Arch Dis Child: first published as 10.1136/adc.38.201.459 on 1 October 1963. Downloaded from Arch. Dis. Childh., 1963, 38, 459. INTESTINAL OBSTRUCTION IN THE NEWBORN WITH SPECIAL REFERENCE TO TRANSIENT FUNCTIONAL ILEUS ASSOCIATED WITH RESPIRATORY DISTRESS SYNDROME BY PETER M. DUNN* From the Maternity Hospital, Birmingham (RECEIVED FOR PUBLICATION FEBRUARY 22, 1963) Surgical advances over the last half century have Case 10. Duodenal atresia; severe hydramnios and steadily reduced the mortality from intestinal premature labour; white stools, thick dark green-brown obstruction in the newborn. However, transient vomit and epigastric distension on second day. Radio- intestinal obstruction of functional rather than graph showed typical 'double-bubble' appearance. anatomical origin is not uncommon in the first Surgical correction on third day. Survived. few days of life. As surgery may be strongly Case 11. Ileal atresia; severe hydramnios; pale green contraindicated in this group, the differential stool, copious thick green-brown vomit and upper diagnosis is extremely important. It is hoped that abdominal distension on second day. Radiograph the following study of this problem made in a showed gross distension of intestine as far as the ileum and no gas below this level (Fig. 1). Surgical correction maternity hospital may indicate some of the clinical copyright. signs of value in the differential diagnosis. on second day. Survived. Case 12. Ileal stenosis due to very recent ulceration Clinical Material near the ileo-colic valve secondary to vascular insuffi- ciency; no hydramnios; premature caesarian delivery During 1960 and 1961, 4,754 babies were born at the because of toxaemia of pregnancy; abdominal distension Birmingham Maternity Hospital. Intestinal obstruction and bile-stained vomiting from the third day; meconium was diagnosed either at birth or during the first few passed daily; bowel sounds intermittent; radiograph days of life in 24 infants. In the former there was no (Fig. 2) showed 'general distension of the gut with air diagnostic difficulty; in the latter, the diagnosis was based down to the rectum; a few small fluid levels present; http://adc.bmj.com/ on the presence of at least two and usually all three of probably an ileus rather than an obstruction'. Surgical the following signs-abdominal distension, delayed correction on sixth day. Survived. passage of meconium and bile-stained vomiting. In The remaining 12 infants (Cases 13-24) presented with 12 infants the intestinal obstruction was due to an signs of intestinal obstruction during the first three days anatomical abnormality. In nine (Cases 1-9) this was of life due to either a functional ileus or to a meconium apparent at birth; in three (Cases 10-12) it became plug. Their clinical features are summarized in Table 1 apparent during the first few days of life. Short case and their case histories reported below. summaries are given below. Case 13. A girl, weighing 2 lb. 10 oz. (1,290 g.), was on September 25, 2021 by guest. Protected Case 1. Duodenal atresia; stillborn; maternal delivered by caesarian section at 33 weeks' gestation hydramnios present. because of maternal toxaemia of pregnancy. Condition Case 2. Duodenal stenosis and multiple abnor- at birth was poor and for three days she was critically ill malities; died on first day; no maternal hydramnios. with respiratory distress and cyanotic attacks. Normal Case 3. Ileal atresia; stillborn following a destructive meconium was passed in small amounts from the first operation because of dystocia due to gross foetal day. Generalized abdominal distension and small bile- abdominal distension. No maternal hydramnios. stained vomits were noted on the second day and con- tinued for a further two days. Moderate jaundice also Cases 4-9. Imperforate anus, six cases. One still- developed. From the fifth day steady progress was made born; two with other malformations died; three survived. and she returned home after seven weeks weighing No maternal hydramnios. 4 lb. 11 oz. (2,124 g.). Case 14. This boy, weighing 2 lb. 14 oz. (1,303 g.), *Present address: Bristol Maternitv Hospital, Bristol, was born by normal delivery at 33 weeks. The mother, 459 Arch Dis Child: first published as 10.1136/adc.38.201.459 on 1 October 1963. Downloaded from TABLE SUMMARY OF THE CLINICAL FINDINGS, TREATMENT, Signs of Intestinal Case No. Birth Weight Obstetric and Type of Gestation Abdeminal First Bowel and Sex (lb. oz.) Maternal Factors Delivery (wks) Distenision Action (day) (day) 13 F 2.10 Uterine fibroids; severe pre-eclamptic Caesarian 33 Generalized: 1 d toxaemia section 2%d-4th 14 M 2.14 Severe pre-eclamptic toxaemia; accidental Normal 33 Generalized: 2 antepartum haemorrhage; heavy sedation 3rd-6th 15 M 5.14 Previous caesarian sections for dispropor- Caesarian ?35 GOeneralized: 2 tion section Ist-Sth 16 F 5.2 Placenta praevia; antepartum haemorrhage Caesarian 35 Generalized: 3 section ist-4th 17 M 7.11 Accidental haemorrhage; heavy sedation Normal 36 Generalized: 2 (morphia) and surgical induction 3rd-4th 18 M 5. 15 Hydramnios; bicornuate uterus; premature Breech 32 Generalized: 2 labour 2nd-6th 19 M 7. 10 Diabetes mellitus; moderate hydramnios; Forceps 33 Generalized: 3 premature labour 3rd-4th 20 M 8.0 Diabetes mellitus; moderate hydramnios Caesarian 35 Generalized: 3 section 3rd-4th 21 F 6.2 Diabetes mellitus Caesarian 36 Generalized: 3 section 3rd 22 M 6.5 Twin pregnancy; rhesus immunization Forceps 38 Generalized: 2 Ist-6th 23 F 5. Bicornuate uterus; extended breech presen- Breech 41 Generalized: 2 tation; placental infarction 2nd 24 F 7.12 Placenta praevia; repeated small ante- Caesarian 37 Generalized: 2 partum haemorrhages section 2nd copyright. B = bile-stained. .. http://adc.bmj.com/ on September 25, 2021 by guest. Protected FIG. 1.-Case 11: Ileal atresia on the second day. (a) Supine A-P view; (b) inverted lateral view. Arch Dis Child: first published as 10.1136/adc.38.201.459 on 1 October 1963. Downloaded from RESULTS AND FINAL DIAGNOSIS IN CASES 13-24 Obstruction Character of Vomiting Concomitant Clinical Treatment Result Final Diagnosis First Stool (day) Findings Meconium - (B) Poor condition at birth; severe respiratory distress; Medical Alive Functional ileus 2nd, 3rd, 5th cyanotic attacks; moderate jaundice Meconium - (B) Poor condition at birth; severe respiratory distress; Medical Alive Functional ileus 3rd cyanotic attacks Meconium - (B) Severe respiratory distress; moderate jaundice Medical Alive Functional ileus 2nd-3rd Meconium - (B) Poor condition at birth; severe respiratory distress Medical Alive Functional ileus 2nd Meconium Poor condition at birth; respiratory distress; cyanotic Medical Alive Functional ileus attacks Meconium (B) Poor condition at birth; severe respiratory distress; Medical Alive Functional ileus 2nd-4th severe jaundice Meconium Cushinoid appearance; severe respiratory distress; Medical Alive Functional ileus; plug severe jaundice meconium plug Meconium Cushinoid appearance; respiratory distress Medical Alive Functional ileus; plug 3rd meconium plug Meconium + (B) Respiratory distress Medical Alive Functional ileus; plug 3rd meconiuni plug Meconium (B) First twin; severe Rh haemolytic disease (cord Hb Medical Alive Functional ileus 2nd-6th 35%); exchange transfusion; inspissated bile syndromiie; haemorrhagic disease Meconium Poor condition at birth; cerebral irritability Medical Alive Functional ileus 2nd Meconium -- (B) Poor condition at birth; shock due to foetal Operation Alive Functional ileus: 2nd exsanguination (cord Hb 55%); transfusion at (2nd day) ? meconium plug birth copyright. http://adc.bmj.com/ on September 25, 2021 by guest. Protected FIG. 2.-Case 12. Ileal stenosis near the ileo-colic valve of recent origin on the 3rd day. (a) Supine A-P view; (b) inverted lateral view. Arch Dis Child: first published as 10.1136/adc.38.201.459 on 1 October 1963. Downloaded from 462 ARCHIVES OF DISEASE IN CHILDHOOD aged 36, who had had two abortions previously, had cyanotic attacks attributed to respiratory distress been admitted following an accidental haemorrhage syndrome. Abdominal distension was noted on the complicating severe toxaemia. She was heavily sedated third day and a radiograph on the fourth day showed and when she went into labour shortly afterwards, the moderate gaseous distension of the intestine down to the foetal heart could not be heard. However, the baby was rectum. A trace of meconium was passed on the second born alive, though in very poor condition and rapidly and third days but was not passed in any quantity developed respiratory distress syndrome. For the first until the fourth day. Thereafter the distension subsided two days he was very ill-limp, lethargic, oedematous and progress was normal. and having cyanotic attacks-but thereafter showed improvement, and feeding was commenced. On the Case 18. A boy weighing 5 lb. 15 oz. (2,692 g.) was third day, abdominal distension was noted and he born by breech extraction at 32 weeks' gestation. The vomited bright green material. Only two small meco- mother had been admitted in labour following premature nium stools had been passed since birth, the first on the rupture of the membranes. Because considerable second day. The abdomen was silent. He was treated hydramnios had been noted a stomach tube was passed conservatively over the next four days. There was no soon after birth to exclude oesophageal atresia. The further vomiting and one meconium stool was passed baby was difficult to resuscitate and soon exhibited each day. At the end of the first week, visible bowel signs of respiratory distress syndrome with which pattern was seen, more stools were passed and the dis- condition he remained critically ill for three days. He tension subsided. When 8 weeks old, he was discharged also became severely jaundiced. Feeding was com- weighing 5 lb. (2,267 g.). menced on the second day and at that time abdominal Case 15. This boy was delivered by elective caesarian distension was first noted. This continued until the section at '39' weeks' gestation because of two previous seventh day.