Patient Case Discussion
Case Summary
Newborn Baby's Abdominal Distension
This case involved a term baby girl with abdominal distension and failure to pass meconium, transferred from an outside hospital for further evaluation and management. The patient was a newborn baby girl, 39 and 3 weeks old, with abdominal distension and failure to pass meconium. The baby was born via C-section at an outside hospital. The clinical team reviewed the baby's exam, noting abdominal distension and a nasogastric tube with bile. They also discussed potential hernias and the importance of rectal irrigation in the diagnostic process. The prenatal history showed no fetal abnormalities at 20 and 30 weeks of gestation. The team agreed that more proximal obstructions are typically more obvious on prenatal ultrasound, while distal obstructions may not be visible until later. The baby was stable with no hemodynamic compromise. The team decided to proceed with X-rays to further assess the situation.
Lower Distal Bowel Obstruction Diagnosis
Radiological findings of a patient's abdomen were discussed, including the presence of numerous dilated bowel loops, lack of air in the rectum, and an NG tube. These results suggested the possibility of distal bowel obstruction and listed potential differential diagnoses, such as Hirschsprung disease, distal ileal atresia, and meconium ileas. The team agreed with this assessment. The radiologist confirmed the presence of a lower distal bowel obstruction and suggested the differential diagnosis includes distal atresia, Hirschsprung disease, and meconium ileus, but noted the presence of air fluid levels makes distal atresia a more likely cause.
Ileal Obstruction Contrast Enema Strategy
Moderator Dr. Sherif Emil discussed the next steps to take when encountering a patient with a suspected ileal obstruction. The consensus was to perform a contrast enema to evaluate the rectosigmoid junction, rule out Hirschsprung disease, and assess for potential meconium ileus or plug. The radiologist was asked to ensure the contrast passes into the colon, refluxes into the terminal ileum, and to look for signs of total colon Hirschsprung disease. The participants agreed that the contrast enema would be both diagnostic and potentially therapeutic.
Hydrosoluble Contrast in Rectal Examinations
The use of hydrosoluble contrast in rectal examinations to diagnose microcolon was discussed, likely due to distal small bowel atresia. It was noted that the absence of contrast reflux into the small bowel and the presence of fecal matter within the microcolon were key features. The team ruled out total colonic Hirschsprung disease because of the absence of reflux into the small bowel. Dr. Emil emphasized the importance of these findings in determining the location of the obstruction and the patency of the colon.
Case Study: Functional Structure Approach
A case study was presented of a functional structure approach. The team discussed the use of a transverse incision and a peri-umbilical approach. They detailed their approach to the case, which involved an omega incision at the superior aspect of the umbilical crease. They encountered unexpected dense adhesions and a hostile abdominal environment, which led to a prolonged and challenging dissection. The team identified an atresia at the terminal ileum and a perforated loop of bowel that had adhered to the liver. They discussed the potential for calcifications or meconium cysts in future cases.
Difficult Dissection and Anastomosis Discussion
A case involving a baby who was hemodynamically stable and underwent a difficult dissection was discussed. The baby received a transfusion and was operated on 24 hours after birth. The team discussed the decision whether to divert or anastomose, noting that both options were reasonable. The baby was clinically doing well, full feet, and meeting weight.
Ischemic Bowel Conditions and Anastomosis
A case involving a post-fixation specimen with a dilated bowel and atresia was discussed. The team reported on the histological findings, including the appearance of the proximal and distal resection margins, the presence of dystrophic calcification, and the abnormal color and texture of the Rosa. Also mentioned was the presence of inflammation and adhesions. It was suggested that the distal portion of the resection may have been ischemic, and there were questions about calcification. The team concluded the presentation by discussing the rationale for performing a primary anastomosis in this case, given the patient's stable condition and the potential complications of a stoma.