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Transcript
Intestinal Obstruction
Malrotation
&
Hirschsprung disease
Supervised by:- Dr/AAyed Al-Qahtany
Presented by:- Maram Al-Zain
Malrotation
• Embryology :-
-Disproportional growth& elongation of the midgut
beginning in the 5th gestational week results in :* Herniation of the 1ry midgut loop ( base of
umbilical cord,10th week) .
*Reduction of the extracoelomic gut (10th-12th
weeks,180 degree ) .
* Fixatation of the intestine into the posterior
wall of the body after the 12th gestational week .
Cont…..
-Malrotation classified into:1- Non-rotation .
2- Mixed OR Incomplete rotation .
3- Mesocolic hernias .
Cont…….
• Non-rotation :Commonest abnormality.
Chch. By inadequate counterclockwise rotation of
the midgut loop around SMA,(absent or arrested
before exceeding 90 degrees).
Colon resides in Lt. abdomen, Cecum is near in the
midline, SI is to the right of midline.
MidgutVOLVULUS & Duodenal
OBSTRUCTION are significant .
Cont……
• Mixed OR Incomplete rotation :2nd common rotational abnormalities .
Chch. By arrest of normal rotational process or at
near 180 degree
Prearterial segment has failed to complete its
rotation post. & Lt. of the SMA .
Cecum resides in the upper abdomen (usually Lt. to
the SMApertoneal band ) .
Midgut volvulus & dudenal obstruction are
relatively common from extrinsic compression.
Cont…..
• Mesocolic hernias:Result from failure of fixation of either the RT. Or
Lt. mesocolon to the post. Body wall .
Rare BUT surgically important anomaly .
The resulting potential cavities may allow
entrapment of small intestine on either side of the
abdomen.
As with any hernia Obstruction, Incarceration &
Strangulation are potential risk .
Clinical presentation
• Incidense :- As high as 1% of the total population .
• Sex :- M:F
2:1 (neonate),But no sexual predilection in pt. older
than 1yr .
• 40%
in the 1st week of life .
• 75% of the pt. diagnosed by the age of 1yr.
• The remaining 25% present after age of 1yr & late adulthood
• Presentation :- 1- Asymptomatic .
2- Duodenal obstruction .
3- Midgut volvulus .
• Older children & adults may present :1- Acute volvulus .
2- Episodic obstructive symptoms .
3- Chronic abdominal pain .
Diagnosis
• History
Maternal
Neonatal
• Examination
General
Specific
• Investigation
Lab
Radiological
History & Examination
• Most of the infant present with Acute duodenal
obstructionforceful vomiting, may/may NOT bilious .
• Chronic duodenal obstructionintermittent abdominal pain,
failure to thrive, bilious vomiting .
• Abdominal distention .
• Bloody stool .
• Tachycardia .
• Tachypnea .
• Shock .
Radiological Investigation
• Plain abdominal x-ray .
• Contrast study .
• Barium swallow .
• Barium enema .
Management
-General :1)
2)
3)
4)
NPO .
IV. Fluid .
Antibiotics .
Pre-operative preparation .
-Specific :1)
2)
NO role of non-operative management of malrotation .
Operative repair of malrotation is nearly achieved by LADD
procedure .
Cont…..
• Surgical repair is performed, the bowel is untwisted
& checked carefully for damage .
• Exploratory laparotomy (1st) .
• If the intestine is healthy, an operation called
LADD’s procedure to prevent another volvulus .
• Appendectomy usually done .
• ?? Bowel viability
Abdomen will be left open &
2nd look procedure will be planned within 24-48 hrs .
• If there is a section of necrotic bowel colostomy
may be needed temporarily .
Hirschsprung disease
• Def. :- It is a congenital agangliosis of the intestine which
result of disordered emberyogenesis involving the myenteric
nervous system .
• Etiology :- Lack of migratory nerve cells to develop .
• Esophagus
6th week .
• Transverse colon
8th week .
• Rectum 12th week .
• Incidence :- 1 per 5000 live births .
• Sex :- M:F 4:1
• Most cases are sporadic, but long segment or total colonic
agangliosis & female gender are strongly associated with
familial disease
Clinical presentation
• 50% of pt. present in the neonatal age .
• Most infant Don’t have normal passage of meconium in the 1st
24 - 48 hrs .
• They maybe discovered during the evaluation of chronic
constipation .
• Abdominal distention .
• Bilious vomiting .
• Malnutrition .
• Failure to thrive .
Physical examination
• Physical examination
NOT diagnostic .
• PR. Examination shows spasm of the rectum, empty rectum .
• Gush of stool or Forceful decompression of gray liquid ,?? Bloody
stool at the time of the rectal examination
??Enterocolitis.
Diagnosis
• History & physical examination .
• Investigation :Lab test
Radiology
1- Plain abdominal x-ray .
2- Contrast enema .
RECTAL BIOBSY .
Anorectal manometry .
Management
1 - General :
• NPO .
• NGT
• IV. Fluid .
• Antibiotic .
2- Specific :
• All operations depend on resection or bypass of distal
aganglionic rectum in conjunction with a low rectal
anastomosis to normally innervated pulled-through
proximal intestine.
• 1st stage
Rlieve obstruction
 Laparotomy
 Identify transition zone between dilated upstream normal
bowel and non-peristaltic,aganglionic distal bowel .
 Colostomy above transition zone .
• 2nd stage
 Swenson :- Proctocolectomy .
 Duhamel :- Post. Pull-through with side to side anastomosis to
a ganglionic rectum .
 Soave :- Pull ganglionated bowel through sleeve of rectum.
 Rectal myomectomy
& All the best
Maram Al-Zain