Congenital intestinal obstruction

Congenital intestinal obstruction is a condition in which the passage of intestinal masses through the digestive tract is disturbed.

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

[1], [2], [3], [4], [5],

Epidemiology

Frequency of occurrence of different forms of intestinal obstruction 1 per 2 000 - 20 000 newborns.

[6], [7], [8]

Causes of the congenital intestinal obstruction

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

• atresia or stenosis of the intestine,
• compression of the intestinal tube (annular pancreas, enterokristoma),
• malformations of the intestinal wall (Hirschsprung's disease),
• cystic fibrosis,
• violation of rotation and fixation of the mesentery (Ledd's syndrome, mid-gut fluke).

[9], [10], [11], [12], [13], [14], [15]

Pathogenesis

Most of the defects of the intestinal tube occur in the early stages of intrauterine development (4-10th week) and are associated with impaired intestinal wall formation, intestinal lumen, intestinal growth and its rotation. From the 18-20th week of intrauterine development, the fetus has swallowing movements, and swallowed amniotic fluid accumulates above the site of obstruction, causing the expansion of the intestine. Anomalies in the development of the posterior pancreas at the 5th-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 ileal gut obturation at the terminal department level. The basis of the genesis of Hirschsprung disease is the delay in the migration of neural ganglion cells from neural combs into the intestinal mucosa, resulting in an aperistaltic zone through which the progress of intestinal contents becomes impossible. When the intestine turns, the blood supply of the intestinal wall is disturbed, which can lead to necrosis and perforation of the intestine.

[16], [17], [18]

Symptoms of the congenital intestinal obstruction

After the birth of a child, the timing of the appearance of clinical signs and their severity depends not so much on the type of blemish as on the level of the obstacle. Congenital intestinal obstruction should be assumed, if aspirations from the stomach immediately after birth, the child received more than 20 ml of contents. There are two main characteristic symptoms of vomiting with pathological impurities (bile, blood, intestinal contents) and the lack of stools more than 24 hours after birth. The distal the level of obstruction, the later there are clinical symptoms and the more pronounced bloating in the child. When strangulation (curvature of the intestine) there is a pain syndrome, which is characterized by bouts of anxiety and crying.

[19], [20], [21]

Forms

High and low intestinal obstruction are distinguished, the level of division is duodenum.

For duodenal obstruction, 40-62% of cases are characterized by chromosomal diseases and associated developmental anomalies:

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

With atresia of the small intestine, in 50% of children an intrauterine inversion of the intestine is detected, combined anomalies occur in 38-55% of cases, chromosomal aberrations are rare.

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

In meconium ileus, respiratory disturbances can occur immediately after birth, or lung involvement is associated later (mixed form of cystic fibrosis).

With Hirschsprung's disease, it is possible to combine with the defects of the central nervous system, the locomotor system and genetic syndromes.

[22], [23], [24]

Complications and consequences

Complications of early postoperative period:

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

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

Diagnostics of the congenital intestinal obstruction

An x-ray of the abdominal organs (visual and contrast) can detect fluid levels with low obstruction, a "double-bubble" symptom with duodenal obstruction, calcification in meconial ileus, or antenatal perforation of the intestine. Diagnosis of Hirschsprung's disease is confirmed on the basis of intestinal biopsy and in the case of irrigography.

Prenatal diagnosis

Congenital intestinal obstruction can be suspected beginning with the 16-18th week of intrauterine development, by widening the gut or stomach of the fetus. The average duration of diagnosis of small bowel obstruction is 24-30 weeks, accuracy is 57-89%. Polyhydramnios appear early and occur in 85-95% of cases, its occurrence is associated with a violation of the mechanisms of amniotic fluid utilization in the fetus. Colonic congenital intestinal obstruction in most cases is not diagnosed, as the liquid is absorbed by the intestinal mucosa, as a result of which the gut does not expand. An important criterion is the absence of caustic and an increase in the size of the abdomen.

[31], [32], [33], [34], [35], [36]

Treatment of the congenital intestinal obstruction

Identification of signs of intestinal obstruction requires urgent transfer of the child to a surgical hospital. In the maternity hospital, a nasogastric tube is injected to decompress the stomach and establish a constant evacuation of the gastric contents. Significant losses of fluid with vomiting and into the "third space", often accompanying intestinal obstruction, quickly lead to severe dehydration, up to hypovolemic shock. That 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 the child is susceptible to vomiting, the operation is carried out in an emergency. Preoperative preparation in this case is limited to 0.5-1 h, infusion therapy is performed 10-15 ml / (kghh) and correction of CBS, prescribe hemostatic drugs, anesthesia [trimiperidine 0.5 mg / kg], if necessary - ventilator. Diagnostic measures include the definition:

• blood group and Rh factor,
• CBS,
• the level of hemoglobin,
• hematocrit,
• blood clotting time.

All children with intestinal obstruction are catheterized by the central vein, since long-term infusion therapy is assumed in the postoperative period.

With low congenital intestinal obstruction, surgery is not so urgent. Preoperative preparation can take place within 6-24 hours, which allows to further examine the child to detect abnormalities in the development of other organs and to achieve a more complete correction of the existing violations of water-electrolyte metabolism. Constant drainage of the stomach and strict registration of the amount of discharge are carried out. Assign infusion therapy, inject antibiotics and hemostatic drugs.

With high congenital intestinal obstruction, the operation can be postponed for 1-4 days, a complete examination of the child and treatment of all violations revealed by vital organs and water-electrolyte status. During the preoperative preparation, a permanent drainage of the stomach is carried out, feeding is excluded. Assign infusion therapy 70-90 ml / kg per day, after 12-24 hours from birth, you can attach preparations of parenteral nutrition. Carry out correction of electrolyte disorders and hyperbilirubinemia, prescribe antibacterial and hemostatic therapy.

Surgical treatment of congenital intestinal obstruction

The purpose of the operation is to restore the patency of the intestinal tube, thereby ensuring the possibility of feeding the baby. The volume of the operation depends on the cause of the intestinal obstruction:

• the imposition of an intestinal stoma,
• resection of the intestine with the imposition of anastomosis or stoma,
• the imposition of a T-shaped anastomosis,
• the expansion of the curtain,
• superposition of bypass anastomosis,
• opening of the lumen of the gut and evacuation of the meconium plug Intensive therapy in the postoperative period.

For minor traumatic interventions in term infants without concomitant diseases, extubation can be performed immediately after surgery. The majority of children with intestinal obstruction after the operation shows prolonged ventilation for 1-5 days. During this time, anesthesia is carried out by intravenous infusion of opioid analgesics [fentanyl at a dose of 3-7 μg / (kghh), trimeperidine at a dose of 0.1-0 mg / (kghh)] in combination with metamizole sodium at a dose of 10 mg / kg or paracetamol in a dose of 10 mg / kg. If an epidural catheter is installed, it is possible to use a continuous infusion of local anesthetics into the epidural space.

Antibiotic therapy necessarily includes drugs with activity against anaerobic bacteria. At the same time, it is necessary to control the microecological status, which is carried out at least twice a week. When peristalsis occurs, oral intestinal decontamination is performed.

After 12-24 h after the operation, preparations are prescribed that stimulate the intestinal motility of neostigmine methylsulfate at a dose of 0.02 mg / kg

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

The possibility of 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 ("small intestine" syndrome). Enteral feeding becomes possible with the appearance of passage through the gastrointestinal tract. After surgery for duodenal obstruction, feeding is carried out with thick mixtures (Frisov, Nutrilon antireflux, Enfamil AP), which contribute to the rapid restoration of the motility of the stomach and duodenum.

For large resections of the intestine or high intestinal stoma ("small intestine" syndrome), feedings are carried out with elemental mixtures (Progestimil, Alfara, Nutrilon Pepti TS, Human LP + SCT) in combination with enzyme preparations (pancreatin).

If after surgery all parts of the intestine are retained (colonostomy, resection of a small intestine site), you can immediately breast-feed.

In all cases, necessarily prescribe biological products (lactobacillus acidophilus, bifidobacteria bifidum, premadofilus).

Forecast

Survival after surgery is 42-95%. Some children need re-operative treatment (stage 2). If after surgery for congenital intestinal obstruction all parts of the digestive tract are preserved, the prognosis is favorable. The arising problems are connected with a disturbance of a food (a hypotrophy, an allergy) and a dysbacteriosis. With significant intestinal resections, a "small intestine" syndrome is formed, which causes significant problems associated with nutrition and severe hypotrophy. Multiple long-term hospitalizations are necessary for parenteral nutrition, and sometimes for repeated operations. With cystic fibrosis, the forecast is unfavorable.

[37], [38], [39], [40],