Congenital intestinal obstruction

Congenital intestinal obstruction is one of the most frequent causes of urgent operations in children of the newborn period. Causes leading to obstruction: 1) malformations of the intestinal tube; 2) violation of the process, rotation of the intestine; 3) developmental defects of other organs of the abdominal cavity and retroperitoneal space.

The most common form of the developmental disorder of the first group is atresia and stenosis, the occurrence of which is associated with defects in the formation of the lumen of the intestinal tube and the violation of blood supply to certain areas of the intestine in the embryonic period. There are 3 types of atresia: in the form of a fibrous cord, membranous form (if there are holes in the membrane talking about stenosis) and complete with the separation of the blind ends.

More often, atresia and stenosis are localized in places of complex embryological processes-in the duodenum, in the initial part of the jejunum, in the ileum; Sometimes there are multiple atresia. Rarely, the reason for the obstruction is doubling of the intestine (duplication, enterogenic cysts), with obstruction more often obturative. Character. To the same group include violations of the bookmarking of nerve ganglia in the intestinal wall, which leads to a change in the peristalsis of the affected area and the difficulty of passage of intestinal contents (see Hirschsprung's disease).

The second group of causes of congenital intestinal obstruction is a violation of the processes of intestinal rotation in the embryonic period. The rotation delay at different stages can cause three types of obstruction: 1) the turn of the so-called midgut, ie, the part of the intestine from the skinny to the middle of the transverse colon, having a common blood supply from the superior mesenteric artery; 2) Ledd's syndrome - the sclerosis of the jejunum in combination with the squeezed duodenum with the peritoneal cords; 3) partial duodenal obstruction due to compression of her belly with tendons and an atypically located caecum.

The cause of intestinal obstruction can also be infringement of the intestine in internal hernias (for example, in the area of ​​the peritoneal pocket in the duodenojunctional transition - the hernia of Treitsa).

The third group includes malformations of the pancreas: the ring-shaped gland and congenital cystic fibrosis. In the first case, the stenosis of the duodenum is caused by the compression of it from the outside, in the second - because of the increased viscosity of meconium, the ileum becomes obstructed.

Atresia and intestinal stenosis, meconium obstruction, are the cause of the symptoms of obstructive obstruction (see Bowel obstruction). When the intestine is curled and the intestine is infringed in the internal hernia, the symptoms of strangulation are characteristic. Depending on the anatomical variant of the defect, the symptoms of intestinal obstruction appear immediately after birth or at a later time.

Congenital intestinal obstruction is divided according to the level of localization and obstruction to high and low, from the degree of narrowing of the gut light to the full and partial, from the time of onset to the intrauterine and postnatal.

High obstruction in newborns occurs with atresia of the duodenum or its stenosis, anomalies of rotation-Ledd's syndrome, curvature of the mid-gut, compression of the gut with peritoneal cords, annular pancreas, aberrant vessel, infringement in hernia of Treitsa. There is a high intestinal obstruction from the first hours or days of life. Its main symptom is persistent vomiting of stagnant gastric contents about an admixture of bile. Children quickly lose body weight; Accidents of water-electrolyte balance and acid-alkaline system increase, oliguria arise, hematocrit grows. With complete intestinal obstruction, developed in utero, there is no meconium stool.

When viewed, the stomach looks sunken, against which background after feeding, the swelling of the epigastric region is clearly visible. With Ledd's syndrome and a twist of the "midgut" are characterized by bouts of neonatal anxiety, which are amplified by palpation. When probing the stomach, stagnant contents are obtained in an amount exceeding the norm, usually with pathological impurities (bile, intestinal contents). It should be remembered that when the obstacle is positioned above the level of the large papilla of the duodenum (faterovaya nipple), vomitic masses do not contain pathological impurities.

Low intestinal obstruction can be due to atresia and stenosis of the lean, ileum and ascending colon, doubling of the intestine, meconium ileus. Low intestinal obstruction is also evident from the first hours or days of life and is characterized by a significant swelling of the abdomen.

A stronger, visible peristalsis of enlarged intestinal loops (Val's symptom) is characteristic. Vomiting is less frequent than with high obstruction, however, vomit always has a stagnant, unpleasant smell, contains a significant admixture of bile and intestinal contents (so-called vomiting). With complete obstruction of the intestine is also characteristic of the absence of meconium withdrawal after birth.

Symptoms of irritation of the peritoneum, as a rule, reveal, as a rule, in the case of late diagnosis of strangulation types of obstruction or intestinal perforation, when peritonitis develops. If there is a suspicion of congenital intestinal obstruction, the doctor of the genitourinary house should conduct the patient's study according to the following scheme: 1) evaluation of the anamnesis (characterized by unfavorable course of pregnancy, polyhydramnios); 2) evaluation of the general condition of the child (detection of intoxication, dehydration, body weight loss greater than physiological loss, high hemoglobin and hematocrit numbers, disturbance of the KHS); 3) examination and palpation of the abdomen; 4) gastric sensing with an assessment of the quantity and quality of the contents; 5) rectal examination (with meconium atresia absent). When confirming the diagnosis of congenital bowel obstruction, the child should be urgently transferred to a specialized surgical hospital where, as a rule, an X-ray examination is performed to determine the level of the obstruction. When performing a survey X-ray in the direct and lateral projections, attention is drawn to the degree of filling of the intestine with gas, the number of fluid levels in the enlarged sections of the digestive tract. With high obstruction, there are two of them - in the stomach and duodenum, at low - multiple levels and gas bubbles. By the width of the liquid level, one can judge the anatomical variant of the developmental defect. With atresia, the level of fluid in the stomach is equal to or greater than the diameter of the stomach. With an unfinished turn of the intestine, the size of the duodenum is normal, there is a scant filling of the intestinal loops with gas. If the review radiographic examination does not provide sufficient information, contrast study of the gastrointestinal tract is used. Aqueous suspension of barium sulfate in the amount of one-time feeding is administered in breast milk.

For high intestinal obstruction is characterized by a violation of the evacuation function of the duodenum, therefore on the roentgenogram two depots of contrast medium are visible - in the enlarged stomach and duodenum. If there is a suspicion of an unfinished turn of the intestine, the study is supplemented by irrigography with air or barium suspension. An incorrect position of the cecum in the epigastric region or high under the liver confirms the diagnosis. With low intestinal obstruction, the contrast test allows us to clarify the degree of expansion of the leading intestinal loops, the localization of fluid levels in them, the nature of the passage through the intestine.

Treatment of congenital intestinal obstruction is only operative. It is carried out after assessing the risk of anesthesia and surgery, pre-preoperative preparation aimed at correcting violations of homeostasis and the functions of vital organs. The nature of surgical intervention depends on the developmental defect: the creation of continuity of the lumen of the intestinal tube through, the performance of entero-enterostomy, duodeno-, duodenenterostomy, membrane excision. Possible douh stage operations with low forms of intestinal obstruction, with the first stage being the imposition of intestinal fistula.

In the unfinished turn of the intestine, the bloating and separation of the embryonic strands are performed. In the meconium pletus, it is necessary to wash the intestine after opening its lumen with a solution of chymotrypsin followed by T-shaped enterostomy and the use of pancreatin in the postoperative period.

The prognosis with timely performed surgical intervention and absence of other developmental anomalies is favorable. The exception is children with multiple developmental defects.