Bowel Atresia

PSS Pediatric Lecture

Bowel Atresia
Intestinal atresia is a broad term used to describe a complete blockage or obstruction anywhere in the intestine.
Occurrence: Every 1 in 1500
About half are pre-matured. Other congenital diseases. 30 % down syndrome.

Bowel Atresia

Types of Bowel Atresia

Type of atresia depends on anatomy
Duodenal atresia Jejunal atresia Ileal atresia Colon atresia

Duodenal atresia has a strong association with Down Syndrome. It is the most common type, followed by ileal atresia.

High Atresia
Duodenal Atresia
First part of the small bowel is blocked, there is only a small amount of dilated or "ballooned" intestine seen due non progression in the development during embryo development 20-30% of infants with duodenal atresia have Down syndrome Associated with other birth defects

Low Atresia
Jejunal atresia - obstruction in the middle part of the intestine
Ileal atresia - obstruction in lower part of the intestine May also be called Jejunoileal atresia.

Bowel Atresia
Confirmation of Bowel Atresia
Polyhydramniosus indications that the fetus may have a bowel obstruction which a more detailed ultrasound study can confirm Plain abdominal radiography of the kidneys, ureters, and bladder (KUB) Barium enema study

Types of Atresia
Type Type I The blockage is created by a membrane (web) present on the inner aspect of the intestine. The intestine usually develops to a normal length. The dilated intestine terminates as a blind end. It is connected to a smaller caliber segment of the intestine by a fibrous scar. The intestine develops to a normal length. The blind ends of intestine are separated by a defect in the intestinal blood supply. This often leads to a significantly shortened intestinal length that may result in long-term nutritional deficiencies or the short gut syndrome. Multiple regions of obstruction exist. This may result in a very short length of useful intestine.

Type II

Type IIIa IIIb

Type IV

Duodenal atresia

Colonic atresia in an infant. The atresia was at the level of the mid-descending colon, with massive colonic distention and microcolon

Ileal Atresia - Multiple dilated loops of proximal small bowel

Treatment
Fetal and neonatal intestinal atresia are treated using laparotomy after birth. If the area affected is small, the surgeon may be able to remove the damaged portion and join the intestine back together. In instances where the narrowing is longer, or the area is damaged and cannot be used for period of time, a temporary Stoma (medicine) may be placed.

Procedural Considerations
Laparotomy set and GI instruments set ESU and suction machine Linear stapler Stoma appliances (eg: colostomy rod, rubber tubing, etc.) NG Tube is inserted after intubation Indwelling urinary catheter is inserted

Procedural Considerations
Minimizing tissue trauma and inflammation with meticulous technique
Reducing the time that the abdomen is open

Irrigating the abdomen with copious amounts of warmed solution before closure
Administering antiinflammatory drugs such as corticosteroids and NSAIDs

Positioning Considerations
Supine position Arms extended on locked armboards at less than a 90degree angle A forced air warming blanket Synchronous compression leggings Put on diathermy pad

 Under General anesthesia

Loss of consciousness Suppression of reflexes Muscle relaxation

Anesthesia effects/drugs

Analgesia

Inhalational Induction: Volatile Agents

Older Halothane Enflurane Isoflurane Newer Sevoflurane Desflurane

Anesthesia effects/drugs
Halothane
Good for inducing children Induction /recovery slow Useful in asthmatics, obsterics Myocardial depressant Arrhythmogenic Postop. Shivering Small risk of halothane hepatitis (avoid repeat halothane within 6 months)

Anesthesia effects/drugs
Hypoventilation Prolonged unconsiousness Confusion, agitation Pain Nausea and vominting Hypotension

Hypertension

Perioperative Nursing Considerations

Pre operative
After diagnosis, investigations & preparations follow
Nil By Mouth (NBM)

Baby should be kept warm with humidified air Vital signs should be frequently assed and oxygen saturation should be monitored Nasopharyngeal aspiration should be done frequently Laboratory investigations are performed: blood is cross-matched Baseline bloods, electrolytes
Oral-gastric tube should be placed for decompression and to avoid aspiration Urinary catheterization for output to ensure hemodynamic stability Intubation for respiratory support in patients with severe abdominal distension or sepsis may be necessary Electrolytes (metabolic and hemodynamic) should be corrected prior to surgery 1 mg of vitamin K is intramuscularly (IM) Broad-spectrum antibiotics are intravenously (IV)

Risk factors to consider

Pharmacology to consider

Perioperative Nursing Considerations

Intra operative
Careful monitoring Blood loss is quantified, intravascular volume kept adequate Anaesthesia effects for neonates Positioning: Supine Premorbidity status of neonate

Perioperative Nursing Considerations

Post operative
Immediate nursing care considerations
NBM Intravenous Fluids Nasogastric Decompression Central Venous Line for Total Parital Nutrition To NICU Close monitoring for vital signs, oxygenation Nausea, upset stomach or vomiting Decreased Blood Pressure Lightheadedness/dizziness Apnea disoriented or delirious Pain - crying, irritability or restlessness Check surgery site for bleeding Gastric output

Recovery room care

Patient & Family Education

Family should be educated on long term effects of illness
Provided there is plenty of bowel length there are no long term consequences of small bowel atresia. If a moderate amount of bowel is missing the baby may have rather loose and frequent bowel motions but this tends to improve over a few months. Following an operation there is always a small risk of future obstruction occurring. If your baby has a bilious vomit or a distended abdomen medical advice should be sought.

Special Care Post Operatively

To watch signs for the following including:
Infection:
Redness and Swelling over surgical site Fever

Intestinal obstruction:
Nausea and vomiting Not taking feeds Distended abdomen

Discharge
The baby will only be discharged when

- Incision is healing well

- Afebrile - Drink, Urinate and have regular bowel movement

At home - formula or breast milk - Pain medication as per DR instruction. Eg, acetaminophen (TYLENOL) - Appointment 2 weeks later

References
Aronson, J. (2009). Meylers side effects of drugs used in anesthesia. California: Elsevier. Retrieved from http://www.scribd.com/doc/35576860/Meylers-Side-Effects-of-DrugsUsed-in-Anesthesia-2009 Cincinnati Children's Hospital Medical Center. (2010, August). Intestinal atresia and stenosis. Retrieved from http://www.cincinnatichildrens.org/health/i/obstructions/ Shalkow, J. (2010, March). Small intestinal atresia and stenosis . Retrieved from http://emedicine.medscape.com/article/939258-overview University Hospital Southampton. (2010, January). Small bowel atresia. Retrieved from http://www.uhs.nhs.uk/OurServices/Childhealth/Neonatalsurgery/Con ditionswetreat/Smallbowelatresia.aspx/