Gastric Atresia - Various Types and Surgical Complications

Introduction:

In newborns, complete blockage or occlusion of the pyloric outlet is infrequent. The cause of gastric atresia is almost unknown. There is a clear indication for operation in cases of complete gastric obstruction. The absence of gas without bile in the vomitus and bowel indicates complete occlusion above the ampulla of Vater (part of the digestive system located at the confluence of the bile duct and pancreatic duct).

What Does Atresia and Stenosis Mean?

A congenital defect is classified into atresia and stenosis based on the extent of blockage:

1. Atresia: A complete obstruction or blockage of the bowel or a lack of bowel continuity.

2. Stenosis: A partial obstruction resulting in narrowing of the bowel (stricture).

What Is Gastric Atresia?

A very rare number of cases have been reported to have gastric atresia. In the early stages, fetuses have a stomach as a hollow organ. No solid stage is found until the fetus's fifth to tenth weeks of life. Touroff, and Susmann state that the fusion of the folds of the mucous membrane in the stages of pyloric bulge development will lead to diaphragmatic occlusion. An insufficient reestablishment of blood flow of the solid stage in the case of duodenal atresia cannot be a cause of gastric atresia.

As cited from a publication, in a case of complete blockage of the pyloric outlet, an operative excision of the membrane through gastrostomy leads to technical difficulties as there can be considerable hypoplasia of the duodenum beyond the membrane. Damage to the wall also can occur during excision. Gastrojejunostomy, though has its advantages and disadvantages, is decided by physicians with reluctance. Its poor prognosis in adults has created a questionable prognosis in children. Therefore, either gastroduodenostomy or pylorus (opening between the stomach and the small intestine) resection is used in newborn infants. Gastroduodenostomy is a surgical procedure in which a connection between the stomach and duodenum is created.

What Is Intestinal Atresia?

It is also known as small bowel atresia and is a birth defect affecting the small intestine. It is further divided into pyloric, duodenal, and jejunoileal atresia.

What is Pyloric atresia?

Pyloric atresia is an uncommon congenital condition characterized by intestinal obstruction occurring in the pylorus. It is very rare and occurs in one in one million births. The exact etiology is unknown, but a failure of excessive endodermal proliferation and epithelial solid cord recanalization are some of the known causes believed by physicians.

Due to intestinal obstruction, there can be bilious and non-bilious vomiting in neonates within 24 to 38 hours after birth, usually following the first feeding. It is also associated with in-utero polyhydramnios (increase in amniotic fluid). This is the main cause of fetal bowel obstruction. Prenatal ultrasound helps in the early detection of duodenal atresia. Double-bubble appearing in the diagnostic tests help identify this condition. The stomach filled with amniotic fluid is the first bubble, and a circular obstructed abdomen structure is the second bubble. Antenatal imaging also shows a double bubble and a fluid-filled duodenum, suggesting the diagnosis of duodenal atresia. A plain X-ray of the abdomen also shows the double bubble, and it is an indicator for diagnosing the condition.

A nasogastric suction is done to decompress the stomach, followed by surgery to correct the obstruction. Duodenoduodenostomy is the typical surgery performed, and it can be done through laparoscopy or open surgery. Prognosis is usually excellent in the treatment of duodenal atresia.

What Is Jejunoileal Atresia?

It is the most frequently occurring intestinal obstruction in neonates. It is often associated with cystic fibrosis, and therefore children should be screened for that. It occurs in about 1 in 1000 to 3000 live births. It is further divided into:

1. Jejunal Atresia: Jejunum is the part of the intestine extending from duodenum to ileum. Obstruction in the jejunum is referred to as jejunal atresia.

2. Ileal Atresia: The ileum is present before the colon (the longest part of the large intestine) and the lower part of the small intestine. Blockage or obstruction in the ileum is called ileal atresia.

Infants with jejunoileal atresia vomit within the first 24 hours of life, accompanied by green-colored bile. Some infants who have obstruction further down in the intestine do not vomit until after two to three days of life. The abdomen is usually distended or swollen, and they do not show any bowel movement on the first day of life. An X-ray of the abdomen is enough for diagnosis to identify the obstruction. Surgery depends on the type of jejunoileal atresia, and factors like the degree of intestinal dilation and the amount of intestine present are also considered. The most common surgical procedure involves the surgical removal of blind segments and suturing of the remaining ends.

What Is Colonic Atresia?

This is the rarest form of congenital intestinal obstruction and accounts for 15 % of all intestinal atresia. Signs and symptoms will resemble jejunoileal atresia, and the stomach is dilated. Diagnosis can be confirmed with an X-ray. The treatment protocol involves removing the enlarged segment and a temporary colostomy, and the ends of the colon are sutured. A colostomy is a surgery done to create an opening for the large intestine or colon through the abdomen.

What Are the Postoperative Complications?

• GERD (Gastroesophageal Reflux Disease): GERD is a gastrointestinal problem in which there is irritation of the esophageal (food pipe) lining due to the flow back of stomach acid or bile.

• Blind Loop Syndrome: It is a condition in which the digested food stops moving or slows down and bypasses a section of the intestine.

• Peptic Ulcer: A sore present in the esophageal lining due to damage caused by the stomach acids.

• Cholecystitis: Inflammation or swelling of the gallbladder is called cholecystitis.

• Megaduodenum: A condition in which the duodenum is dilated due to mechanical or functional abnormalities in the body.

• Esophagitis: Inflammation of the esophagus is called esophagitis.

• Pancreatitis: Inflammation or swelling of the pancreas is called pancreatitis.

• Anastomotic leak: It is a dreadful complication post intestinal surgery where an anastomotic leak will create communication between extra and intraluminal compartments, and contents of the reconnected portion start leaking.

Conclusion:

Children with atresia need to be treated at the earliest. Babies must be stabilized before the procedure, and a regular follow-up is required post-procedure. Postoperative complications rarely occur. The progress and prognosis of the babies depend on the length of the intestine left and any associated abnormality that may be present.