Obstruction of the Intestine

Obstruction of the intestine and colon related to obturation by meconium or foreign material generally occurs in normal intestine. The most common disorders of this nature in the newborn are meconium ileus, meconium plug syndrome, and neonatal small left colon syndrome. In older children obturation obstruction is generally associated with foreign bodies, bezoars, or parasites. In each instance, however, complete or high-grade partial intestinal obstruction is the primary mode of presentation.

Approach to the infant with a bowel obstruction

Evaluation of the newborn or infant with a small or large bowel obstruction is one of the great challenges of pediatric surgery. Figure 69-1 is a schematic representation of some of the thought processes which the surgeon should go through when evaluating such a patient. The surgeon should clearly rule out the most clinically significant abnormalities first, followed by those which are not immediately life-threatening. Clearly, if a child with malrotation and volvulous is suspected an immediate upper gastrointestinal series should be performed. Most proximal (duodenal) and very distal (imperforate anus) obstructions can be fairly directly ruled-out. The surgeon should always inquire if the neonate was delivered with marked abdominal distension. This finding should prompt three potential disorders: complicated meconium ileus, bilateral ureteral obstruction (posterior urethral valves), and hyrdrocolpos. Other etiologies are also possible, including ascites, but can be adequately addressed with plain films inspecting for calcifications and an abdominal ultrasound. A barium enema should then be performed. Although not always diagnostic, it will often direct the surgeon in the most expedient direction. The finding of a microcolon is found with intestinal atresia, meconium ileus, or in a rare case megacystis, microcolon syndrome. A small left colon may be seen with Hirschsprung's disease, small left colon syndrome or meconium plug syndrome. A normal barium enema with normal appearing abdominal radiographs, although suggestive of no pathology, may still be seen with Hirschsprung's disease or with more proximal small bowel atresias.

Figure1. Diagram illustrating the approach to a child with a potential bowel obstruction. See text for explanation.

Suggested readings authored by the University of Michigan, Section of Pediatric Surgery

1. DelPin CA, Czyrko C, Ziegler MM et a1: Management and survival of meconium ileus, a 30 year review, Ann Surg 215:179, 1992. This 30-year review provides a valuable follow-up of the extensive experience of Bishop and Koop.
2. Noblett HR: Treatment of uncomplicated meconium ileus by Gastrografin enema: a preliminary report, J Pediatr Surg 4:190,1969. Noblett describes a novel nonoperative approach to uncomplicated meconium ileus that is also applicable to other forms of obturation obstruction of the intestine.
3. Vinograd I, Mogle P, Peleg O et al: Meconium disease in premature infants with very low weight, J Pediatr 103:963, 1983. This paper describes various forms of obstruction in low-birth-weight infants from inspissated meconium associated with poor intestinal motility.
4. Rosenstein, BJ, Zeitlin, PL: Cystic Fibrosis (Seminar). Lancet 851:277-282, 1998. An excellent review of cystic fibrosis, including pathophysiology.
5. FitzSimmons, SC, Burkhart, GA, Borowitz, Grand, RJ,, et al: High-dose pancreatic- enzyme supplements and fibrosing colonopathy in children with cystic fibrosis. NEJM 336:1283-1289. Excellent review of the development of fibrotic structuring of the colon in cystic fibrosis patients receiving high dose pancreatic enzymes.
6. Olsen, MM, Luck, SR, Lloyd-Still, Raffensperger, JG: The spectrum of meconium disease in infancy. J Pediatr Surg 175(5):479-81, 1982. Discusses the risk of cystic fibrosis with all meconium disorders.

This information is provided by the University of Michigan Department of Surgery, Section of Pediatric Surgery and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. For additional health information, please contact your health care provider or our offices.