Introduction

Neonatal intestinal obstruction can pose a diagnostic dilemma in some of the most critically ill patients in the hospital. The decision and timing to operate on a neonate, particularly when premature, can have significant physiologic consequences. Additionally, operating on a neonate for obstruction can set the stage for long term issues including short bowel syndrome and future adhesive obstructions. Obstructive processes and their causes are not always immediately obvious and although it is one of the most common concerns that prompts a surgical consult, deliberate thought and an organized approach to the patient work up are critical to appropriate patient management and avoiding adverse outcomes.

What is the general approach to optimize the use of diagnostic tests?

1. Thorough patient history and physical including maternal and familial factors.
2. Pay attention to the timing of symptom development and associated changes in vital signs and lab abnormalities.
3. Start simple - an abdominal radiograph is very helpful in determining next steps.
4. The utilization of decubitus films can often help expedite the determination for operative intervention if pneumoperitoneum is found.
5. With a history of bilious emesis, choosing an upper gastrointestinal (UGI) series first will efficiently diagnose malrotation and the presence of volvulus.
6. In patients with an apparent distal obstruction, a contrast enema will guide determination for operative intervention based on the bowel caliber. There will also be faster contrast evacuation to proceed with proximal studies if distal study is nondiagnostic.
7. Abdominal ultrasound may be helpful in in narrowing the differential diagnosis with a palpated, suspicious mass or gasless abdomen on plain film.
8. Computerized tomography generally has little utility in diagnosing neonatal intestinal obstructive processes.

intestinal atresia

Supine abdominal radiograph suspicious for distal obstruction with dilated proximal bowel loops and no definitive rectal air.

microcolon

A contrast enema suspicious for distal obstructive process with a microcolon of disuse and inabilty of contrast to pass further proximally.

content in this topic is referenced in SCORE Neonatal Obstruction overview