Familial small bowel atresia and stenosis

A proposed classification system for familial intestinal atresia and its relevance to the understanding of the etiology of jejunoileal atresia

Familial cases of the various types of intestinal atresia are well described, and we now report an additional family. Based on a review of the literature, a classification system for the different types of familial atresia is presented. Current teaching attributes most jejunoileal atresias to in utero vascular accidents occurring relatively late in gestation (after the 11th or 12th week). Although some cases clearly occur this way, as a result of processes such as volvulus and intussusception, knowledge of the familial form of the disease indicates that most cases of jejunoileal atresia actually result from disruption of a normal embryologic pathway, most likely the development of the superior mesenteric artery and its branches. They should be considered to be true embryologic malformations rather than acquired lesions.

Intestinal atresia

Intestinal atresia accounts for about one third of all cases of neonatal intestinal obstruction. The survival rate has improved to 90% in most of the series with the operative mortality being < 1%. The survival rate improves with distal atresias. An increased mortality is observed in multiple atresias (57%), apple peel atresia (71%), and when atresia is associated with meconium ileus (65%), meconium peritonitis (50%) and gastroschisis (66%). Although appearance of echogenic bowel on prenatal ultrasonography is suggestive of GI, it is confirmed in only 27% cases. Prenatal ultrasonography is more reliable in detection of duodenal atresia than more distal lesions. Short bowel syndrome is the major impediment in the management of jejunoileal atresia. Although total parenteral nutrition (TPN) is the main adjunctive treatment, it delays intestinal adaptation and may cause cholestasia and subsequent liver damage. Graduated enteric feedings, use of growth hormone, glutamine and modified diets containing low fat, complex carbohydrates and protein supplements have been used in a adults with short bowel syndrome to successfully diminish TPN requirements and enhance nutrient absorption in nearly half of the patients. Utilization of growth factors to facilitate intestinal adaptation and advances in small bowel transplant may improve the long-term outcomes in future.

Malrotation of the intestine

Malrotation of the intestinal tract is a product of a well defined aberrant embryology. Because the consequences of malrotation associated with a midgut volvulus may be catastrophic, an understanding of the anatomy, diagnostic criteria, and appropriate therapy for this putative emergency illness is imperative. This report summarizes a recent 18-month experience with this diagnosis and contrasts this experience with that in the published literature. More than half (14/22) of the patients presented during the first month of life, and all had vomiting, which in most cases was bilious. The barium upper gastrointestinal series was the preferred diagnostic study, being both sensitive (18/19, 95%) and accurate (18/21, 86%). In this series two-thirds of the patients presented with volvulus (15/22, 68%) of whom five had ischemic intestine requiring resection. One of these children died of overwhelming sepsis. A Ladd procedure was the preferred treatment, which as defined by us includes evisceration and inspection of the mesenteric root, counterclockwise derotation of a midgut volvulus, lysis of Ladd's bands with straightening of the duodenum along the right abdominal gutter, inversion-ligation appendectomy, and placement of the cecum into the left lower quadrant. A high index of suspicion in the neonate with vomiting, rapid diagnosis, and appropriate operative therapy results in a predictable favorable outcome for children with intestinal malrotation.

Familial intestinal malrotation with midgut volvulus and facial anomalies: a disorder involving a gene controlling the normal gut rotation?

We report on 2 sisters with congenital midgut volvulus. Both had similar facial changes different from those of their parents and the other 2 unaffected sibs. Both parents had normal barium meal roentgenograms. The occurrence of these abnormalities in sibs born to parents with apparently normal gastrointestinal tract anatomy suggest autosomal recessive inheritance, although a coincidence, multifactorial or autosomal dominant inheritance with nonpenetrance in either of the parents cannot be excluded.

Familial duodenal atresia: a report of two families and review

We report on 2 families with recurrence of uncomplicated duodenal atresia. The presence of consanguinity in one family, the frequent occurrence of consanguinity in parents of affected children previously reported, and the equal sex ratio suggest autosomal recessive inheritance.