The aim of investigating cases of suspected obstruction of the small intestine is two-fold: first, to identify the nature and anatomical location of the lesion, to allow for planning of correct treatment; and second, to identify patients with malrotation in whom there is a risk of midgut volvulus and intestinal ischemia. These cases require urgent surgical intervention to reduce the risk of potentially catastrophic intestinal necrosis. The history and examination may give clues as to the location of the lesion as described above. An abdominal X-ray may simply confirm the presence of dilated intestinal loops but may also give further clues in some cases. A double-bubble appearance on abdominal X-ray with a lack of air in the distal intestine (Figure 2.2) is characteristic of duodenal obstruction. Multiple air-filled loops of proximal bowel often with air-fluid levels along with a paucity or complete absence of gas in the distal bowel is highly suggestive of obstruction of the ileum. Intestinal perforation if present will usually be apparent on abdominal X-ray, and in the rare cases of antenatal perforation there may be widespread or localized flecks of calcification representing calcified meconium within the peritoneum.

In cases in which the diagnosis is not clear on abdominal X-ray or in which midgut malrotation or volvulus is suspected, a limited upper gastrointestinal contrast study is indicated. The classical finding in cases of malrotation is that the duo-denojejunal flexure lies to the right side of the spine instead of in its normal left-sided position (Figure 2.3). This finding should prompt urgent surgical treatment, because of the risk of co-existing midgut volvulus. The contrast study may also identify the presence of a stenotic segment or complete obstruction.

Cases of lower ileal stenosis or atresia are often more difficult to diagnose and a contrast enema is invaluable in distinguishing between ileal and colonic obstruction and could be therapeutic in cases of meconium ileus (see below).

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