmental anomalies of other organs and achieve more complete correction of existing water-electrolyte metabolism disorders. Constant drainage of the stomach and strict accounting of the amount of discharge are carried out. Infusion therapy is prescribed, antibiotics and hemostatic drugs are administered.

In case of high congenital intestinal obstruction, the operation can be postponed for 1-4 days, a full examination of the child and treatment of all identified disorders of vital organs and water-electrolyte status are carried out. During preoperative preparation, constant drainage of the stomach is carried out, feeding is excluded. Infusion therapy is prescribed 70-90 ml/kg per day, after 12-24 hours from birth, parenteral nutrition drugs can be added. Correction of electrolyte disorders and hyperbilirubinemia is carried out, antibacterial and hemostatic therapy is prescribed.

Surgical treatment of congenital intestinal obstruction

The goal of the operation is to restore the patency of the intestinal tube, thereby ensuring the possibility of feeding the child. The scope of the operation depends on the cause of the intestinal obstruction:

• intestinal stoma placement,
• resection of a section of the intestine with the creation of an anastomosis or stoma,
• T-shaped anastomosis,
• straightening out the twist,
• bypass anastomosis,
• opening of the intestinal lumen and evacuation of the meconium plug. Intensive care in the postoperative period.

In minimally invasive interventions in full-term infants without concomitant diseases, extubation can be performed immediately after surgery. In most children with intestinal obstruction, prolonged mechanical ventilation is indicated for 1-5 days after surgery. During this time, pain relief is provided by intravenous infusion of opioid analgesics [fentanyl at a dose of 3-7 mcg / (kg x h), trimeperidine at a dose of 0.1-0. mg / (kg x h)] in combination with metamizole sodium at a dose of 10 mg / kg or paracetamol at a dose of 10 mg / kg. If an epidural catheter is installed, it is possible to use continuous infusion of local anesthetics into the epidural space.

Antibacterial therapy necessarily includes drugs with activity against anaerobic bacteria. At the same time, it is necessary to monitor the microecological status, carried out at least twice a week. When peristalsis appears, oral decontamination of the intestine is performed.

12-24 hours after surgery, drugs that stimulate intestinal peristalsis are prescribed: neostigmine methylsulfate at a dose of 0.02 mg/kg

All children after surgery for congenital intestinal obstruction are shown early (12-24 hours after surgery) parenteral nutrition.

Full enteral feeding will be possible only after 7-20 days, and in some cases the need for parenteral nutrition will persist for many months (short bowel syndrome). Enteral feeding becomes possible when passage through the gastrointestinal tract occurs. After surgery for duodenal obstruction, feeding is carried out with thick mixtures (Frisovom, Nutrilon antireflux, Enfamil AR), which promote rapid restoration of motility of the stomach and duodenum.

In case of large intestinal resections or high intestinal stomas (short bowel syndrome), feeding is carried out with elemental mixtures (Progestimil, Alfare, Nutrilon Pepti MCT, Humana LP+MCT) in combination with enzyme preparations (pancreatin).

If after the operation all sections of the intestine are preserved (colostomy, resection of a small section of the intestine), breastfeeding can be started immediately.

In all cases, biological preparations (lactobacilli acidophilus, bifidobacteria bifidum, premadophilus) are prescribed.

Forecast

The survival rate after surgery is 42-95%. Some children need repeated surgical treatment (stage 2). If all sections of the gastrointestinal tract are preserved after surgery for congenital intestinal obstruction, the prognosis is favorable. The problems that arise are associated with nutritional disorders (malnutrition, allergy) and dysbacteriosis. With significant intestinal resections, a "short bowel" syndrome is formed, which causes significant problems associated with nutrition and severe malnutrition. Multiple long-term hospitalizations are required for parenteral nutrition, and sometimes repeated surgeries. With cystic fibrosis, the prognosis is unfavorable.

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