What are the causes and management of pediatric subacute bowel obstruction (Partial Intestinal Obstruction)?

From the Guidelines

Pediatric subacute bowel obstruction should be managed with a focus on improving quality of life, while minimizing the risk of mortality and morbidity, and the primary goal of treatment should be to alleviate symptoms and prevent complications. The management of pediatric subacute bowel obstruction involves a multidisciplinary approach, including bowel rest, nasogastric decompression, and intravenous fluid resuscitation 1. The child should receive nothing by mouth (NPO), have a nasogastric tube placed for decompression, and receive IV fluids with electrolyte replacement (typically normal saline or Ringer's lactate at 1.5-2 times maintenance rate).

Key Considerations

• Pain management with medications like morphine (0.05-0.1 mg/kg IV every 4-6 hours) or hydromorphone (0.01-0.02 mg/kg IV every 4-6 hours) should be provided to alleviate discomfort and prevent complications 1.
• Antiemetics such as ondansetron (0.1 mg/kg IV every 6-8 hours, maximum 4 mg) can help control vomiting and prevent dehydration.
• Serial abdominal examinations and imaging (abdominal X-rays every 12-24 hours) are essential to monitor progression and detect any potential complications early.
• The use of octreotide, an anticholinergic, can be considered to manage symptoms, especially if the prognosis is greater than 8 weeks 1.

Risks and Complications

• The risk of mortality, morbidity, and re-obstruction should be discussed with the patient's family, and the management plan should be tailored to minimize these risks 1.
• Risk factors for poor surgical outcome include ascites, carcinomatosis, palpable intraabdominal masses, multiple bowel obstructions, previous abdominal radiation, very advanced disease, and poor overall clinical status 1.

Management Approach

• A conservative management approach should be considered first, with surgical consultation necessary if symptoms worsen or fail to improve. Common causes in children include adhesions from previous surgery, intussusception, malrotation, or foreign body ingestion.
• The subacute nature of the obstruction suggests partial rather than complete obstruction, which allows time for conservative management, but close monitoring is crucial as deterioration can occur rapidly in children due to their smaller fluid reserves and risk of dehydration.

From the Research

Definition and Diagnosis of Paediatric Sub Acute Bowel Obstruction

• Paediatric sub acute bowel obstruction refers to a condition where there is a partial or complete blockage of the bowel in children, which can lead to severe complications if not diagnosed and treated promptly 2.
• The diagnosis of bowel obstruction in children can be challenging due to non-specific symptoms, and bedside ultrasonography performed by a pediatric emergency physician can be a useful tool in diagnosing small bowel obstruction 2.

Types of Paediatric Bowel Obstruction

• Paediatric intestinal pseudo-obstruction (PIPO) is a rare disorder characterized by the clinical features of bowel obstruction in the absence of mechanical occlusion, and its management presents a challenge due to limited evidence on available medical and surgical therapy 3.
• Adhesive bowel obstruction is a common cause of bowel obstruction in children who have had previous abdominal surgery, with an incidence of 1-12.6% 4.
• Short bowel syndrome is a serious condition that occurs in children with congenital or acquired reduction in length of the small intestine, resulting in excessive fluid loss, nutrient malabsorption, and electrolyte abnormalities 5.
• Neonatal bowel obstruction is a common reason for admission to neonatal ICUs, with an estimated incidence of 1 in 2000 live births, and its presentation can vary from subtle to severe symptoms 6.

Management and Complications of Paediatric Bowel Obstruction

• The management of PIPO often involves parenteral nutrition, and long-term therapy may culminate in life-threatening complications, including intestinal failure-related liver disease, central line thrombosis, and sepsis 3.
• Adhesive bowel obstruction usually requires surgical intervention, although conservative management is usually trialled first, and new materials such as Seprafilm® have been studied to prevent the formation of adhesions 4.
• The primary goal of treatment for short bowel syndrome is to restore enteral autonomy and reduce long-term dependence on parenteral support, and treatment options include pharmacologic agents, parenteral nutrition, dietary strategies, surgical lengthening procedures, and small bowel transplant 5.
• Neonatal bowel obstruction requires prompt diagnosis and treatment, including concomitant resuscitation, to prevent severe complications and improve outcomes 6.