When a newborn baby vomits repeatedly he may have: (1) Some severe infection, such as septicaemia, originating in an infection of his umbilicus. (2) Intestinal obstruction, due to the conditions described in this chapter. (3) Meningitis. (4) Intracranial haemorrhage. The first three of these are often readily treatable[md]if you diagnose them early.
Most babies vomit a few times during the first few days of life, but bile-stained vomiting soon after birth almost always indicates gut obstruction. A childs's gut can be obstructed at the level of his oesophagus, his duodenum, his small gut, or, rarely, in his colon; but it is most often often obstructed at his anus. Anorectal malformations form a separate group, and present as the failure to pass meconium, combined with abdominal distension, rather than vomiting; so they are described separately in Section 28.4. Here we are concerned with obstruction higher up a child's gut.
Congenital obstruction of a child's small gut presents as bilious vomiting shortly after birth, and often (but not always) the failure to pass meconium. If the obstruction is proximal to the middle of his small gut, his abdomen does not distend, but if the obstruction is below this point, it does. The distension may be localized or generalized.
An obstructed gut is an emergency. Electrolyte loss and energy lack affect a baby sooner than an adult, so he needs urgent treatment, usually a laparotomy, within a few hours. If you are a careful, nimble operator, you may be able to save a few of these children with some of the most technically demanding methods described in this manual.
Hypertrophic pyloric stenosis presents later, as a previously healthy baby 2 to 3 weeks old who starts to vomit, and does not have diarrhoea. This form of obstruction is readily treatable and is described in Section 28.4. In Africa it is about as common as duodenal atresia.
Fig. 28-2 TWO CAUSES OF NEONATAL GUT OBSTRUCTION. A, an X-ray showing the ''double bubble' of duodenal atresia. B, duodenal atresia relieved by a duodeno-jejunostomy. C, an X-ray showing the multiple fluid levels of jejuno-ileal atresia. D, jejuno- ileal atresia showing how the proximal dilated loop is resected at 90[de], and the narrower distal one at 45[de]. E, a single layer end to end anastomosis. F, if, despite the 90[de][nd]45[de] ]]manoeuvre, it is still difficult to anastomose the ends, you can make a nick in the antemesenteric border of the distal end. Partly after Ravitch et al., ''Textbook of Paediatric Surgery'. Yearbook Medical, with kind permission.
NEONATAL GUT OBSTRUCTION EXAMINATION. Assess the distension of the child's abdomen, look for visible peristalsis. Feel for the mass of a hypertrophic pylorus. Examine for visible and palpable coils of terminal ileum, that feel as if they might be filled with inspissated meconium (meconium ileus, not described here).
CAUTION ! Neither the passage of meconium during the first 3 days, nor the absence of distension, excludes obstruction.
X-RAYS. After 12 hours he will have swallowed enough air to assist diagnosis. If possible, take erect straight films before you start aspirating his stomach.
]]CAUTION ! (1) The neonatal jejunum, ileum, and colon all have the same smooth outline, and normally contain a few fluid levels. (2) Don't use contrast media.
THE DIFFERENTIAL DIAGNOSIS [s7]OF NEONATAL GUT OBSTRUCTION Suggesting septicaemia[md]a site of origin for the infection, such as an infected umbilicus; he is more ill than you would expect from obstruction alone; a positive blood culture.
Suggesting raised intracranial pressure [md]signs of cerebral irritation, a swollen fontanelle (enlargement of the head and papilloedema are late signs).
Suggesting some other cause of abdominal distension [md]a part of the abdomen which is dull to percussion. Causes include distension of the bladder in urethral obstruction, tumours, ascites, and congenital cystic kidneys, etc.
GENERAL MANAGEMENT. As soon as you suspect the diagnosis, pass a nasogastric tube, strap it to his face, see that it is aspirated at least every 30 minutes, and let it decompress into a bag[md]aspiration is a common cause of death. Put up a drip. Keep him warm. If possible refer him[md]urgently. If not, consider operating as soon as possible (28.3).
SPECIFIC CONDITIONS [s7]OBSTRUCTING THE NEONATAL GUT OESOPHAGEAL ATRESIA is often associated with a tracheo-oesophageal fistula. The proximal oesophageal pouch fills with saliva, so that he dribbles excessively. If he is given milk or water, he is likely to aspirate it into his trachea. He froths, coughs, and becomes cyanotic. If oesophageal atresia is common in your area, pass a nasogastric tube on all neonates. It has a higher incidence in underweight babies.
Confirm the diagnosis by passing a small (8 Ch in a full term baby and 5 Ch preterm one) firm (you don't want it to curl up) nasogastric tube with a radio-opague line in it as far as it will go, and then taking AP and lateral chest X-rays. This will show his oesophagus ending in a blind pouch. Suck out the contrast medium immediately afterwards.
Refer him immediately with the tube reaching the blind end of his proximal oesophagus. Frequent aspiration is particularly important to prevent him aspirating saliva. Also, give him a small dose of atropine (A 2-4) to minimize secretion. Make sure that the staff who accompany him understand that they must continue to aspirate the tube, and suck out his pharynx during transport, to prevent fluid entering his lungs. If you cannot refer him, there is little you can do.
DUODENAL ATRESIA AND STENOSIS present as vomiting on the first day of life. His vomit is usually bile-stained, because the obstruction is usually below the ampulla of Vater. His upper abdomen is distended. If the obstruction is above the ampulla of Vater, there will be no bile in his vomit. The absence of dribbling saliva and cyanosis after feeding distinguishes duodenal from oesophageal atresia.
Erect AP and lateral films show a characteristic ''double bubble', with no air (or very little) in his small gut beyond. The bubble on the right is in his distended duodenal cap, and that on the left is in his stomach. He may also have Down's syndrome. If you cannot refer him, you may possibly be able to do a duodeno-jejunostomy or a duodeno-duodenostomy (28.3).
JEJUNO-ILEAL ATRESIA OR STENOSIS may occur at any point in the small gut. Typically, it presents as bilious vomiting within 24 hours of birth[md]slightly later than with duodenal atresia, perhaps an hour after the first breast-feed; but it may be delayed for 2 or 3 days. If he has jejunal stenosis rather than atresia, it may be delayed for as long as 2 weeks. Obstruction in the upper jejunum is more common. If the obstruction is low, it presents more slowly, with distension more evident than vomiting. About half these children pass some meconium. Hydramnios is common in the mother.
Erect AP and lateral films show considerable gaseous distension, ending at the site of obstruction, usually with several fluid levels[md]one or two are normal. Unfortunately, by the time that several fluid levels are present obstruction is advanced.
If you cannot refer him you may be able to resect and anastomose his gut (28.3).
VOLVULUS OF THE SMALL GUT may present in older children, as in Section 10.9, with sudden abdominal pain, distension and shock, or it may present in the first week of life, usually very soon after birth, as an acute abdomen with bile-stained vomiting and abdominal distension. Volvulus usually involves the distal small gut and proximal colon, and is due to a congenital malrotation. If Ladd's bands (see below) are responsible, surgery is simple, because there no need to anastomose gut. Strangulation obstruction develops rapidly.