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Intestinal obstruction of the newborn
INTESTINAL OBSTRUCTION OF THE NEWBORN _h REPORT OF FIVE PATIENTS SUCCESSFULLY RELIEVED BY SURGERY
ALFRED D. BraGS, M.D., AND GuY V. PONTIUS, M.D. CHICAGO, ILL.
obstruction of the newborn may be caused by atresia of the I NTESTINAL bowel, which signifies complete obliteration of the lumen, or stenosis, which signifies incomplete obliteration of the lumen. The bowel may also be compressed from without. This is extrinsic obstruction. Our patients are three with atresia and two with extrinsic obstruction. A few brief sentences will adequately describe the symptoms and signs observed in these five newborn infants with intestinal obstruction. The g e n eralizations deducted from them are greatly strengthened by the fact that these observations largely coincide with those made by Ladd 1 on a much larger series. The diagnosis rests largely ,on two important symptoms. The first is vomiting, which is unlike ordinary vomiting of the newborn. It begins early, usually the first day of life. It is frequent, copious, persistent, bile stained, and usually nonprojectile. The pediatrician is likely to see the bile-stained vomitus in the basinet. The vomitus is more likely to roll out than to shoot out. One is at once struck with the fact that this is no ordinary vomiting of the newborn. The nurse offers the information that the baby began to vomit soon after birth. The bile in the vomitus attracts attention. The obstruction is seldom proximal to the ampulla of Vater. This occurred only once in Ladd's entire series of fifty-two patients with congenital atresia of the bowel. The second cardinal symptom is distention of the abdomen. It may be distended at birth, but usually is not until after birth, and distention may be so slight that it scarcely attracts attention, or it may be enormous. The amount of the distention depends, at least in part, on the location of the lesion; the lower the lesion the greater the distention. Visible, deep, peristaltic waves, when present, are pathognomonic of obstruction. They were a prominent feature in our patients with atresia except the one with perforation. They were lacking or inconspicuous in the two patients with extrinsic obstruction. In depth, these waves resemble those of pyloric stenosis. They may be in a n y portion of the abdomen. Hypertrophy and distention above the point of atresia are so great that the location of the distended loops is not a reliable guide to the anatomic site of the obstruction. Roentgenograms are helpful, but the barium sulfate meal is usually not necessary to establish diagnosis. It is dangerous and causes considerable delay when time is very valuable. It is an added insult to a gastrointestinal tract which is already badly out of adjustment. 1Vforeover, the flat film usul~rom the Departments of Pediatrics and Surgery of l~orthwestern University ~edical School and St. Luke's Hospital. 306
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ally yields the desired information. If the lesion is atresia and is high in the gastrointestinal tract, both the stomach and upper bowel may appear as huge gas bubbles, as in Case 3. If atresia is lower in the bowel, numerous gas distended loops are likely to cover the film, as in Case 2. If the obstruction is not complete, gas will be distributed throughout the tract, as in Cases 1 and 5. The time element is of paramount importance. The consultant seldom sees these babies before the third day, while ordinarily they must be operated on by the fourth day if the issue is to be successful. Diagnosis must be made promptly. The pediatrician should secure the services of a surgeon who is skilled in infant surgery.
Fig. 1.--Case 1. Photograph of 5 era. enteric cyst with resected Dortion of the jejunum laid open. Note that it is closely bound to the cyst. CASE REPORTS CAS~ 1 . - - B a b y P. was a full-term male i n f a n t born in the Ingalls Memorial Hospital, Harvey, Ill. on Nov. 14, 1943. Consultation was requested on the third day of life, when he appeared normal except for dehydration from almost continuous vomiting of a thin, light green fluid. V o m i t i n g was not projectile. He lost one pound, one ounce in the first three days of life. On the f o u r t h day he was t r a n s f e r r e d to St. L u k e ' s Hospital, Chicago, and improved w i t h supporting measures. Besides meconium he passed a little bile-stained mucus. This led to a diagnosis of stenosis r a t h e r t h a n atresia. We temporized, hoping for improvement. Delay was a serious error. Peristalsis became prominent, the abdomen distended, and the b a b y ' s condition grew worse. A barium sulfate meal was given on the s e v e n t h day w i t h inconclusive results, and repeated on the eighth day. Obstruction was reported and operation was p e r f o r m e d on t h a t day.
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A firm, globular, enteric cyst, 5 cm. in diameter, lay in the l e f t upper q u a d r a n t (Fig. 1). The cyst wall contained all layers of the small bowel but it did not communicate with the lumen of the bowel. The proximal jejunum, before rising over this cyst, was folded on itself b e n e a t h it. This almost completely obliterated the lumen. Apparently~ nothing had passed this point except the bile-stained mucus. Struggling against this obstruction, the jejunum had completely severed itself into two portions. The barium must have added materially to the shearing action of peristalsis i~ severing the bowel. The distal, severed end of the jejunum was closely bound to the cyst; the proximal end lay loose in the abdomen, which was filled with bowel content and barium sulfate. A side-to-side anastomosis was made and the abdomen closed.
Fig. 2.--Case 2. l=~oentgen-ray film of the abdomen soon after birth, showing marked distention. The gas-distended loops which largely fill the entire abdomen were of the upper gastrointestinal tract. The postoperative condition was v e r y poor and grew even worse. We ordered 2 8 9 grains of sulfadiazine to be given subcutaneously. By error, 2.5 Gin. or 37 grains were injected. ~ Severe nephritis followed, characterized b y generalized edema w i t h a large number of red cells and casts in the urine. I n addition to this catastrophe the wound suppurated and opened widely. The b a b y almost eviscerated. A f t e r the b a b y ' s survival of these events, matters gradually improved. The edema disappeared two weeks a f t e r the onset of nephritis and the urine returned to normal a f t e r an additional two weeks. The baby left the hospital six weeks after operation, weighing 3 ounces less than at birth. A t the age of one year he returned to the hospital f o r observation. A complete x-ray study of the gastrointestinal tract with barium sulfate revealed no abnormality. He was normal except for some deformity of his belly wall.
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CASm 2 . - - B a b y S. was a full-term male i n f a n t b o r n at St. Francis Hospital, Blue Island, Ill. at 4:30 P.~., J u l y 13, 1944, and was first seen by us sixty-eight hours a f t e r birth. Three hours a f t e r b i r t h he began v o m i t i n g a copious amount of bile-stained fluid. The abdomen w a s greatly distended at b i r t h (Fig. 2). This was noticed in the delivery room. Four large l o o p s of bowel were observed in vigorous peristalsis. The diagnosis was obstruction of the bowel, probably atresia. We advised against giving barium sulfate. The baby was operated upon three hours later or seventy-one hours after birth.
Fig. 3.--Case 2. Itesected portion of ileum. Note rounded end (a) without an attached cord. Note also smooth, unattached edges of ~nesentery of the proximal defect (b) and the smaller distal defect (c) through which the herniation occurred. A t a point about 30 em. below the ligament of Treltz the ileum ended in a blind, rounded end. Above this point, the bowel was enormously dilated and markedly hypertrophied to 35 or 40 ram. in diameter. The distended gut largely filled the abdomen. Distally, the ileum and colon were collapsed. They contained a light green, inspissated meconium which did not pass until a f t e r operation. The ileum here measured 7 to 9 ram. in diameter and b e g a n w i t h a rounded end. There was no connection between the two portions, not even a chord. I n addition to this deformity there were two large defects in the m e s e n t e r y (Fig. 3). A narrow, fibrous b a n d representing mesentery lay between the two defects, and another narrow, fibrous b a n d connected the proximal tip of the distal portion of ileum to the root of the mesentery, thus representing another segment of mesentery. N e i t h e r of these mesenterlc rudiments contained pulsating vessels. Through the distal and smaller mesenterie defect the terminal ileum, cecum, and ascending colon had herniated from anterior to posterior. There was impending p e r f o r a t i o n in the portion of the ileum corresponding to the middle of the lower mesenteric defect. This was probably due to the tension of the herniation. The hernia was reduced, and the bowel divided at the site of the impending perforation. The segment of bowel b e t w e e n this point and the point of atresia was resected by simple l i g a t i o n of the two bands of rudimentary mesentery and a side-to-side anastomosis
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was accomplished. A catheter was placed in the bowel by the Witzel method above the anastomosis and brought out of the upper angle of the wound~ which was closed in layers. The resected bowel measured 118 cm. (Fig. 3). This was estimated to be about one-half of the small bowel present.
Fig. 4.--Case 2. Photograph o f autopsy specimen showing ostomy between the upper and lower portions of the ileum. Note marked contrast in size even after some equalization.
t'ostoperat~ve Course.--~econium passed per ano on the f o u r t h day. The catheter was removed on the s i x t h day. The fistula closed spontaneously on the f o u r t e e n t h day. The b a b y developed a celiac-like syndrome~ t a k i n g an unusually large a m o u n t of food and discharging frequent thin, foul-smelling stools containing fat. F o r a time the b a b y gained slowly, a t t a i n i n g a m a x i m u m w e i g h t of 6 oz. above b i r t h weight. L u n g infections were frequent, suggesting p a n c r e a t i c disease. On the e i g h t y - t h i r d day of life the b a b y was transferred to St. Luke's Hospital, Chicago. A barium sulfate meal showed a lagging a t t h e site of a n a s t o m o s i s . The b a b y h a d adequate stools, however, as i n d i c a t e d b y the f a c t that~ the abdomen f r o m this time on diminished i n size a d j u s t i n g t o w a r d t h e normal proportions. F a t disappeared from the stools a n d abdominal d i s t e n t i o n became less. Nevertheless, the b a b y continued to lose weight a n d died on the one h u n d r e d t w e l f t h day of life w i t h signs of t e r m i n a l lung infection, weighing 6 oz. less t h a n a t birth.
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Autopsy.--Death was due to i n a n i t i o n and t e r m i n a l bronchopneumonla. The diameter of t h e bowel below t h e ostomy h a d doubled, measuring 15 mm.; t h a t above h a d decreased a b o u t one third, m e a s u r i n g 30 ram. except for a pouch j u s t proximal to the ostomy. Thus the two diameters seemed to be equalizing themselves (Fig. 4). The e n t i r e r e m a i n i n g small bowel m e a s u r e d 210 cm. This is much g r e a t e r t h a n the estimated l e n g t h at t h e time of operation. The p a n c r e a s was essentially normal.
Fig. 5.--Case 3. Roentgen-ray film of abdomen before operation. Note two large gas bubbles largely filling the abdomen. One represents the stomach ; the other, the duodenum. CASE 3 . - - B a b y B. was a full-term male i n f a n t b o r n a t t h e l~oseland Community Hospital, Chicago, J u l y 4, 1944. H e was seen i n consultation t h i r t y - f o u r hours later. The p r e s e n t i n g symptom was vomiting. I t was f r e q u e n t a n d persistent, occurring e v e r y few minutes, a n d b e g a n a f e w hours a f t e r b i r t h . The vomitus was bile stained. The b a b y was d e h y d r a t e d , a n d i n t h r e e days lost 1 lb., 6 oz. He passed large amounts of meconium. F o r t h i s reason t h e a t t e n d i n g p h y s i c i a n was r e l u c t a n t to accept the c o n s u l t a n t ' s diagnosis of obstruction. Deep p e r i s t a l t i c waves were observed progressing downward into the l e f t lower q u a d r a n t . We made a diagnosis of obstruction, p r o b a b l y atresia, located high in t h e small bowel a n d advised i m m e d i a t e operation. Circumstances did not p e r m i t operation u n t i l t w e n t y - f o u r hours later. I n the interim, a fiat film disclosed two large, confluent a i r bubbles of the a b d o m e n (Fig. 5). These were of a b o u t equal size and were correctly i n t e r p r e t e d b y t h e roentgenologist to represent the stomach a n d duodenum. A f t e r passing a c a t h e t e r into t h e stomach, t h e y disappeared. A subsequent film revealed no air a t all i n t h e abdomen, sealing t h e diagnosis of a t r e s i a of the bowel (Fig. 6). A t operation, the duodenum presented itself equal in size to the stomach. The pylorus could n o t b e identified. The o b s t r u c t i o n was located in the t h i r d portion of the duodenum near t h e l i g a m e n t of Treitz; i t was not dissected out. A n anastomosis b e t w e e n t h e duodenum a n d j e j u n u m was made. P o s t o p e r a t i v e course was stormy. The b a b y l e f t t h e hospital a f t e r four weeks, h a v i n g regained his b i r t h weight. A t t h e age of 4 m o n t h s t h e i n f a n t appeared to be perfectly normal. A complete g a s t r o i n t e s t i n a l x-ray s t u d y a t this time revealed t h a t the duodenum had not completely
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returned to normal size b u t was approximating it. A barium and m i l k mixture had not completely passed from the stomach at the end of three and a half hours, b u t i t did pass from the stomach before the end of five hours. The i n f a n t stomach should e m p t y itself of a barium and milk mixture within three hours. Prior to 4 months of age, this child's gastrointestinal t r a c t had become adequate for his physlo]ogie needs. However, anatomically it had not completely readjusted itself.
Fig. 6.--Case $. Roentgen-ray film after escape of gas from stomach and duodenum. Note there is no gas in the entire gastrointestinal tract. CASE 4 . - - B a b y Mi. was a full-term infant, born Aug. 12, 1945, at St. L u k e ' s Hospital, Chicago. The pediatric resident was called t h i r t y hours a f t e r b i r t h on account of persistent vomiting and marked abdominal distention. Visible peristalsis was absent and the abdomen was silent. Dr. S. C. t I e n n made a diagnosis of bowel obstruction w i t h peritonitis thirty-eight hours a f t e r birth. E i g h t hours later cellotomy was performed. The abdomen was filled w i t h air and meconium. The small bowel was a d h e r e n t to the a n t e r i o r abdomina~ wall~ where there were two perforations. Adhesions were fibrous, necessitating sharp dissection from the anterior peritoneum, liver, stomach, and gall bladder. This process had evidently been going on in ntero for a considerable time. A f t e r the bowel was freed, the mechanism could be identified, and was found to consist of a cord atresia of the ileum, 3 cm. above the iliocecal junction, and a defect in the m e s e n t e r y through which the terminal ileum had herniated. I t had then r o t a t e d counterclockwise, h a v i n g made two complete turns. There was a third perforation, this one of the terminal portion of the ileum. Here the ileum was firmly bound to the posterior peritoneum, which was also perforated~ and the retroperitoneal space was filled with meconium. The serosa of all of the involved bowel was dull. There were mlmerous areas of threatened perforation. This damaged portion of the bowel (Fig. 7), when resected, measured 53 cm. A side-to-side ileocecostomy was performed. Toilet of the abdominal cavity and retroperitoneal space was done b y aspiration. The abdominal wall was closed in layers w i t h interrupted~ chromic
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catgut a n d silk. Cultures showed a l i g h t g r o w t h of colon bacilli a t the end of t w e n t y - f o u r hours. Penicillin was a d m i n i s t e r e d postoperatively. The wound healed bY p r i m a r y union. Pos~ope~'~tive Co~rse.--The bowels moved on t h e f o u r t h day. W a t e r was given b y mouth for t h e first time on the t h i r d day, and f o r m u l a on the fourth. W e i g h t on t h e f o u r t h day was 8 pounds, 5 ounces. The abdomen b e g a n to distend during the second week postoperatively and t h e stools became f r e q u e n t a n d fatty. ]By the fifth week, t h e w e i g h t was 9 pounds, 1 ounce. A t this time the b a b y became acutely ill, the t e m p e r a t u r e rising to 102 ~ ~'. The stools became w a t e r y and frequent, up to t w e n t y a day. Stool cultures revealed organisms of the salmonella group. S u l f a g u a n l d i n e and penicillin were administered. The t e m p e r a t u r e r e t u r n e d to normal and the stools became m u c h less frequent,
Fig. 7.--Case 4. Resected portion of ileum. Note hypertrophy and distention. a v e r a g i n g three or four a day, b u t the weight continued downward to 7 pounds b y the n i n t h w e e k of life (Fig. 8). A l t h o u g h d e a t h seemed i n e v i t a b l e , we s t a r t e d the b a b y on a c o n c e n t r a t e d p a n c r e a t i c e x t r a c t , 0.5 Gin. three times daily. The w e i g h t increased, stools became more normal, and the abdominal d i s t e n t i o n receded, t i e b e g a n to take note of his surroundings. His vigor greatly improved. W h e n 108 days old, t h e b a b y weighed 10 pounds, 7 ounces, a n d appeared to be on the w a y to recovery. A t this time, an epidemic of upper r e s p i r a t o r y virus i n f e c t i o n b r o k e out on the c h i l d r e n ' s floor. This b a b y , the second one of five to die, b e g a n to cough on the one hundred t w e l f t h day of life. The temperature rose to 104 ~ F 4 the abdomen again became distended, and the baby died on the one hundred fifteenth day of fife. hrevrop~.---Cause of death was bronehopneumonla and inanition. There were passive congestion a n d b r o n e h o p n e u m o n i a of t h e lower lobes of b o t h lungs, moderate f a t t y change of the liver, distention of the stomach, ileum, and the colon, and a well-healed ileoeolostomy measuring 12 era. in diameter (Fig. 9). The small bowel from the l i g a m e n t u m of Treitz to the ileocolostomy measured 220 cm. There was no obstruction of the g a s t r o i n t e s t i n a l t r a c t . T h e p a n c r e a s w a s normal.
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CASE 5 . - - B a b y l~a., a l~egro male i n f a n t w e i g h i n g eight pounds, eight ounces, was born by cesarean section o f a diabetic mother a t St. L u k e ' s Hospital, Chicago, and transf e r r e d to t h e p e d i a t r i c service 7:30 P.~., April 18, 1946, f o r t y - t h r e e hours a f t e r b i r t h , on account of f r e q u e n t vomiting. The vomitus was bile stained. The b a b y h a d n o t r e t a i n e d a feeding since birth. I t h a d passed n o t h i n g b u t meconium a n d a little blood-tinged mucus p e r ano.
Fig. 8.--Case 4. Photograph of baby a t lowest ebb. Note celiac-like appearance. The abdomen was greatly distended and bowel sounds were present. Visible peristalsis was not present. A barium enema on admission to pediatrics revealed t h a t the lower bowel was patent up to the cecum. Absence of large gas bubbles on a flat plate spoke a g a i n s t atresia. Gas d i s t r i b u t e d t h r o u g h b o t h t h e l a r g e a n d small bowel also spoke a g a i n s t complete obstruction. A thin barium mixture given per os the next morning showed t h a t the obstruction was not complete, b u t the b a b y continued to distend a n d r e t a i n e d n o t h i n g b y mouth. The i n f a n t had b e e n receiving subcutaneous fluids, A f t e r surgical consultation w i t h Dr. F o s t e r l~Icl~illan, operation was p l a n n e d while the p a t i e n t was still in good condition. The operation was p e r f o r m e d seventy-three hours a f t e r birth. A g r e a t l y distended hyperemic ileum w i t h o u t inflammatory signs bulged from the incision. I t was four times the normal size. The colon had largely r o t a t e d , b u t descent
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was incomplete. The caput coli lay a t the level of the umbilicus, a n g u l a t e d l a t e r a l l y a t a 90 Q angle, a n d was b o u n d b y a fibrous band. This a n d o t h e r fibrous s t r a n d s to the posterior a b d o m i n a l wall constricted t h e h e a d of t h e cecum and t h e t e r m i n a l ileum enough to cause almost complete obstruction. W h e n the bowel was f r e e d the ileum decompressed i t s e l f into the cecum, which was t h e n b r o u g h t into n o r m a l position a n d fixed. Postoperative Co~rse.--During the first, second, and t h i r d day, the b a b y progressed well w i t h o u t a b d o m i n a l d i s t e n t i o n or regurgitation. Food was r e t a i n e d and t h e bowels moved. On t h e f o u r t h day signs of skin i n f e c t i o n a b o u t the wound as well as on o t h e r p a r t s of t h e body appeared. The wound s u p p u r a t e d and the skin sutures sloughed out. The wound was supported b y adhesive bridges:
Fig. 9.--Case 4. Autopsy specimen showing ostomy between ileum and cecum. The b a b y gained ground slowly. He r e t a i n e d most of his feedings b u t r e g u r g i t a t e d some each day. The day before operation he weighed 8 pounds, 4 ounces. T e n days l a t e r he weighed 7 pounds, 13 ounces. A t t h e end of four weeks he h a d r e g a i n e d his b i r t h weight. D u r i n g t h e subsequent five weeks he g a i n e d a n o t h e r pound. A t t h i s t i m e he stopped r e g u r g i t a t i n g , b e g a n to g a i n rapidly, a n d was discharged t e n weeks a f t e r b i r t h , w e i g h i n g 9 pounds, 10 ounces. B y this t i m e the wound was completely healed. Penicillin was the chief anti-infection drug used. SU~I~ARY
We have presented the salient features of five cases of intestinal obstruction of the newborn, three of atresia and two of extrinsic obstruction. Two
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cases of demonstrated atresia had other defects which necessitated the resection of large portions of the ileum, 118 cm. in Case 2 and 55 cm. in Case 4. These two cases deserve special consideration. Each patient survived the immediate effect of the operation but developed a celiac-like syndrome. Case 2, having lost 118 cm. of small bowel, developed a greatly distended abdomen and passed f a t t y stools for several weeks. Later, the stools lost their fat and the abdomen adjusted toward the normal. Nevertheless the baby died of inanition on the one hundred twelfth day of life. The same syndrome developed in Case 4 after resection of 55 cm. of ileum. The baby appeared to be approaching its demise when concentrated pancreatin, well diluted in the formula, rapidly changed the picture. He then appeared to be on the road to recovery, when he was carried off by an epidemic of severe respiratory infection which took four other babies in the same nursery. Arnheim 2 reported a patient who developed a similar syndrome after resection of 23 cm. of ileum. He found pancreatin helpful in a successful but long drawn out struggle. These clinical facts, coupled with the autopsy findings in Cases 2 and 4 and the postoperative x-ray findings in Cas e 3, indicate that the young bowel has a remarkable compensatory ability. The large lumen above the atresia and the small lumen below tend to equalize each other, and the shortened bowel grows rapidly in length. Linear growth is a normal function of the infant bowel, and apparently the rate of growth is accelerated in the shortened bowel. It is suggested, therefore, in cases of massive resection, that every effort be made to keep these babies alive until the compensatory factors accomplish their goal. Pancreatin is a material aid. We wish to emphasize the following facts : 1. The pediatrician does not usually see babies with congenital bowel obstruction until the third day of life. 2. The cardinal symptoms "are persistent, nonprojectile, bile-stained vomiting, abdominal distention, and visible peristaltic waves. 3. Roentgen-ray films are helpful, but barium sulfate by mouth is unnecessary. It is usually harmful and wastes precious time. 4. The necessity for early operation cannot be overemphasized. 5. Ladd demonstrated the value of establishing continuity of the lumen by side-to-side anastomosis. REFERENCES
1. Ladd, W. E., and Gross, Robert E.: Abdominal Surgery of Infancy and Childhood, Philadelphia, 1941, W. Bo Saunders Co. 2. Arnheim, Ernest, E.: Congenital Ileal Atresia With Gangrene, Perforation, and Peritonitis in a Newborn Infant, Am. J. Dis. Child. 69: 108, 1945.
ALFRED D. BraGS, M.D., AND GuY V. PONTIUS, M.D. CHICAGO, ILL.
obstruction of the newborn may be caused by atresia of the I NTESTINAL bowel, which signifies complete obliteration of the lumen, or stenosis, which signifies incomplete obliteration of the lumen. The bowel may also be compressed from without. This is extrinsic obstruction. Our patients are three with atresia and two with extrinsic obstruction. A few brief sentences will adequately describe the symptoms and signs observed in these five newborn infants with intestinal obstruction. The g e n eralizations deducted from them are greatly strengthened by the fact that these observations largely coincide with those made by Ladd 1 on a much larger series. The diagnosis rests largely ,on two important symptoms. The first is vomiting, which is unlike ordinary vomiting of the newborn. It begins early, usually the first day of life. It is frequent, copious, persistent, bile stained, and usually nonprojectile. The pediatrician is likely to see the bile-stained vomitus in the basinet. The vomitus is more likely to roll out than to shoot out. One is at once struck with the fact that this is no ordinary vomiting of the newborn. The nurse offers the information that the baby began to vomit soon after birth. The bile in the vomitus attracts attention. The obstruction is seldom proximal to the ampulla of Vater. This occurred only once in Ladd's entire series of fifty-two patients with congenital atresia of the bowel. The second cardinal symptom is distention of the abdomen. It may be distended at birth, but usually is not until after birth, and distention may be so slight that it scarcely attracts attention, or it may be enormous. The amount of the distention depends, at least in part, on the location of the lesion; the lower the lesion the greater the distention. Visible, deep, peristaltic waves, when present, are pathognomonic of obstruction. They were a prominent feature in our patients with atresia except the one with perforation. They were lacking or inconspicuous in the two patients with extrinsic obstruction. In depth, these waves resemble those of pyloric stenosis. They may be in a n y portion of the abdomen. Hypertrophy and distention above the point of atresia are so great that the location of the distended loops is not a reliable guide to the anatomic site of the obstruction. Roentgenograms are helpful, but the barium sulfate meal is usually not necessary to establish diagnosis. It is dangerous and causes considerable delay when time is very valuable. It is an added insult to a gastrointestinal tract which is already badly out of adjustment. 1Vforeover, the flat film usul~rom the Departments of Pediatrics and Surgery of l~orthwestern University ~edical School and St. Luke's Hospital. 306
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ally yields the desired information. If the lesion is atresia and is high in the gastrointestinal tract, both the stomach and upper bowel may appear as huge gas bubbles, as in Case 3. If atresia is lower in the bowel, numerous gas distended loops are likely to cover the film, as in Case 2. If the obstruction is not complete, gas will be distributed throughout the tract, as in Cases 1 and 5. The time element is of paramount importance. The consultant seldom sees these babies before the third day, while ordinarily they must be operated on by the fourth day if the issue is to be successful. Diagnosis must be made promptly. The pediatrician should secure the services of a surgeon who is skilled in infant surgery.
Fig. 1.--Case 1. Photograph of 5 era. enteric cyst with resected Dortion of the jejunum laid open. Note that it is closely bound to the cyst. CASE REPORTS CAS~ 1 . - - B a b y P. was a full-term male i n f a n t born in the Ingalls Memorial Hospital, Harvey, Ill. on Nov. 14, 1943. Consultation was requested on the third day of life, when he appeared normal except for dehydration from almost continuous vomiting of a thin, light green fluid. V o m i t i n g was not projectile. He lost one pound, one ounce in the first three days of life. On the f o u r t h day he was t r a n s f e r r e d to St. L u k e ' s Hospital, Chicago, and improved w i t h supporting measures. Besides meconium he passed a little bile-stained mucus. This led to a diagnosis of stenosis r a t h e r t h a n atresia. We temporized, hoping for improvement. Delay was a serious error. Peristalsis became prominent, the abdomen distended, and the b a b y ' s condition grew worse. A barium sulfate meal was given on the s e v e n t h day w i t h inconclusive results, and repeated on the eighth day. Obstruction was reported and operation was p e r f o r m e d on t h a t day.
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A firm, globular, enteric cyst, 5 cm. in diameter, lay in the l e f t upper q u a d r a n t (Fig. 1). The cyst wall contained all layers of the small bowel but it did not communicate with the lumen of the bowel. The proximal jejunum, before rising over this cyst, was folded on itself b e n e a t h it. This almost completely obliterated the lumen. Apparently~ nothing had passed this point except the bile-stained mucus. Struggling against this obstruction, the jejunum had completely severed itself into two portions. The barium must have added materially to the shearing action of peristalsis i~ severing the bowel. The distal, severed end of the jejunum was closely bound to the cyst; the proximal end lay loose in the abdomen, which was filled with bowel content and barium sulfate. A side-to-side anastomosis was made and the abdomen closed.
Fig. 2.--Case 2. l=~oentgen-ray film of the abdomen soon after birth, showing marked distention. The gas-distended loops which largely fill the entire abdomen were of the upper gastrointestinal tract. The postoperative condition was v e r y poor and grew even worse. We ordered 2 8 9 grains of sulfadiazine to be given subcutaneously. By error, 2.5 Gin. or 37 grains were injected. ~ Severe nephritis followed, characterized b y generalized edema w i t h a large number of red cells and casts in the urine. I n addition to this catastrophe the wound suppurated and opened widely. The b a b y almost eviscerated. A f t e r the b a b y ' s survival of these events, matters gradually improved. The edema disappeared two weeks a f t e r the onset of nephritis and the urine returned to normal a f t e r an additional two weeks. The baby left the hospital six weeks after operation, weighing 3 ounces less than at birth. A t the age of one year he returned to the hospital f o r observation. A complete x-ray study of the gastrointestinal tract with barium sulfate revealed no abnormality. He was normal except for some deformity of his belly wall.
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CASm 2 . - - B a b y S. was a full-term male i n f a n t b o r n at St. Francis Hospital, Blue Island, Ill. at 4:30 P.~., J u l y 13, 1944, and was first seen by us sixty-eight hours a f t e r birth. Three hours a f t e r b i r t h he began v o m i t i n g a copious amount of bile-stained fluid. The abdomen w a s greatly distended at b i r t h (Fig. 2). This was noticed in the delivery room. Four large l o o p s of bowel were observed in vigorous peristalsis. The diagnosis was obstruction of the bowel, probably atresia. We advised against giving barium sulfate. The baby was operated upon three hours later or seventy-one hours after birth.
Fig. 3.--Case 2. Itesected portion of ileum. Note rounded end (a) without an attached cord. Note also smooth, unattached edges of ~nesentery of the proximal defect (b) and the smaller distal defect (c) through which the herniation occurred. A t a point about 30 em. below the ligament of Treltz the ileum ended in a blind, rounded end. Above this point, the bowel was enormously dilated and markedly hypertrophied to 35 or 40 ram. in diameter. The distended gut largely filled the abdomen. Distally, the ileum and colon were collapsed. They contained a light green, inspissated meconium which did not pass until a f t e r operation. The ileum here measured 7 to 9 ram. in diameter and b e g a n w i t h a rounded end. There was no connection between the two portions, not even a chord. I n addition to this deformity there were two large defects in the m e s e n t e r y (Fig. 3). A narrow, fibrous b a n d representing mesentery lay between the two defects, and another narrow, fibrous b a n d connected the proximal tip of the distal portion of ileum to the root of the mesentery, thus representing another segment of mesentery. N e i t h e r of these mesenterlc rudiments contained pulsating vessels. Through the distal and smaller mesenterie defect the terminal ileum, cecum, and ascending colon had herniated from anterior to posterior. There was impending p e r f o r a t i o n in the portion of the ileum corresponding to the middle of the lower mesenteric defect. This was probably due to the tension of the herniation. The hernia was reduced, and the bowel divided at the site of the impending perforation. The segment of bowel b e t w e e n this point and the point of atresia was resected by simple l i g a t i o n of the two bands of rudimentary mesentery and a side-to-side anastomosis
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was accomplished. A catheter was placed in the bowel by the Witzel method above the anastomosis and brought out of the upper angle of the wound~ which was closed in layers. The resected bowel measured 118 cm. (Fig. 3). This was estimated to be about one-half of the small bowel present.
Fig. 4.--Case 2. Photograph o f autopsy specimen showing ostomy between the upper and lower portions of the ileum. Note marked contrast in size even after some equalization.
t'ostoperat~ve Course.--~econium passed per ano on the f o u r t h day. The catheter was removed on the s i x t h day. The fistula closed spontaneously on the f o u r t e e n t h day. The b a b y developed a celiac-like syndrome~ t a k i n g an unusually large a m o u n t of food and discharging frequent thin, foul-smelling stools containing fat. F o r a time the b a b y gained slowly, a t t a i n i n g a m a x i m u m w e i g h t of 6 oz. above b i r t h weight. L u n g infections were frequent, suggesting p a n c r e a t i c disease. On the e i g h t y - t h i r d day of life the b a b y was transferred to St. Luke's Hospital, Chicago. A barium sulfate meal showed a lagging a t t h e site of a n a s t o m o s i s . The b a b y h a d adequate stools, however, as i n d i c a t e d b y the f a c t that~ the abdomen f r o m this time on diminished i n size a d j u s t i n g t o w a r d t h e normal proportions. F a t disappeared from the stools a n d abdominal d i s t e n t i o n became less. Nevertheless, the b a b y continued to lose weight a n d died on the one h u n d r e d t w e l f t h day of life w i t h signs of t e r m i n a l lung infection, weighing 6 oz. less t h a n a t birth.
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Autopsy.--Death was due to i n a n i t i o n and t e r m i n a l bronchopneumonla. The diameter of t h e bowel below t h e ostomy h a d doubled, measuring 15 mm.; t h a t above h a d decreased a b o u t one third, m e a s u r i n g 30 ram. except for a pouch j u s t proximal to the ostomy. Thus the two diameters seemed to be equalizing themselves (Fig. 4). The e n t i r e r e m a i n i n g small bowel m e a s u r e d 210 cm. This is much g r e a t e r t h a n the estimated l e n g t h at t h e time of operation. The p a n c r e a s was essentially normal.
Fig. 5.--Case 3. Roentgen-ray film of abdomen before operation. Note two large gas bubbles largely filling the abdomen. One represents the stomach ; the other, the duodenum. CASE 3 . - - B a b y B. was a full-term male i n f a n t b o r n a t t h e l~oseland Community Hospital, Chicago, J u l y 4, 1944. H e was seen i n consultation t h i r t y - f o u r hours later. The p r e s e n t i n g symptom was vomiting. I t was f r e q u e n t a n d persistent, occurring e v e r y few minutes, a n d b e g a n a f e w hours a f t e r b i r t h . The vomitus was bile stained. The b a b y was d e h y d r a t e d , a n d i n t h r e e days lost 1 lb., 6 oz. He passed large amounts of meconium. F o r t h i s reason t h e a t t e n d i n g p h y s i c i a n was r e l u c t a n t to accept the c o n s u l t a n t ' s diagnosis of obstruction. Deep p e r i s t a l t i c waves were observed progressing downward into the l e f t lower q u a d r a n t . We made a diagnosis of obstruction, p r o b a b l y atresia, located high in t h e small bowel a n d advised i m m e d i a t e operation. Circumstances did not p e r m i t operation u n t i l t w e n t y - f o u r hours later. I n the interim, a fiat film disclosed two large, confluent a i r bubbles of the a b d o m e n (Fig. 5). These were of a b o u t equal size and were correctly i n t e r p r e t e d b y t h e roentgenologist to represent the stomach a n d duodenum. A f t e r passing a c a t h e t e r into t h e stomach, t h e y disappeared. A subsequent film revealed no air a t all i n t h e abdomen, sealing t h e diagnosis of a t r e s i a of the bowel (Fig. 6). A t operation, the duodenum presented itself equal in size to the stomach. The pylorus could n o t b e identified. The o b s t r u c t i o n was located in the t h i r d portion of the duodenum near t h e l i g a m e n t of Treitz; i t was not dissected out. A n anastomosis b e t w e e n t h e duodenum a n d j e j u n u m was made. P o s t o p e r a t i v e course was stormy. The b a b y l e f t t h e hospital a f t e r four weeks, h a v i n g regained his b i r t h weight. A t t h e age of 4 m o n t h s t h e i n f a n t appeared to be perfectly normal. A complete g a s t r o i n t e s t i n a l x-ray s t u d y a t this time revealed t h a t the duodenum had not completely
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returned to normal size b u t was approximating it. A barium and m i l k mixture had not completely passed from the stomach at the end of three and a half hours, b u t i t did pass from the stomach before the end of five hours. The i n f a n t stomach should e m p t y itself of a barium and milk mixture within three hours. Prior to 4 months of age, this child's gastrointestinal t r a c t had become adequate for his physlo]ogie needs. However, anatomically it had not completely readjusted itself.
Fig. 6.--Case $. Roentgen-ray film after escape of gas from stomach and duodenum. Note there is no gas in the entire gastrointestinal tract. CASE 4 . - - B a b y Mi. was a full-term infant, born Aug. 12, 1945, at St. L u k e ' s Hospital, Chicago. The pediatric resident was called t h i r t y hours a f t e r b i r t h on account of persistent vomiting and marked abdominal distention. Visible peristalsis was absent and the abdomen was silent. Dr. S. C. t I e n n made a diagnosis of bowel obstruction w i t h peritonitis thirty-eight hours a f t e r birth. E i g h t hours later cellotomy was performed. The abdomen was filled w i t h air and meconium. The small bowel was a d h e r e n t to the a n t e r i o r abdomina~ wall~ where there were two perforations. Adhesions were fibrous, necessitating sharp dissection from the anterior peritoneum, liver, stomach, and gall bladder. This process had evidently been going on in ntero for a considerable time. A f t e r the bowel was freed, the mechanism could be identified, and was found to consist of a cord atresia of the ileum, 3 cm. above the iliocecal junction, and a defect in the m e s e n t e r y through which the terminal ileum had herniated. I t had then r o t a t e d counterclockwise, h a v i n g made two complete turns. There was a third perforation, this one of the terminal portion of the ileum. Here the ileum was firmly bound to the posterior peritoneum, which was also perforated~ and the retroperitoneal space was filled with meconium. The serosa of all of the involved bowel was dull. There were mlmerous areas of threatened perforation. This damaged portion of the bowel (Fig. 7), when resected, measured 53 cm. A side-to-side ileocecostomy was performed. Toilet of the abdominal cavity and retroperitoneal space was done b y aspiration. The abdominal wall was closed in layers w i t h interrupted~ chromic
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catgut a n d silk. Cultures showed a l i g h t g r o w t h of colon bacilli a t the end of t w e n t y - f o u r hours. Penicillin was a d m i n i s t e r e d postoperatively. The wound healed bY p r i m a r y union. Pos~ope~'~tive Co~rse.--The bowels moved on t h e f o u r t h day. W a t e r was given b y mouth for t h e first time on the t h i r d day, and f o r m u l a on the fourth. W e i g h t on t h e f o u r t h day was 8 pounds, 5 ounces. The abdomen b e g a n to distend during the second week postoperatively and t h e stools became f r e q u e n t a n d fatty. ]By the fifth week, t h e w e i g h t was 9 pounds, 1 ounce. A t this time the b a b y became acutely ill, the t e m p e r a t u r e rising to 102 ~ ~'. The stools became w a t e r y and frequent, up to t w e n t y a day. Stool cultures revealed organisms of the salmonella group. S u l f a g u a n l d i n e and penicillin were administered. The t e m p e r a t u r e r e t u r n e d to normal and the stools became m u c h less frequent,
Fig. 7.--Case 4. Resected portion of ileum. Note hypertrophy and distention. a v e r a g i n g three or four a day, b u t the weight continued downward to 7 pounds b y the n i n t h w e e k of life (Fig. 8). A l t h o u g h d e a t h seemed i n e v i t a b l e , we s t a r t e d the b a b y on a c o n c e n t r a t e d p a n c r e a t i c e x t r a c t , 0.5 Gin. three times daily. The w e i g h t increased, stools became more normal, and the abdominal d i s t e n t i o n receded, t i e b e g a n to take note of his surroundings. His vigor greatly improved. W h e n 108 days old, t h e b a b y weighed 10 pounds, 7 ounces, a n d appeared to be on the w a y to recovery. A t this time, an epidemic of upper r e s p i r a t o r y virus i n f e c t i o n b r o k e out on the c h i l d r e n ' s floor. This b a b y , the second one of five to die, b e g a n to cough on the one hundred t w e l f t h day of life. The temperature rose to 104 ~ F 4 the abdomen again became distended, and the baby died on the one hundred fifteenth day of fife. hrevrop~.---Cause of death was bronehopneumonla and inanition. There were passive congestion a n d b r o n e h o p n e u m o n i a of t h e lower lobes of b o t h lungs, moderate f a t t y change of the liver, distention of the stomach, ileum, and the colon, and a well-healed ileoeolostomy measuring 12 era. in diameter (Fig. 9). The small bowel from the l i g a m e n t u m of Treitz to the ileocolostomy measured 220 cm. There was no obstruction of the g a s t r o i n t e s t i n a l t r a c t . T h e p a n c r e a s w a s normal.
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CASE 5 . - - B a b y l~a., a l~egro male i n f a n t w e i g h i n g eight pounds, eight ounces, was born by cesarean section o f a diabetic mother a t St. L u k e ' s Hospital, Chicago, and transf e r r e d to t h e p e d i a t r i c service 7:30 P.~., April 18, 1946, f o r t y - t h r e e hours a f t e r b i r t h , on account of f r e q u e n t vomiting. The vomitus was bile stained. The b a b y h a d n o t r e t a i n e d a feeding since birth. I t h a d passed n o t h i n g b u t meconium a n d a little blood-tinged mucus p e r ano.
Fig. 8.--Case 4. Photograph of baby a t lowest ebb. Note celiac-like appearance. The abdomen was greatly distended and bowel sounds were present. Visible peristalsis was not present. A barium enema on admission to pediatrics revealed t h a t the lower bowel was patent up to the cecum. Absence of large gas bubbles on a flat plate spoke a g a i n s t atresia. Gas d i s t r i b u t e d t h r o u g h b o t h t h e l a r g e a n d small bowel also spoke a g a i n s t complete obstruction. A thin barium mixture given per os the next morning showed t h a t the obstruction was not complete, b u t the b a b y continued to distend a n d r e t a i n e d n o t h i n g b y mouth. The i n f a n t had b e e n receiving subcutaneous fluids, A f t e r surgical consultation w i t h Dr. F o s t e r l~Icl~illan, operation was p l a n n e d while the p a t i e n t was still in good condition. The operation was p e r f o r m e d seventy-three hours a f t e r birth. A g r e a t l y distended hyperemic ileum w i t h o u t inflammatory signs bulged from the incision. I t was four times the normal size. The colon had largely r o t a t e d , b u t descent
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was incomplete. The caput coli lay a t the level of the umbilicus, a n g u l a t e d l a t e r a l l y a t a 90 Q angle, a n d was b o u n d b y a fibrous band. This a n d o t h e r fibrous s t r a n d s to the posterior a b d o m i n a l wall constricted t h e h e a d of t h e cecum and t h e t e r m i n a l ileum enough to cause almost complete obstruction. W h e n the bowel was f r e e d the ileum decompressed i t s e l f into the cecum, which was t h e n b r o u g h t into n o r m a l position a n d fixed. Postoperative Co~rse.--During the first, second, and t h i r d day, the b a b y progressed well w i t h o u t a b d o m i n a l d i s t e n t i o n or regurgitation. Food was r e t a i n e d and t h e bowels moved. On t h e f o u r t h day signs of skin i n f e c t i o n a b o u t the wound as well as on o t h e r p a r t s of t h e body appeared. The wound s u p p u r a t e d and the skin sutures sloughed out. The wound was supported b y adhesive bridges:
Fig. 9.--Case 4. Autopsy specimen showing ostomy between ileum and cecum. The b a b y gained ground slowly. He r e t a i n e d most of his feedings b u t r e g u r g i t a t e d some each day. The day before operation he weighed 8 pounds, 4 ounces. T e n days l a t e r he weighed 7 pounds, 13 ounces. A t t h e end of four weeks he h a d r e g a i n e d his b i r t h weight. D u r i n g t h e subsequent five weeks he g a i n e d a n o t h e r pound. A t t h i s t i m e he stopped r e g u r g i t a t i n g , b e g a n to g a i n rapidly, a n d was discharged t e n weeks a f t e r b i r t h , w e i g h i n g 9 pounds, 10 ounces. B y this t i m e the wound was completely healed. Penicillin was the chief anti-infection drug used. SU~I~ARY
We have presented the salient features of five cases of intestinal obstruction of the newborn, three of atresia and two of extrinsic obstruction. Two
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cases of demonstrated atresia had other defects which necessitated the resection of large portions of the ileum, 118 cm. in Case 2 and 55 cm. in Case 4. These two cases deserve special consideration. Each patient survived the immediate effect of the operation but developed a celiac-like syndrome. Case 2, having lost 118 cm. of small bowel, developed a greatly distended abdomen and passed f a t t y stools for several weeks. Later, the stools lost their fat and the abdomen adjusted toward the normal. Nevertheless the baby died of inanition on the one hundred twelfth day of life. The same syndrome developed in Case 4 after resection of 55 cm. of ileum. The baby appeared to be approaching its demise when concentrated pancreatin, well diluted in the formula, rapidly changed the picture. He then appeared to be on the road to recovery, when he was carried off by an epidemic of severe respiratory infection which took four other babies in the same nursery. Arnheim 2 reported a patient who developed a similar syndrome after resection of 23 cm. of ileum. He found pancreatin helpful in a successful but long drawn out struggle. These clinical facts, coupled with the autopsy findings in Cases 2 and 4 and the postoperative x-ray findings in Cas e 3, indicate that the young bowel has a remarkable compensatory ability. The large lumen above the atresia and the small lumen below tend to equalize each other, and the shortened bowel grows rapidly in length. Linear growth is a normal function of the infant bowel, and apparently the rate of growth is accelerated in the shortened bowel. It is suggested, therefore, in cases of massive resection, that every effort be made to keep these babies alive until the compensatory factors accomplish their goal. Pancreatin is a material aid. We wish to emphasize the following facts : 1. The pediatrician does not usually see babies with congenital bowel obstruction until the third day of life. 2. The cardinal symptoms "are persistent, nonprojectile, bile-stained vomiting, abdominal distention, and visible peristaltic waves. 3. Roentgen-ray films are helpful, but barium sulfate by mouth is unnecessary. It is usually harmful and wastes precious time. 4. The necessity for early operation cannot be overemphasized. 5. Ladd demonstrated the value of establishing continuity of the lumen by side-to-side anastomosis. REFERENCES
1. Ladd, W. E., and Gross, Robert E.: Abdominal Surgery of Infancy and Childhood, Philadelphia, 1941, W. Bo Saunders Co. 2. Arnheim, Ernest, E.: Congenital Ileal Atresia With Gangrene, Perforation, and Peritonitis in a Newborn Infant, Am. J. Dis. Child. 69: 108, 1945.