[Prognostic factors related to mortality in newborns with jejunoileal atresia]

BACKGROUND

Jejuno-ileal atresia is one of the main causes of intestinal obstruction in neonates. The origin is vascular accidents in the fetal intestine. It is an entity that requires early and specialist management.

OBJECTIVE

to know the factors related to mortality in neonates with jejunoileal atresia.

METHODS

Case-control nested in a cohort design, comparative study during ten years, between deceased and survivors analyzing factors related to mortality before surgery and during surgery and in the postoperative course.

RESULTS

We analyzed 70 patients in 10 years, there were 10 deaths (14.2%). No one had a prenatal diagnosis. Factors related to mortality were: intestinal perforation with a relative risk (RR) of 4.4, peritonitis (RR: 5.6), the need of stomas (RR: 4.9), the presence of sepsis (RR: 4.6) and when the residual small bowel length was below 1 meter (RR: 7.4).

CONCLUSION

The delay in diagnosis causes late intervention and increased mortality delayed diagnosis promotes late transport of the neonate and enhances mortality, factors associated with mortality related to intestinal perforation. It is necessary to spread this disease in the medical community to improve prenatal and postnatal diagnosis.

[Nonimmune hydrops fetalis associated with congenital small bowel atresia--a case study]

Nonimmune hydrops fetalis is observed with the frequency of 1:3000 cases diagnosed pre- and postnatally. In the following paper the authors analyzed the course of pregnancy complicated by fetal ascites and polyhydramnios with the appearance of colonic ileus and they presented the postnatal condition of the baby The preliminary diagnosis was confirmed after birth and the newborn was operated in the second day of his life. The congenital small bowel atresia was qualified as a III B type (Grossfeld qualification), which is called the "pagoda" syndrome [3]. The colonic atresia is located then around the superior mesenteric vessels, which leads to colonic necrosis (Figure 1).

Evolution of sonographic findings in a fetus with ileal atresia

We report a case of a meconium pseudocyst secondary to ileal atresia and midgut volvulus. Initially, a single anechoic cyst was detected on prenatal sonography. The cyst gradually increased in size during the second trimester and eventually appeared as a large mass in the lower abdomen with echogenic content and associated with bowel dilatation. This case indicates that until the mid third trimester a single sonolucent cyst without signs of bowel obstruction may be associated with congenital intestinal obstruction.

Congenital colonic atresia: report of one case

Colonic atresia is a very rare cause of intestinal obstruction, and surgical management is the mainstay of therapy. A case of congenital colonic atresia is reported in a full-term neonate who presented with delayed passage of meconium, abdominal distention and bilious vomiting. The present case and the pertinent literature are discussed, with an emphasis on surgical management.

Situs inversus abdominalis and duodenal atresia: a case report and review of the literature

Fewer than 20 patients born with situs inversus and duodenal atresia have been reported in the literature. We present a patient with this condition. A newborn baby presented shortly after birth with persistent bilious vomiting. An abdominal radiograph showed a right-sided stomach bubble and a second bubble on the left - typical of duodenal atresia but with mirror image configuration. Laparotomy confirmed the diagnosis of situs inversus abdominalis, which was also demonstrated by contrast studies and ultrasound. Duodenoduodenostomy was performed and the patient discharged on day 8 postoperatively. Situs inversus is associated with other congenital malformations including splenic malformations, left-sided liver and cardiac abnormalities; it is rarely associated with duodenal atresia. Duodenal obstruction in the presence of situs inversus has been described, including obstruction due to a web, stenosis, pre-duodenal portal vein and complete atresia. The patient presented in this paper had a duodenal web in the second part of the duodenum. Before undertaking surgery it is important to establish the presence of associated gastrointestinal and cardiac abnormalities.

Intrauterine umbilical cord hemorrhage with associated jejunal atresia captured by real-time ultrasound

The presence of unexplained umbilical cord ulceration and hemorrhage has been sporadically reported in fetuses with antenatally suggested intestinal atresia. This case report illustrates a patient with spontaneous intrauterine umbilical cord hemorrhage, captured by real-time ultrasonography, in the setting of jejunal atresia with volvulus of the distal jejunal segment.

Multiple jejunoileal atresia and colonic atresia managed by multiple primary anastomosis with a single gastroperineal transanastomotic tube without stomas

Multiple jejunoileal atresia is a challenge to the pediatric surgeon. The aim of the study is to preserve bowel length and prevent the long-term complications of short bowel syndrome. The authors present a rare case of combined multiple jejunoileal atresia and colonic atresia managed by 9 primary anastomoses over a gastroperineal transanastomotic tube. This technique avoided the use of stomas and their attendant complications.

Duodenal atresia in an infant with triple-X syndrome: a new associated malformation in 47,XXX

BACKGROUND

An association between the triple-X syndrome (47,XXX) and gastrointestinal malformations is extremely rare. Most 47,XXX patients present with a normal phenotype, but genitourinary malformations have been described.

CASE

We report a case of a child with 47,XXX and duodenal atresia. Antenatal ultrasound scan showed a dilated fetal stomach and upper part of the duodenum (double bubble phenomenon) at 31 weeks of gestation in a 31-year-old woman with polyhydramnion. The amniotic fluid karyotype showed 47,XXX. After a scheduled delivery, duodenal atresia was confirmed and treated with duodeno-duodenostomy.

CONCLUSIONS

The possible association of gastrointestinal and genitourinary tract anomalies requires a detailed postnatal clinical investigation and ultrasonographic examination of the abdomen, retroperitoneum, and pelvis on all triple-X syndrome patients.

Single or double bubble: sign of trouble! Congenital pyloric atresia: report of two cases and review of literature

Congenital pyloric atresia is a very rare anomaly. It can occur as an isolated anomaly and can be associated with other conditions such as aplasia cutis congenital/epidermolysis bullosa or multiple intestinal atresias. We present two cases of congenital pyloric atresia, solitary air bubble on X-ray abdomen being pathognomonic sign of pyloric atresia. However, it might present with an intermittent double bubble sign.

Second-trimester intra-abdominal bowel dilation in fetuses with gastroschisis predicts neonatal bowel atresia

OBJECTIVE

To determine in fetuses with gastroschisis the association between intra-abdominal bowel dilation in the second trimester and neonatal bowel atresia.

METHODS

We reviewed ultrasound and medical records of fetuses with gastroschisis from January 1998 to August 2004. Fetuses with intra-abdominal bowel dilation in the second trimester were identified and followed into the neonatal period.

RESULTS

We identified 58 mother-infant pairs showing fetal gastroschisis, with at least one prenatal ultrasound at our hospital and which were delivered there, or were transported there as newborns. Forty-eight of the 58 fetuses had no intra-abdominal bowel dilation and none of these neonates had bowel atresia. Ten of the 58 fetuses had intra-abdominal bowel dilation and all had bowel atresia at birth (P<0.0001). In eight cases in which ultrasound was performed at <25 weeks' gestation, intra-abdominal bowel dilation was already present.

CONCLUSION

Intra-abdominal bowel dilation in the second trimester predicts neonatal bowel atresia in fetuses with gastroschisis.

Pyloric obstruction, duodenal dilatation, and extrahepatic cholestasis: a neonatal triad suggesting multiple intestinal atresias

Whereas physiologic jaundice constitutes a common finding in neonates, a few cases present with cholestatic jaundice owing to various pathologic conditions, including extrahepatic biliary obstruction. We report the case of a 2-day-old female neonate presenting with neonatal cholestasis, nonbilious vomiting with pyloric obstruction, and multiple intestinal atresias. A pathognomonic clinicoradiologic triad is described, based on clinical data, plain abdominal x-ray, and ultrasound examination.

Intrauterine hemorrhage from an umbilical cord ulcer associated with fetal duodenal atresia: a case report

In the recent years, the association between congenital intestinal atresia and umbilical cord ulceration has been demonstrated; however, this complication is rarely encountered. To the best of our knowledge, only 14 cases on this association have been published previously. We encountered a case of acute intrauterine hemorrhage from an umbilical cord ulcer in a fetus with duodenal atresia that resulted in early neonatal death. There is little information available on the association between congenital intestinal atresia and umbilical cord ulceration. Greater understanding may alter the obstetric management. Although the prevention of sudden perinatal death is considered to be difficult, frequent fetal monitoring and detailed ultrasonographic examinations may facilitate the early detection of this condition, thereby enabling the rescue of the affected fetuses. Further investigation is required to establish the management protocol.

Sudden fetal death associated with both duodenal atresia and umbilical cord ulcer: a case report and review

We encountered one case of duodenal atresia complicated by massive intrauterine hemorrhage due to the perforation of an umbilical cord ulceration (UCU). UCU is an extremely rare complication in the perinatal period. Although the prenatal diagnosis of upper intestinal atresia has been established, little is known about the association between UCU and upper intestinal atresia. In this article, we report our case, review past articles, and discuss the underlying pathophysiological mechanisms of the cause of an UCU. Given the characteristic sites of upper intestinal atresia, we speculate that regurgitation of gastric or intestinal juice into the amniotic fluid could be responsible for the development of UCU. We also believe that close observation is required for patients who have upper intestinal atresia.

[Oral cholangiography and duodenal atresia]

A newborn male patient with trisomy-21 presented with bilious hemesis. The patient was icteric with slight hepatomegaly. Simple abdominal X-ray and upper gastrointestinal series with barium showed a dilated duodenal loop and inflammatory changes involving the duodenal mucosa. This image known as "double bubble" is characteristic of congenital duodenal obstruction. Simultaneously the gallbladder and choledochus were visualized. The former X-ray finding is very unusual. An uneventful Kimura procedure was performed.

Prenatal counselling of small bowel atresia:watch the fluid!

OBJECTIVE

To evaluate polyhydramnios as a sign of extreme disproportion of atretic segments in small bowel atresia (SBA).

METHODS

Twenty-eight patients with a prenatal diagnosis (PD) of SBA undergoing neonatal surgical treatment were reviewed retrospectively. Parameters recorded were gestational age, birth weight, surgical procedure, rate of complications, parenteral nutrition (PN) days and length of stay (LOS). Patients were divided into two groups: Group A with delayed anastomosis and Group B with direct anastomosis.

RESULTS

Seventeen subjects were in Group A while 11 were in Group B. The two groups did not differ with regard to gestational age at diagnosis, birth weight and obstetrical management. Polyhydramnios was present in both Group A (64.7%) and Group B (9%) (p < 0.05). Patients in Group A needed a longer period on PN, had a longer LOS and exhibited significantly higher rates of complication.

CONCLUSION

In the absence of other malformations, association of dilated bowel loops and polyhydramnios is highly predictive of severe SBA, which can in no instance be amenable to one-stage reconstruction. Because of its consequences on postnatal treatment, such information should be conveyed to the prospective parents at the time of counselling.

Double bubble, double trouble

Duodenal atresia (DA) is not uncommon, either as an isolated anomaly or associated with trisomy 21, malrotation, or cardiac anomalies. It may be diagnosed on antenatal ultrasound by a "double-bubble" sign, which typically persists after birth on a plain abdominal radiograph. DA as a familial association is rare but has been reported with or without other associated anomalies. We report DA in two siblings of nonconsanguineous parents, one case occurring with an annular pancreas in association with gestational diabetes. These two cases suggest possible genetic and environmental components in the aetiology of this anomaly.

A case report of midgut atresia and spontaneous closure of gastroschisis

We report a case in which a neonate with a prenatal diagnosis of gastroschisis was born with midgut atresia and the mummified remains of the midgut arising from a spontaneously closed abdominal wall defect. As our ability to prenatally diagnose abdominal wall defects has improved, we have gained some insight into the prenatal natural history of this pathological process. We present a case in which an abdominal wall defect spontaneously closed and was associated with an apparent in utero midgut vascular accident. This unusual case provides some insight into the mechanisms underlying the pathophysiology of gastroschisis.

Jejunal atresia in an infant with triple-X syndrome

A 33-year-old woman presented at 31 weeks' gestation with polyhydramnios that required repeated amniodrainage. An antenatal scan at 32 weeks showed dilated fetal bowel loops, which were not confirmed on subsequent scans. The amniotic fluid karyotype confirmed 47,XXX. After birth, jejunal obstruction was confirmed. To our knowledge, this is the first report of an association of triple-X syndrome and jejunal atresia.

Acquired ileal atresia in infancy: report of two cases

Two infants, aged 3 months and 4 months, with acquired ileal atresia in the distal ileum are described. Both of them presented with features of intestinal obstruction following a diarrhoeal episode. In both patients the time interval between the onset of symptoms and detection of atresia at surgery was very short, i.e. 2 weeks. In our opinion, strangulation with subsequent resorption of gangrenous gut could have been the underlying mechanism in both patients. However, a short interval between initiation of symptomatology and detection of atresia prompted us to postulate a thromboembolic phenomenon as the cause of these lesions. While in one patient intussusception was noted on sonography, in the other there was no clear-cut aetiology present except for a high-lying caecum with a long mesentery that might have led to volvulus. We have reviewed the pertinent literature of this very rare sequela of gut inflammation.

Serial transverse enteroplasty as primary therapy for neonates with proximal jejunal atresia

Small bowel atresia is associated with a large size discrepancy between the proximal and distal segments of bowel that has traditionally been managed by resection of the dilated segment, tapering enteroplasty, or plication. Longitudinal intestinal lengthening is rarely performed at the time of the initial operation. Many patients with small bowel atresia also have a short length of residual small intestine secondary to in utero resorption. The authors present the clinical application of the novel intestinal lengthening procedure, the serial transverse enteroplasty, in a neonate with proximal jejunal atresia and suggest that it become part of the armamentarium for surgeons treating patients with this anomaly.

Characteristic findings for diagnosis of baby complicated with both the VACTERL association and duodenal atresia

The VACTERL [vertebral defects (V), anal atresia (A), cardiac anomaly (C), tracheal-esophageal fistula with esophageal atresia (TE), renal defects (R), and radial limb dysplasia (L)] association can sometimes be diagnosed by ultrasonography and magnetic resonance imaging (MRI). Although the preaxial limb anomalies on ultrasonography were strongly associated with VACTERL association, the rate of limb anomalies is low. On ultrasonography, useful findings for prenatal diagnosis are a combination of esophageal atresia with hydramnion and renal anomalies. If esophageal atresia cannot be detected due to masking, diagnosis may be very difficult. In this case report, we reported the VACTERL association along with duodenal atresia. The detection of characteristic findings (enlarged stomach and duodenum, possibly change in gallbladder) by use of ultrasonography and MRI might be useful for the prenatal diagnosis of such cases.

Intrauterine intussusception presenting as fetal ascites at prenatal ultrasonography

Intrauterine intussusception, an uncommon cause of bowel obstruction, has rarely been detected by prenatal ultrasonography. We report two cases of intrauterine intussusception after gestation, which presented as isolated fetal ascites at 30 weeks of gestation by ultrasonography. In case 1, on the follow-up ultrasonography at 32 weeks of gestation, the previously observed ascites had disappeared, whereas the echogenicity of the bowel was increased without any sign of dilation, suggesting the presence of meconium peritonitis. The fetus was delivered at 39 weeks. In case 2, however, the amount of fetal ascites became increased, and the fetus was delivered at 34 weeks of gestation. After delivery, both infants were surgically explored with resection of the ileum with end-to-end anastomosis because of intrauterine intussusception and ileal atresia. From the experience of these cases, we suggest that the ultrasonographic finding of isolated or transient fetal ascites might contribute to the early diagnosis and management of intrauterine intussusception.

The effect of antenatal diagnosis on the management of small bowel atresia

The aim of this study was to determine whether babies with small bowel atresia (SBA) diagnosed antenatally followed a different course from those diagnosed postnatally. We reviewed the records of neonates admitted to a single institution between 1985 and 2000 with a diagnosis of SBA. Thirty-nine neonates presented with SBA, with antenatal diagnosis (AND) being made in 12 (31%). There was no difference between the AND and postnatal diagnosis (PND) groups in terms of gestational age at birth, but the AND group had a lower mean birth weight. The babies in the AND group were operated on more quickly than those in the PND group. Ten out of 12 (83%) AND patients required parenteral nutrition compared with 12 out of 27 (44%) in the PND group, and the AND group had a significantly longer mean length of stay and spent a longer time on parenteral nutrition than the PND group.