Clinical features

Obstructive lesions of the small intestine from the pylorus down to the ileocecal valve may give rise to polyhydramnios in the antenatal period which is detectable by antenatal ultrasonography. As a general rule, the more proximal the lesion the more severe the degree of polyhydramnios; distal ileal lesions may be present in the absence of poly-hydramnios.7 The list of differential diagnoses giving rise to polyhydramnios is extensive, and it is rare for an obstructive lesion of the GI tract to be confirmed before birth.

Following birth, the most common and important clinical manifestation of obstructive lesions of the GI tract is bile-stained vomiting. Vomiting with truly bilious staining is abnormal in the neonatal period and always requires investigation. Lesions in the duodenum and jejunum usually result in bilious vomiting within hours. In addition, the abdomen may appear empty or even scaphoid and visible gastric peristalsis may be observed. Lesions lower in the ileum result in a distended abdomen if the obstruction is complete, and there may be failure to pass meconium. Obstructive lesions may also give rise to intestinal perforation in the neonatal period and occasionally antenatally. In all cases of neonatal intestinal obstruction, infants become progressively hypovolemic and are prone to circulatory and respiratory collapse. They require fluid resuscitation and may require venti-latory support. GI tract obstruction should therefore be considered in any infant who is dehydrated, especially if there is a history of vomiting.

Stenotic lesions of the small bowel in which the obstruction is incomplete may give rise to increased diagnostic difficulty. Affected infants often present with intermittent vomiting and episodes of partial obstruction. They eventually fail to thrive or develop complete obstruction, at which stage they are fully investigated and the diagnosis becomes apparent.

Intestinal malrotation is considered separately, as it may present with a spectrum of clinical scenarios depending on the degree of intestinal obstruction or midgut volvulus or both. The clinical pictures of all types of abnormal rotation are those of acute or chronic intestinal obstruction and/or acute or chronic abdominal pain suggestive of intestinal ischemia. True malrotation typically presents in the first year of life with symptoms of upper gastrointestinal tract obstruction including vomiting, which is usually bile-stained. A coexisting volvulus may be suspected by abdominal pain, peritonitis and hypovolemic shock associated with intestinal ischemia. However, these signs may be relatively non-specific in the young infant. Malrotation may also present later in life with similar symptoms.

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