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GI Emergencies in the NICU. Christy Cummings, MD, CLC Neonatology Yale New Haven Hospital. Objectives. Case-based learning Discussion of open abdominal wall defects and their treatment Discussion of closed abdominal wall defects and their treatment Q&A. Gastroschisis.

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gi emergencies in the nicu

GI Emergencies in the NICU

Christy Cummings, MD, CLC

Neonatology

Yale New Haven Hospital

objectives
Objectives
  • Case-based learning
  • Discussion of open abdominal wall defects and their treatment
  • Discussion of closed abdominal wall defects and their treatment
  • Q&A
gastroschisis
Gastroschisis
  • Full-thickness defect of abdominal wall exposing intestinal contents
  • Generally a small defect (3-6 cm) located right, lateral to the umbilicus
  • 1 : 40,000 births, Male> female
  • Infants are generally preterm or SGA
  • Malrotation affects all infants
  • Generally seen on U/S
  • Survival rate is higher than omphalocele, 95%
gastroschisis treatment
Gastroschisis - Treatment
  • Gastric decompression
  • Gut rest
  • Antibiotics
  • Silo suspension
    • Sealed plastic device surgically attached to infant and suspended above infant
    • Allows the bowel to return to normal size
    • Infants commonly have underdeveloped abdominal capacity, not allowing for primary closure
    • Daily decompression allows for stretching of the abdominal tissue and minimizes intestinal damage, respiratory decompensation
    • Primary closuregenerally for small defects or those term infants with adequate abdominal tissue
omphalocele
Omphalocele
  • Failure of the intestines to return from the umbilical cord into the abd cavity resulting in a transparent membrane that encapsulates intestinal tissue
  • 1 :5,500 births, Male > female
  • Frequently associated (50% - 77%) with other syndromes such as trisomies, CHD, CDH
  • Defects range from 2-15 cm on average
    • Smaller defects may be overlooked
    • Larger defects may include spleen and liver also
  • Most defects are clearly visible on U/S prenatally
  • Survival rates are high (75% - 95%)
    • But not as high as gastroschisis (higher incidence anomalies)
omphalocele treatment
Omphalocele - Treatment
  • Gastric decompression
  • Antibiotics
  • Gut rest and delayed feedings are important to allow inflamed intestinal lumen to return to normal size
  • Antibiotics
  • Surgical repair is generally reserved for the most severe cases and involves using gortex flaps to cover the transparent sac.
  • An unfortunate result of non-surgical closure is malrotation
duodenal atresia
Duodenal Atresia
  • Result of incomplete recanalization of the lumen
  • 1 : 6,000 - 10,000 births
  • 25% associated with Trisomy 21
    • Other associated anomalies: TEF, malrotation, VACTERL and renal anomalies
  • Polyhydramnios is the # 1 identifying risk factor
  • 70% of infants do not pass meconium
  • Proximal atresias/obstruction generally results in vomiting within the first few hours of life
  • Distal atresias/obstruction results in emesis longer after delivery
  • Classic “double bubble” on xray; gasless pattern after the atresias
  • Survival rate 65%-84% with early intervention
  • Treatment: Gastric decompression, surgical removal of the atresia area with a side to side anastomosis
esophageal atresia ea
Esophageal Atresia (EA)
  • Failure of the trachea to differentiate from the esophagus
  • Different types of disorder:
    • 85% have EA and a TE fistula
    • 8% have EA without any connection to the trachea
    • 1% have esophageal fistula and no connection to the stomach
    • 4% are an H type fistula
  • 1 : 4,500 births
  • VATER and VACERL association is common
  • 20%-30% are preterm
  • Clinical signs: excessive oral secretions, inability to pass OG/NG, aspiration, chronic pneumonias
  • survival rates 97% with intervention
  • Mortality is associated with associative disorder
  • Surgery depends on the type of disorder
necrotizing entercolitis nec
Necrotizing Entercolitis (NEC)
  • Necrosis of the mucosal/submucosal layer of intestinal lining
  • Any portion of the GI tract can be affected
  • Etiology is still a debate…
    • Selective bowel ischemia?
    • Delayed or lack of proper bacterial establishment? Infection?
    • The effects of feedings, medications, RBCs?
    • Osmolarity of certain formulas and the lack of feeding EBM play large roles in increasing the risk of NEC
  • Early EBM feeding decreases risk of NEC by 65% in premies
  • 65%-92% of infants affected with NEC are preterm infants
  • Most commonly seen in infants 3-21 days post delivery
necrotizing entercolitis nec1
Necrotizing Entercolitis (NEC)
  • Signs/symptoms:
    • Abdominal distention, dusky abdomen, feeding intolerance, increased emesis, bloody stools, VS instability
  • Xray:
    • Dilated loops, abnormal gas patter, thickened bowel wall
    • Pneumatosis (tiny lucent soap bubbles)
  • Treatment:
    • Bowel rest
      • NPO, Replogle to suction for 10-14 days
    • Prevention of progressive injury
      • NPO, Fluid management, antibiotics
    • Serial KUBs to monitor status
intestinal perforation
Intestinal Perforation
  • Spontaneous rupture of intestine/colon allowing leakage of air into the abdominal cavity (pneumoperitoneum)
  • Most associated with NEC and ischemic bowel
  • Most common risk factors:
    • NEC, sepsis, mechanical ventilation, prematurity, long term steroid usage, postoperative abdominal complications
  • Survival is directly related to how quickly the staff is able to identify clinical changes
intestinal perforation1
Intestinal Perforation
  • KUB: (A/P and left-lateral decubitus)
    • Pneumoperitoneum, Football Sign, Rigler Sign, Ligament Sign
  • Treatment involves:
    • Surgery immediately
    • Bowel rest—NPO for 10-14 days
    • Gastric decompression
    • Prevention of progressive injury
      • NPO, Fluid management, antibiotics
    • Placement of abdominal drain +/-
congenital diaphragmatic hernia cdh
Congenital Diaphragmatic Hernia (CDH)
  • Herniation of intestinal contents into thoracic cavity
    • Results in pulmonary hypoplasia leading to respiratory distress
  • 1 : 4,000 births
  • Signs/symptoms:
    • Cyanosis, respiratory distress, scaphoid abdomen
  • Usually seen during routine prenatal U/S
    • L:H ratio, presence of liver or other organs in chest
  • Post delivery xray reveals intestinal loops in chest cavity
  • Immediate intubation and gastric decompression is essential to higher survival rates
    • Intubation should be performed by most experienced team member
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