Intestinal obstruction: the most frequent forms in paediatric age
Intestinal obstruction is a complex syndrome characterised by the intestinal transit of faeces and gas being blocked. The most frequent forms in paediatric age are mechanical in nature
Intestinal obstruction is a complex syndrome characterised by the arrest of the intestinal transit of faeces and gas
It can be functional, due to the arrest of intestinal motility (typical of peritonitis), or mechanical due to an obstacle to intestinal transit.
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The most frequent forms of intestinal obstruction in the paediatric age are those of a mechanical nature.
The most common are represented by:
- Intestinal invagination in children aged between 4 and 12 months;
- Choked hernia in patients up to 3-4 years of age;
- Intestinal volvulus on Meckel’s diverticulum in children aged 4-12 years;
- Occlusion by adherent bridges in patients who have previously undergone abdominal surgery (ex. outcome of peritonitis).
The occlusive syndrome is represented by this symptom “poker”:
- Abdominal pain with often violent colic progression;
- Biliary vomiting (bottle green in colour);
- Increased intestinal meteorism;
- Stopped gas and stool emission.
The “parade” of symptoms may also be associated with a general condition that varies according to the site and nature of the mechanical obstruction.
In fact, in some children it may be well preserved, while in others a real state of shock may occur, with a characteristic suffering facies and a small and frequent pulse (typical of intestinal volvulus).
Paediatrician’s diagnosis of intestinal obstruction
Objective examination (physical examination) reveals a distended and globular abdomen due to the increased amount of intestinal gas, while palpation may give the sensation of a “balloon full of air”, and in some cases palpatory pain may be evoked (sign of worsening).
On palpation there may be an increase in bowel movements (peristalsis) or true auscultatory silence, the latter being typical of the late stages when peritonitis due to intestinal perforation secondary to occlusion sets in.
Any abdominal pain accompanied by bile green vomiting and other important general signs always requires referral to a specialist to reduce the risk of a late diagnosis.
The diagnosis of intestinal obstruction should always be made by a specialist, because it is not always as easy or intuitive as in the case of intestinal volvulus from Meckel’s diverticulum.
An X-ray examination performed with targeted projections is almost always conclusive for diagnosis.
An ultrasound examination, and in selected cases a computed tomography (CT) scan, can help in making the diagnosis.
Once a mechanical bowel obstruction has been diagnosed, emergency surgery is always mandatory.
In selected cases, conservative medical treatment can be attempted by decompressing the intestine with a nasogastric tube.
Surgery varies depending on the aetiology and severity of the intestinal obstruction
It can be limited to simple evagination manoeuvres (in the case of intestinal invagination), or intestinal debridement and repositioning (in the case of intestinal adhesions), or more complex interventions such as intestinal resection (in the case of Meckel’s diverticulum) may be necessary.
In the case of intestinal obstruction with bowel perforation and severe secondary peritonitis, a temporary ostomy (preternatural anus) may be performed, which will be closed after a few months (usually 3-6 months).
In the most serious cases of intestinal obstruction, the surgical procedure is combined with the placement of a central venous catheter, which allows venous hyper-nourishment of the young patient to compensate for the prolonged fasting caused by the delayed recovery of intestinal function (delayed channelling) that follows the surgical procedure.
Postoperative problems depend on the severity of the intestinal obstruction and the complexity of the surgery.
In the case of intestinal invagination the small patient is discharged after 4-5 days.
In occlusions in which intestinal resections are performed or in which a stoma is performed, the postoperative course may be longer and more complex.
Once the occlusion has been resolved, with the resumption of intestinal canalization and normal oral intake, the child is discharged with the cautions typical of all abdominal surgeries such as rest from physical activity for a few months and a regular and never immoderate diet.
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