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Jejunoileal Atresia

By William J. Cochran, MD, Geisinger Clinic, Danville, PA

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Jejunoileal atresia is incomplete formation of part of the small intestine. Diagnosis is by abdominal x-ray. Treatment is surgical repair.

Neonates with jejunoileal atresia usually present late during day 1 or on day 2 with increasing abdominal distention, failure to pass stools, emesis, and feeding problems.

Etiology

Jejunoileal atresias occur as a result of an ischemic insult during pregnancy. The ischemic insult can be due to intussusception, perforation, volvulus, intestinal strangulation via a hernia, or thromboembolism. Maternal smoking and cocaine use have been associated with intestinal atresia. There is an estimated incidence of about 1 to 3 in 10,000 live births. This disorder affects both sexes equally. Jejunoileal atresias are equally distributed between the jejunum and ileum.

Associated congenital anomalies are less common with jejunoileal atresia than duodenal atresia. The most common associated conditions are cystic fibrosis, malrotation, and gastroschisis, all of which are present in about 10% of cases. Peritoneal calcifications suggest the presence of meconium peritonitis, which is a sign of intrauterine intestinal perforation and can be seen in about 10% of cases. The presence of meconium peritonitis should raise suspicion of meconium ileus and cystic fibrosis.

Classification

There are 5 major types of jejunoileal atresia:

  • Type I consists of a membrane completely occluding the lumen with the intestine intact.

  • Type II is a gap in the intestine with a fibrous cord between the proximal and distal segments of intestine.

  • Type IIIA is a mesenteric gap without any connection between the segments.

  • Type IIIB is jejunal atresia with absence of the distal superior mesenteric artery; the distal small bowel is coiled like an apple peel, and the gut is short.

  • Type IV consists of multiple atretic segments (resembling a string of sausages).

Diagnosis

  • Abdominal x-rays

Plain abdominal x-rays are done; they may reveal dilated loops of small bowel with air-fluid levels and a paucity of air in the colon and rectum. A barium enema reveals a microcolon (due to disuse).

Because about 10% of patients also have cystic fibrosis (nearly 100% if meconium ileus is also present), testing for cystic fibrosis should be done.

Treatment

  • Surgical repair

Preoperative management of jejunoileal atresia consists of placing an NGT, giving nothing by mouth, and providing IV fluids.

Surgical repair is the definitive therapy. During surgery, the entire intestine should be inspected for multiple areas of atresia. The atretic portion is resected, usually with a primary anastomosis. If the proximal portion of the ileum is extremely dilated and difficult to anastomose to the distal, unused part of the intestine, it is sometimes safer to do a double-barreled ileostomy and defer anastomosis until the caliber of the distended proximal intestine has diminished.

The prognosis for infants with jejunoileal atresia is very good with > 90% survival. Prognosis is based on the length of remaining small bowel and the presence of the ileocecal valve. Infants who subsequently develop short bowel syndrome require TPN for extended periods. They should be provided continuous enteral feedings to promote gut adaptation, maximize absorption, and minimize the use of TPN. Infants should also be provided small amounts of nutrition by mouth to maintain sucking and swallowing. Prognosis for infants with ultrashort bowel syndrome has improved significantly because of newer surgical techniques including bowel-lengthening procedures (eg, serial transverse enteroplasty procedure or STEP), improved medical care, and the ability to do small bowel transplantation ( 1, 2, 3).

Treatment references

1. Thompson JS, Rochling FA, Weseman RA, Mercer DF : Current management of short bowel syndrome. Curr Probl Surg 49:52–115, 2012. doi: 10.1067/j.cpsurg.2011.10.002.

2. Infantino BJ, Mercer DF, Hobson BD, et al : Successful rehabilitation in pediatric ultrashort small bowel syndrome. J Pediatr163:1361–1366, 2013. doi: 10.1016/j.jpeds.2013.05.062.

3. Squires RH, Duggan C, Teitelbaum DH, et al : Natural history of pediatric intestinal failure: Initial report from the Pediatric Intestinal Failure Consortium. J Pediatr 161:723–728, 2012. doi: 10.1016/j.jpeds.2012.03.062.

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