0:00

Last but not least, we're gonna talk about the classic

0:03

x-rays appearance of the neonatal bowel obstructions.

0:06

So this was a newborn infant

0:07

who has a repo type enteric tube

0:09

with the tip just into the proximal stomach.

0:12

And we have a markedly dilated loop

0:14

of bowel in the central abdomen.

0:16

So, um, my favorite description of um, distinguishing

0:20

between proximal

0:21

and a distal obstruction is you draw a line along the

0:26

equator, if you will.

0:27

So you're looking at your northern hemisphere,

0:29

which is the upper abdomen,

0:30

and then you're looking at the southern hemisphere

0:32

and the equator is the umbilicus.

0:35

So if you have as many dilated ball loops above the equator

0:39

as below the equator,

0:40

then you're looking at a distal BGAs obstruction.

0:44

If you have more dilated bowel loops north of the equator,

0:48

then you're thinking about proximal obstruction

0:50

and you'll go on to upper GI as the next step.

0:53

If you have a distal obstruction, typically

0:55

with in the absence of ous emesis,

0:58

then you go on to contrast enema.

1:00

So let's look at this example.

1:01

We have this markedly dilated loop of bowel in the kind

1:05

of center of the abdomen.

1:06

This baby has this umbilical clamp along our equator.

1:10

This patient has more dilated loops

1:12

above the equator than below the equator.

1:15

So this patient would be proximal obstruction would

1:18

and would go to upper GI

1:19

as the next step in the workup of this infant.

1:23

Same thing for this infant.

1:24

So it can be challenging if you have a opal type enteric

1:27

tube where they have been decompressing the stomach,

1:30

but we have more dilated bowel loops

1:32

above the equator than below.

1:35

And so, um, this would be concerning

1:37

for proximal obstruction.

1:38

The next step in the workup

1:40

of this infant would be upper gi, um,

1:42

rather than contrast enema.

1:44

And this actually was a case of a anular pancreas.

1:46

And so we had a dilated proximal duodenum

1:49

and this stomach should be more dilated,

1:51

but it's decompressed by this enteric tube.

1:55

How about this one? So we have crazy

1:57

dilated bowel loops everywhere.

1:58

When you have a loop of bowel

2:00

that is this massively distended, you know

2:02

that it's some sort of an in utero longstanding dilation

2:06

'cause this bowel loop had time to get

2:08

that markedly dilated.

2:10

So again, we draw our equator along the

2:12

umbilicus of this infant.

2:14

We have about as many dilated bowel loops above

2:17

and below the equator.

2:18

So this is probably gonna be a distal obstruction.

2:20

And this patient will go on

2:22

to contrast enema in the next step

2:23

of their bowel obstruction workout.

2:27

One more example of distal balgas obstruction.

2:31

We draw a line along the equator of this infant.

2:34

We have as many dilated bowel loops above

2:36

and below this, um, equator.

2:39

Same thing with this infant over here

2:41

who has an umbilical venous catheter to help us try to tell

2:44

where the, where our equator line should be drawn.

2:47

But both of these are distal balgas obstructions.

2:50

Both of these patients will go on to contrast enema

2:53

as the next step in the workup of these infants.

2:55

And this is an example of meconium IUs. This is one of those

2:58

Two infants contrast enemas

3:00

where we could not reflux contrast into the terminal ilium.

3:04

And we have all these meconium filling defects

3:06

on our contrast enema.

3:07

One last thing to talk about when we talk about meconium

3:10

ileus because once we have a diagnosis of meconium ilis,

3:13

we have a diagnosis of cystic fibrosis

3:15

until proven otherwise.

3:17

Patients with CF will often present

3:19

with meconium ileus at birth.

3:21

The other thing I want you to look

3:22

for when there's a patient with concern

3:24

for possible meconium ileus

3:26

or possible cystic fibrosis is meconium peritonitis.

3:30

So this is the last thing that I look for on all

3:32

of my abdominal x-rays.

3:34

I look for any sort of abnormal calcification.

3:37

So calcifications where they don't belong.

3:40

This is a very subtle little curve

3:42

of linear eggshell calcification in the rightward

3:45

aspect of the abdomen.

3:46

And we have an abnormally dilated loop

3:48

of bowel in the right mid abdomen

3:50

and here it is blown up a little bit for you to see.

3:52

So this is meconium peritonitis. Um, I'm not sure why.

3:57

Um, when you have a bowel perforation in utero,

4:00

the meconium causes this sort of eggshell calcification as

4:04

as the body is trying to sort of contain that perforation

4:07

that happened in utero.

4:09

So when you see this classic eggshell,

4:12

it can be very subtle.

4:13

So make sure you take your mouse and uh, make your windowing

4:16

and leveling very, very contrasty to be able

4:19

to see this eggshell calcification of, um,

4:22

meconium peritonitis in this, um, infant

4:24

with cystic fibrosis.