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Jejunal and Ileal Obstruction

Neonates with jejunal or ileal obstruction may also present with bilious vomiting depending on the level (most likely proximal) of obstruction. This clinical symptom is usually less severe than in duodenal obstruction.

A distended abdomen is virtually always present the more distal the level of intestinal obstruction. Failure to pass meconium may be an additional symptom. Atresia of the jejunum and ileum is twice as common as duodenal atresia, about equal in jejunum and ileum, with an incidence of 1 in 4-500 live births. Multiple atresias occur in 10%-20% of cases (Carty et al. 2005; Parker 2003; Grier 1999; Devos and Meradji 2003; Berrooal et al. 1999). Intestinal vascular accidents, such a thromboem-

Fig. 5.7. a Duodenal stenosis caused by a duodenal web with a "windsock" appearance. b Eccentric narrowing of the descending duodenum at the level of the sphincter of Oddi: annular pancreas b a

Fig. 5.7. a Duodenal stenosis caused by a duodenal web with a "windsock" appearance. b Eccentric narrowing of the descending duodenum at the level of the sphincter of Oddi: annular pancreas bolic occlusion, hypoxia or volvulus, are thought to be the cause of an atretic jejunum or ileum. This ischemic event may also cause perforation leading to meconium peritonitis. The atretic or stenotic intestinal segment is mostly monoloculated and rarely multiloculated.

The radiological diagnosis of obstruction is usually visible on the conventional (plain) radiograph. In uncomplicated cases these radiographs of the abdomen are sufficient. The pre-atretic intestinal loops are dilated because of accumulation of large amounts of fluid and fluid levels are usually present on horizontal beam films. In case of jejunal atresia only a few loops of distended jejunum are present in the left upper abdomen, while in ileal atresia many dilated loops are identified. In complicated cases, especially with an abnormally distended and painful abdomen, a colon enema or US can be useful- particularly from the differential diagnostic point of view to exclude meconium ileus or meconium peritonitis. In case of atresia, a microcolon without the presence of meconium is usually found (Devos and MEradji 2003).

sterile bowel contents (such as desquamated cells, lanugo hairs and vernix) escape into the peritoneal cavity causing an intense inflammatory reaction. This chemical peritonitis may lead to adhesions, granulomata, cystic changes and frequently to calcifications. The calcifications may extend into the scrotal cavity. Antenatal perforation due to meconium ileus in patients with cystic fibrosis is frequently the main cause of meconium peritonitis. A newborn with meconium peritonitis may have a distended, painful abdomen and may be lethargic. The child may have bilious vomiting and often produces no meconium.

Diagnosis is made by plain film and US. Plain film shows a swollen abdomen with a few or no air-containing bowel loops (Fig. 5.8). The bowel loops may be variably dilated. Often calcifications are visible. US shows not only the calcifications but also the extraluminal meconium and cystic fluid accumulations. The wall of the intestine is thickened (Fig. 5.9) (Parker 2003; Devos and Meradji 2003).

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