Initial Management of Neonatal Intestinal Obstruction (Suspected Hirschsprung Disease)
The correct answer is D - nasogastric decompression with supportive care is the initial management for this full-term neonate presenting with tachypnea, abdominal distention, and contrast enema findings consistent with Hirschsprung disease.
Immediate Stabilization
Nasogastric tube decompression is the cornerstone of initial management to relieve abdominal distention and prevent aspiration in neonates with intestinal obstruction 1, 2.
Intravenous crystalloid fluid resuscitation should be initiated immediately to correct fluid and electrolyte imbalances that occur with bowel obstruction 1, 2.
Insert a Foley catheter to monitor urine output and assess adequacy of resuscitation 1.
Administer broad-spectrum antibiotics covering gram-negative and anaerobic organisms if there is evidence of perforation, ischemia, or enterocolitis 2, 3.
Why Not the Other Options?
Exchange transfusion (Option A) has no role in managing intestinal obstruction or Hirschsprung disease - this would only be indicated for conditions like severe hyperbilirubinemia or hemolytic disease.
Immediate surgical intervention (Option B) is premature before adequate resuscitation and stabilization. Surgery is definitive treatment but should follow initial stabilization with nasogastric decompression and fluid resuscitation 1, 2.
Extended antibiotics alone (Option C) are insufficient as primary management. While antibiotics may be needed if enterocolitis develops (a complication occurring in up to one-third of Hirschsprung patients), they do not address the mechanical obstruction requiring decompression 4.
Diagnostic Confirmation
The contrast enema findings of proximal dilation with narrowing of the descending colon suggest a transition zone characteristic of Hirschsprung disease 4, 5.
Rectal suction biopsy is required to confirm the diagnosis by demonstrating absence of ganglion cells and hypertrophic nerve trunks in the colonic submucosa 4, 5.
This can be performed after initial stabilization and does not delay supportive management 4.
Critical Monitoring During Initial Management
Monitor closely for signs of Hirschsprung-associated enterocolitis, which is a significant cause of mortality and includes fever, explosive diarrhea, and worsening abdominal distention 4, 5.
Watch for clinical deterioration including peritonitis, increasing white blood cell count, and rising lactate that would necessitate urgent surgical intervention 1, 3.
Assess for signs of intestinal ischemia or perforation through serial clinical examinations and laboratory monitoring 1, 2.
Definitive Management Planning
Once the infant is stabilized with nasogastric decompression and fluid resuscitation, surgical consultation should be obtained for definitive treatment 2.
Surgical removal of the aganglionic bowel segment (Swenson, Soave, or Duhamel procedure) is the definitive treatment but should only proceed after proper stabilization 5.
Early diagnosis through this systematic approach is important to prevent life-threatening complications such as enterocolitis and colonic rupture 4.