Immediate Surgical Evaluation is Required
This newborn requires immediate pediatric surgical consultation before any diagnostic imaging studies, as the combination of absent bowel sounds with abdominal tenderness indicates peritonitis or bowel compromise that mandates urgent surgical evaluation. 1
Critical Clinical Context
The presentation of absent bowel sounds combined with abdominal tenderness represents peritoneal signs suggesting bowel ischemia, perforation, or advanced obstruction—all surgical emergencies that cannot wait for diagnostic imaging. 1 This clinical picture differs from uncomplicated distal obstruction where contrast enema would be appropriate after plain radiographs. 1
Why Surgical Evaluation Takes Priority
Peritoneal signs override imaging algorithms: The American College of Radiology explicitly recommends proceeding directly to surgery when peritonitis is present on examination, as delaying surgical consultation for imaging studies can lead to significant morbidity and mortality. 1, 2
Midgut volvulus risk: 20% of neonates with bilious vomiting in the first 72 hours have midgut volvulus requiring urgent surgery, and this condition can present with absent bowel sounds and tenderness when bowel compromise has occurred. 1
Time-sensitive pathology: Neonates with unrecognized intestinal obstruction deteriorate rapidly, showing increased morbidity, and appropriate surgical treatment becomes more hazardous with delays. 3
The Standard Algorithm (When Peritoneal Signs Are Absent)
For comparison, in a newborn with delayed meconium passage and distention without peritoneal signs, the appropriate sequence would be:
Plain abdominal radiographs first: These demonstrate the level of obstruction, showing dilated bowel loops and presence/absence of distal gas. 4, 1, 2
Contrast enema second: For suspected distal obstruction (multiple dilated loops with absent distal gas), contrast enema is the diagnostic imaging procedure of choice, differentiating between meconium plug (therapeutic), ileal atresia (surgical), or Hirschsprung disease (requiring rectal biopsy). 4, 1, 2
Rectal biopsy when indicated: A transition zone on contrast enema combined with delayed meconium passage, abdominal distension, and vomiting strongly suggests Hirschsprung disease and warrants rectal biopsy for definitive diagnosis. 5, 6
Key Pitfall to Avoid
Never delay surgical consultation for imaging in a neonate with peritoneal signs. The absence of bowel sounds with tenderness is not simply obstruction—it suggests compromised bowel that may require immediate laparotomy. 1 Barium enema studies are contraindicated when perforation is suspected, and the time spent obtaining imaging could result in irreversible bowel necrosis or sepsis.
Surgical Evaluation Will Include:
- Immediate assessment for surgical abdomen requiring laparotomy
- Intraoperative decision-making regarding the need for rectal biopsy if Hirschsprung disease is suspected after excluding other causes
- Management of potential intestinal atresia, volvulus, or perforation found at surgery
The surgical team can obtain appropriate imaging (if safe) or proceed directly to operative intervention based on clinical stability and examination findings. 1, 2