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Chapter 35. Gastroenterology

  • The delayed passage of meconium may be the result of a mechanical or functional bowel obstruction.
  • Virtually all infants, term and preterm, will have passed meconium by 48 h of age.
  • The evaluation of any infant with delayed passage of meconium should begin with a thorough physical examination and history.
  • For infants who are unstable, the infant must first be stabilized before the investigation begins as to the cause of delayed stooling.

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Cause

Diagnosis

Management

Anorectal abnormality (imperforate anus, anal stenosis)

Imperforate anus should be evident on physical examination

Anal stenosis may be evident on physical examination

Surgical consult

Repogle to low intermittent suction

IV fluids

Remember that high anal atresias may be associated with GU abnormalities

Meconium plug

Contrast enema shows the meconium plug with a normal-caliber colon

Enema is usually therapeutic

If abnormal stooling continues, consider diagnosis of Hirschsprung's disease and rectal biopsy

Meconium ileus

Contrast enema reveals a microcolon from ileal obstruction with stool

Enema can be therapeutic but may need surgical intervention

Hirschsprung's disease

Contrast enema shows a distally narrowed segment (aganglionic) leading to a dilated proximal segment (normal colon)

If suspected, rectal biopsy will provide the definitive diagnosis

Surgical consult

Repogle to low intermittent suction

IV fluids

Diverting colostomy is standard; end-to-end anastomosis if affected segment is very short

Ileal atresia

Contrast enema shows no reflux of contrast into the terminal ileum

Surgical consult

Repogle to low intermittent suction

IV fluids

Malrotation

Infants usually present with bilious emesis

Upper GI or contrast enema shows a malpositioned cecum

Surgical consult

Repogle to low intermittent suction

IV fluids

Volvulus

Surgical emergency because the ischemic gut may progress to frank necrosis

Plain film of the abdomen reveals a massively dilated proximal colon

Contrast enema reveals a midtransverse colon obstruction

Emergent surgical consult

Repogle to low intermittent suction

IV fluids

Ileus

May be secondary to a number of factors:

  • Sepsis
  • NEC
  • Hypokalemia
  • Hypothyroidism
  • Hypermagnesemia
  • Narcotic analgesia therapy

Bowel rest

IV fluids

Treatment of underlying condition causing the ileus

  • The evaluation of any infant with GI bleeding should begin with a thorough physical examination and history.
  • For infants who have massive bleeding and are unstable, the infant must first be stabilized before the investigation begins.

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Cause

Confirmatory Tests

Management

Swallowed maternal blood (bleeding on the first day)

  • Apt test on gastric contents to evaluate for maternal hemoglobin

No treatment necessary

NEC

  • Plain radiograph of abdomen with left lateral decubitus view to evaluate for pneumatosis intestinalis and pneumoperitoneum
  • Rare to have upper GI bleeding; indicates severe, late disease
  • Infants will generally be extremely ill
  • See “Necrotizing Enterocolitis” section for specific management

Coagulopathy

  • Check PT, PTT, fibrinogen, D-dimer, platelets to evaluate for the presence of DIC
  • May see bleeding from other sources as well
  • Confirm that vitamin K was given at delivery
  • Specific factor deficiencies can cause extensive GI bleeding and should be investigated ...

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