imagerie des occlusions neonatales...imagerie des occlusions neonatales ... 9!!!!! "#
TRANSCRIPT
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IMAGERIE DES OCCLUSIONS NEONATALES !
$%!&'()*!+%!$,(-(./*!0%!1.,)2,33/*!$%!4/5.'6*!7%!8'9(:;-''2!!!<;-/..(=-:,;! )(! -.';>:-! ):9/>-:?! >(.@/;';-! =/;)';-! A/>! BC! =./3:/.>! D,(.>! )/! @:/*! A/>! ,66A(>:,;>!
;E,;'-'A/>!./AF@/;-!)GE-:,A,9:/>!@'.:E/>!H(:!=/(@/;-!I-./!,.9';:H(/>!,(!?,;6-:,;;/AA/>%!8:!A'!=A(='.-!)/>!malformations digestives! >,;-!)E=:>-E/>!='.! AJE62,9.'=2:/!anténatale!6,;)(:>';-!K!(;/!=.:>/!/;! 62'.9/! )(! LELE! )F>! A'! ;':>>';6/*! 6/.-':;/>! 6'(>/>! ,.9';:H(/>! =/(@/;-! ='>>/.! :;'=/.M(/>! /;!=.E;'-'A! /-! >/! .E@EA/.! '=.F>! A'! ;':>>';6/%! N/! =A(>*! les occlusions fonctionnelles! H(:! ;G,;-! ='>!)G/O=./>>:,;!';-E;'-'A/*!>/!3';:?/>-/;-!/O6A(>:@/3/;-!en post-natal%!!
Tout vomissement vert! 62/P! (;! ;,(@/'(Q;E! 6,;>-:-(/! (;! @E.:-'LA/! >:9;'A! )J'A'.3/*! =,(@';-!.E@EA/.!(;!,L>-'6A/!3'D/(.! >(.! A'!=,.-:,;! >,(>Q@'-E.:/;;/!)(! -(L/!):9/>-:?%!$G/>-! =,(.H(,:*! :A! ),:-!I-./!6,;>:)E.E!6,33/!./A/@';-!)G(;/!6'(>/!62:.(.9:6'A/!D(>H(GK!=./(@/!)(!6,;-.':./%!<A! :3=,>/!(;!!-.';>?/.-!)(!;,(@/'(Q;E!/;!3:A:/(!>=E6:'A:>E!/-!A'!.E'A:>'-:,;!)G(;!L:A';!)G:3'9/.:/%!!R'!=A'6/!)(!.'):,A,9(/!/>-!?,;)'3/;-'A/!)';>!A/!):'9;,>-:6%!RJ:3'9/.:/!/>-!L'>E/!>(.!le!couple
ASP-échographie.! SAA/! =/.3/-! A/! =A(>! >,(@/;-! (;! ):'9;,>-:6! =.E6:>! /-T,(! ,.:/;-/! @/.>! (;/!,='6:?:6'-:,;! ):9/>-:@/%! R/! ):'9;,>-:6! E-:,A,9:H(/! =.E6,6/! =/.3/-! (;! -.':-/3/;-! U3E):6'A! /-T,(!62:.(.9:6'AV! ')'=-E*! '@';-! A'! >(.@/;(/! )/! 6,3=A:6'-:,;>! ='.?,:>! -.F>! 9.'@/>! U)E>25).'-'-:,;*!)E>,.)./>!3E-'L,A:H(/>*!=E.:-,;:-/!='.!=/.?,.'-:,;*!/;-E.,6,A:-/V%!!
1. Données cliniques 1.1. Les signes d'appel >,;-!'>>,6:E>!)/!?'M,;!@'.:'LA/%!
!Les vomissements!>,;-!A/!>:9;/!3'D/(.%!<A>!>,;-!A/!=A(>!>,(@/;-!verdâtres*!6'.!AG,L>-'6A/!/>-!
=./>H(/!-,(D,(.>!>,(>Q@'-E.:/;%!<A>!=/(@/;-!I-./!-.F>!=.E6,6/>!,(!./-'.)E>!>(:@';-!A/!>:F9/!/-!A/!-5=/!)/!AJ,L>-'6A/%!!
Les anomalies d'émission du méconium!>,;-!:;6,;>-';-/>%!RJE3:>>:,;!)(!3E6,;:(3!=/(-!I-./!'L>/;-/*!=/(!'L,;)';-/!,(!./-'.)E/%!RJ'L>/;6/!-,-'A/!)JEA:3:;'-:,;!)(!3E6,;:(3!'(Q)/AK!)/!A'!WXF3/!2/(./!/>-!A/!=A(>!>,(@/;-!='-2,A,9:H(/%!R/!3E6,;:(3!=/(-!I-./!';,.3'A!='.!>,;!'>=/6-!D'(;Y-./!/-!)(.!U:A!/>-!;,.3'A/3/;-!;,:.*!@:>H(/(O!/-!'L,;)';-V%!!S;!./@';62/*!AJEA:3:;'-:,;!)J(;!3E6,;:(3!;,.3'A!)(.';-!A/!=./3:/.!D,(.!)/!@:/!;/!=/.3/-!='>!)JEA:3:;/.!(;/!,66A(>:,;!3I3/!6,3=AF-/!>:!/AA/!/>-!2'(-!>:-(E/%!
Un ballonnement abdominal!,.:/;-/!@/.>!(;/!occlusion basse%!<A!/>-!)J'(-';-!=A(>!:3=,.-';-!H(/!AJ,L>-'6A/!/>-!L'>!>:-(E%!<A!=/(-!I-./!./>=,;>'LA/!)G(;/!9I;/!./>=:.'-,:./%!RG/O'3/;!6A:;:H(/!EA:3:;/!(;/!3'A=,>:-:,;!';,./6-'A/!/-!@E.:?:/!A/>!,.:?:6/>!2/.;:':./>%!!Un abdomen plat!'@/6!(;!L'AA,;;/3/;-!E=:9'>-.:H(/!-E3,:9;/!)Gune occlusion haute. 1.2. Les données anténatales sont!-.F>!:3=,.-';-/>!K!=.E6:>/.%!! !!0;! ./62/.62/! AG/O:>-/;6/! )Jun hydramnios! E@,6'-/(.! )J(;! ,L>-'6A/! ):9/>-:?! 2'(-*! A'! =.E>/;6/!
)Gune! dilatation digestive! K! AJE62,9.'=2:/! U:3'9/! /;! ),(LA/! L(AA/! 6'.'6-E.:>-:H(/! )J(;! ,L>-'6A/!)(,)E;'A*! ):A'-'-:,;! )(! 9.IA/! E@,6'-.:6/! )J(;/! '-.E>:/! )(! 9.IA/V%! R'! )E-/6-:,;! )G(;/! E62,9E;:6:-E!';,.3'A/!)(!3E6,;:(3!,.:/;-/!@/.>!(;!.'A/;-:>>/3/;-!)(!-.';>:-!?Z-'A%!!!!!
1.3 Le contexte familial et périnatal!=/(-!,.:/;-/.!A/!):'9;,>-:6%!!!N/>! ';-E6E)/;->! )/! mucoviscidose! ,(! )/! maladie de Hirschsprung! )';>! A'! ?.'-.:/! >,;-!
E@,6'-/(.>%!!
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$%! diabète maternel&! '%(! prématurité&! '%! petit poids de naissance! )*+(%,(%,! -(*.! '%(!+//0,'*+,1!2)3+4'(!,*0%.+,)+*(!5)'!6)'27)%!/12)%+03!!)'!.8%9*)/(!9'!:(,+,!2)3)%!;0'27(<=!!>0!%),+)%!d'extrême prématurité!9)+,!?0+*(!:(%.(*!@!'%!+31'.!9'!:*1/0,'*1=!!Une trisomie 21!:(',!A,*(!0..)2+1(!@!'%!)6.,023(!9')91%03!)'!@!'%(!/0309+(!9(!B+*.27.:*'%;=!
!!
2. Imagerie de base >C+/0;(*+(!(.,!60.1(&!90%.!%),*(!:*0,+4'(&!.'*!3(!2)':3(!DEFG127);*0:7+(=!!
2.1. Abdomen sans préparation
Un cliché thoraco-abdominal de face couché! (.,! +%9+.:(%.063(! :)'*! 0::*12+(*! 0'! /+('H! 30!/)*:7)3);+(! (,! 30! ,):);*0:7+(! 9(.! 0%.(.! 9+30,1(.=! I3! *(27(*27(! 9C1-(%,'(33(.! 2032+?+20,+)%.!+%,*0069)/+%03(.&! '%! 1:0%27(/(%,! +%,*0:1*+,)%103! (,! 9(.! 0%)/03+(.! )..('.(.! 0..)2+1(.=! Une incidence rayon horizontal! (.,!:*(.2*+,(! 3)*.4'(! 3J)%! *(27(*27(!9(.!%+-(0'H!789*)01*+4'(.!)'!'%!:%('/):1*+,)+%(=!Le cliché de profil!(.,!',+3(!90%.!3(.!)223'.+)%.!60..(.!:)'*!1-03'(*!'%(!9+.:0*+,1!9(!203+6*(!*(2,).+;/)K9+(%%(&!)'!*(:1*(*!3(!2L3)%!;0'27(!9(-0%,!3(!*027+.=!!
3 segments digestifs fixes!.)%,!?02+3(/(%,! +9(%,+?+1.! 3)*.4'J+3.!.)%,!9+30,1.&! 30!;*)..(! ,'61*).+,1!;0.,*+4'(!.)'.!30!2)':)3(!;0'27(&!3(!9')91%'/!@!9*)+,(!9'!*027+.!.)'.!3(!?)+(!(,!3(!*(2,'/!9(-0%,!3(!.02*'/=! >(! 2L3)%! ,*0%.-(*.(! 9+.,(%9'! :0*! 3(.! ;0M! (.,! :0*033N3(! @! 30! ;*0%9(! 2)'*6'*(! ;0.,*+4'(=!>C0%;3(!2)3+4'(!;0'27(!(.,!.+,'1!(%!9(7)*.!9(!30!;*0%9(!2)'*6'*(!;0.,*+4'(=!E+!3(!%)/6*(&!3(!.+N;(&!3C0.:(2,!(,!3(!-)3'/(!9(.!0%.(.!:(*/(,,(%,!:0*?)+.!9(!:*12+.(*!3(!%+-(0'!9(!
3C)6.,023(& la différenciation entre le grêle et le colon dilatés est souvent impossible 20*!3(!;*A3(!9+.,(%9'!:*(%9!30!:302(!9'!2)3)%&!(,!3(!2)3)%!9+30,1!:(*9!.(.!70'.,*0,+)%.=!
La connaissance de la physiologie normale! (.,! +%9+.:(%.063(! :)'*! +%,(*:*1,(*! 3JDEF=! >0!:%('/0,+.0,+)%!+%,(.,+%03(&!.(2)%90+*(!@!3J0+*!91;3',+!0:*N.!30!%0+..0%2(&!0,,(+%,!3(!2O2'/!-(*.!30!PN/(!7('*(! (,! 3(! *(2,'/! -(*.! 30! QRN/(! 7('*(&! 0-(2! 9(! ;*0%9(.! -0*+0,+)%.! 4'+! %(! .)%,! :0.! ?)*21/(%,!:0,7)3);+4'(.!(,!4'+!91:(%9(%,!9'!2)%,(H,(!23+%+4'(=!!>(! 2)%,*0.,(! 01*+4'(! 1,0%,! 30! 60.(! 9J+%,(*:*1,0,+)%! 9(! ,)',! DEF&! un cliché trop précoce ne
permet ni d'affirmer ni de situer un obstacle. S(!:3'., 2(*,0+%(.!20'.(. 5-)/+..(/(%,.&!0.:+*0,+)%!;0.,*+4'(&!1:0%27(/(%,!:1*+,)%103!06)%90%,&!91.789*0,0,+)%&!0,*1.+(!9(! 3CT.):70;(!.0%.! ?+.,'3(!9'!.(;/(%,!+%?1*+('*U<!:('-(%,!A,*( *(.:)%.063(.!9C069)/(%.!:('!01*1.&!9+??+2+3(/(%,!+%,(*:*1,063(.=!! !
2.2. Echographie >J127);*0:7+(!(.,!*103+.1(!0-(2!'%(!.)%9(!9(!70',(!?*14'(%2(&!.+!%12(..0+*(!90%.!30!2)'-('.(=!>C1,0:(! 30! :3'.! +/:)*,0%,(! (.,! 9(! -1*+?+(*! la position des vaisseaux mésentériques! 50*,N*(!
%)*/03(/(%,!@!;0'27(!9(!30!-(+%(<!(,!9C0%038.(*!3('*!,*0V(,!90%.!30!*02+%(!9'!/1.(%,N*(=!!W33(!*(27(*27(!une dilatation duodénale ou grêle=!>(!;*A3(!%)*/03!(.,!9(!,):);*0:7+(!2(%,*03(&!
:1*+.,03,+4'(&!@!2)%,(%'!3+4'+9+(%!(,!01*+4'(&!@!:0*)+!?30.4'(=!!W33(!1,'9+(!le calibre et le contenu du colon=!>(!2L3)%!%1)%0,03!%)*/03!(.,!9(!203+6*(!*1;'3+(*&!
/(.'*0%,!#!@!QX!//!9(!9+0/N,*(&!2)%,(%0%,!'%!/12)%+'/!78:)127);N%(&!:3'.!)'!/)+%.!:)%2,'1!9J+/0;(.!01*+4'(.!127);N%(.=!"!.(;/(%,.!2)3+4'(.!.)%,!?02+3(/(%,!/(.'*063(.&!3(!*(2,'/!(%!0**+N*(!9(!30!-(..+(&!3(!2L3)%!;0'27(!90%.!3(!?30%2!;0'27(!5.,*'2,'*(!9+;(.,+-(!30!:3'.!(H,(*%(!.+,'1(!9(-0%,!3(!:.)0.<!(,!3(!2L3)%!9*)+,!90%.!30!*1;+)%!.)'.!71:0,+4'(=!!>(!.+;/)K9(!:3'.!:*)?)%9&!9(!,):);*0:7+(!-0*+063(!56)'23(!9*)+,(!)'!;0'27(<&!1270::(!.)'-(%,!@!
3J1,'9(=! Y7(M! 3(! %)'-(0'G%1! 3(! 2O2'/! (,! 3(! 2L3)%! 9*)+,! %(! .)%,! .)'-(%,! :0.! (%2)*(! 022)31.! 0'!:1*+,)+%(!:0*+1,03!:).,1*+('*&!3(!2O2'/!(.,!?*14'(//(%,!(%!,):);*0:7+(!.)'.!71:0,+4'(=!>C127);*0:7+(! :(*/(,! 9C+9(%,+?+(*! 3(! .(;/(%,! 9+;(.,+?! 9+30,1! .'*,)',! 3)*.4'(! 3J069)/(%! (.,! :('!
01*1! (,! 9(! 9+??1*(%2+(*! 3(! 2)3)%! (,! 3(! ;*A3(=! Z)',(?)+.&! 3C(H0/(%! :(',! A,*(! 3+/+,1! :0*! '%(!78:(*01*0,+)%!9+;(.,+-(!(,!'%!6033)%%(/(%,!069)/+%03!:('!91:*(..+63(=!!!
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3. Démarche diagnostique 3.1. Diagnostic positif $%&''&()*)+,! -%.,! +/0*&123! 0.(! 23! *(&1*.0! -)430*)5! 30*! (30'+,0&/23! -%.,3! 0*&03! -&,0! 2&! 2.6)7(3!
),*30*),&23! ! &831! -)0*3,0)+,! -30! &,030! -%&6+,*! 3*! -)0'&()*9! -3! 1&2)/(3! &831! 230! &,030! -%&8&2:!!$+(0;.%3223! 0.(8)3,*! '3,-&,*! 2&! 8)3! 5<*&23=! *+.*3! ),*3((.'*)+,! 1+6'27*3! -.! *(&,0)*! 3,*(&),3! .,3!&/03,13!-3!5+,1*)+,,363,*!-30!&,030!-%&8&2!-+,*!23!1&2)/(3!30*!(9-.)*!>6)1(+4(?23=!6)1(+1+2+,@:!!$%3A'2+(&*)+,! (&-)+B91C+4(&'C);.3! 1+,5)(63! 230! 0)4,30! -3! 0*&03! &9();.3! 3*D+.! 2);.)-)3,,3! 3,!
&6+,*! -3! 2%+/0*&123:! $%EFG! +/H31*)83! 2&! -)0*3,0)+,! &9();.3=! 2%91C+4(&'C)3! 3A'2+(3! 2&! -)2&*&*)+,!2);.)-)3,,3!'&22)&,*!&.A!-)55)1.2*90!-%),*3('(9*&*)+,!-%.,!EFG!+'&;.3!+.!'3.!&9(9:!!!!
3.2!Diagnostic topographique!!!$%)6&43()3!-3!/&03!'3(63*!94&2363,*!-3!'(91)03(! 23!0)743!-3!2I+/0*&123!3*!-3!-95),)(!"! *&/23&.A!
(&-)+12),);.30!'(),1)'&.A:!!
3.2.1. L’obstruction duodénale $%+/0*(.1*)+,!-.+-9,&23 30*!(30'+,0&/23!-%.,3 +112.0)+,!J!83,*(3!'2&*!&831!'&(5+)0!.,3!8+.00.(3!
9')4&0*();.3:!!En imagerie=! 2&! '(903,13! -%.,3! )6&43! 3,! -+./23! /.223! &831! )6'+(*&,*3! -)0*3,0)+,! 3*! &/03,13!
-%&9(&*)+,!-%&8&2!30*!1&(&1*9()0*);.3!-%.,3!&*(90)3!-.+-9,&23:!$%91C+4(&'C)3!92)6),3!2%3A13'*)+,,32!8+28.2.0!*(70!03((9!0.(!6&2(+*&*)+,:!!F)! 2&! -)2&*&*)+,! 30*!6+),0! )6'+(*&,*3! &831!.,3! &9(&*)+,!-%&8&2! +.! 0)! 2%EFG!30*! '3.! 1+,*()/.*)5=!
2%91C+4(&'C)3!'3(63*!23!'2.0!0+.83,*!-%)-3,*)5)3(!2%+/0*&123!K!-)&'C(&463=!-.'2)1&*)+,=!8+28.2.0!0.(!6&2(+*&*)+,=!83),3!'+(*3!'(9-.+-9,&23:!!
Le transit baryté!'3.*!?*(3!.*)23!-&,0!230!+112.0)+,0!),1+6'27*30!2+(0;.3!2%91C+4(&'C)3!,%&!'&0!'.!)-3,*)5)3(! 2%+/0*&123!>4&L!-)430*)50@!+.!'+.(!&''(91)3(! 23!(3*3,*)00363,*!-%.,3!-.'2)1&*)+,!0.(! 23!1&-(3!-.+-9,&2:!M2!03!5&)*!-3!'(959(3,13!'&(!2%),*3(69-)&)(3!-3!2&!0+,-3!4&0*();.3=!13!;.)!'3(63*!2&!(9&0')(&*)+,!-.!'(+-.)*!-3!1+,*(&0*3:!!!!!!3.2.2. L’obstruction du grêle
L’occlusion du grêle 03! *(&-.)*! '&(! .,! /&22+,,363,*! &/-+6),&2! '2.0! +.! 6+),0! )6'+(*&,*! 3,!
5+,1*)+,!-.!0)743!-3!2%+/0*&123:!!L’imagerie de base!63*!3,!98)-3,13!.,!4(?23!-)2&*9!&831!.,3!6+('C+2+4)3!&((+,-)3!+.!*./.293!3*!
-30!'&(+)0!0+.0! *3,0)+,:!F+,!-)&67*(3!30*! 0.'9()3.(!J!NOBNP!66:!$%91C+4(&'C)3!30*! ),-)0'3,0&/23!'+.(!&''(91)3(! 23!'9()0*&2*)063!),*30*),&2=!&,&2Q03(!2&!'&(+)!3*! 23!1+,*3,.!-30!&,030!3,!&6+,*!3*!3,!&8&2! -3! 2%+/0*&123:!R,! 9'&,1C363,*! ),*(&'9()*+,9&2! (9&1*)+,,32! '2.0! +.!6+),0! &/+,-&,*! 30*! ;.&0)!1+,0*&,*:! $%91C+4(&'C)3! '3(63*! -%)-3,*)5)3(! 0+)*! .,! 6)1(+1S2+,! ;.)! ,%&! '&0! 5+,1*)+,,9=! 0+)*! .,!+/0*&123!0.(!23!4(?23!>-.'2)1&*)+,=!),8&4),&*)+,!T@:!
Le lavement aux hydrosolubles! 30*! ),-)0'3,0&/23! 1&(! 13(*&),30! 9*)+2+4)30! '3.83,*! /9,95)1)3(!-%.,3!*C9(&'3.*);.3!69-)1&23!>)29.0!691+,)&2!+.!)29.0!-.!'(96&*.(9@:!M2!30*!1+,*(3B),-);.9!3,!1&0!-3!1+6'2)1&*)+,!>'9()*+,)*3!691+,)&23=!8+28.2.0!0.(!)29.0!691+,)&2@:!$%3,5&,*!-+)*!?*(3!réchauffé! >2&6'3!J! ),5(&B(+.43@=!'3(5.09=! 0+.0!1+,*(S23!-3! 2I9;.)2)/(3!CQ-(+B
9231*(+2Q*);.3:!U,!.*)2)03!.,3!0+,-3!-3!V+23Q!3*!.,3!03(),4.3!-3!PO!11!1+,*3,&,*!.,!CQ-(+0+2./23!(91C&.559=!983,*.322363,*!-)2.9!>'(96&*.()00)63@:!
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$%&'()*+&,'!-)!./&+!-,0-!*,'+123)!-*,4&50)!/6)*!0'!+,0+!4)+&+!*7/849!$)!1/:&,3,;0)!)-+!/041<-!:0!',06)/0='>!)+!3)!8,?&3&-)!/0!8&)0@9!A3!4)0+!B+1)!/8)'>!C!41)--)1!3)-!.)--)-!3%0')!*,'+1)!3%/0+1)!4,01!)84B*7)1!3)-!.0&+)-9!D30-&)01-!*3&*7>-!-,'+!41&-!:)!./*)!)+!:)!41,.&39!!
3.2.3.!L’obstruction colique $%,?-+10*+&,'!*,3&50) -)!8/'&.)-+)!4/1!0'!8>+>,1&-8)!7,8,;<')9!!En imagerie,! 3/! :&-+)'-&,'! :&;)-+&6)! )-+! :&..0-)! E;1B3)! )+! *,3&50)F! *,'.&18>)! 4/1! 3G/?-)'*)! :)!
8&*1,*23,'!C!3%>*7,;1/47&)!)+!3%&:)'+&.&*/+&,'!:%0'!*,3,'!*,'+)'/'+!0'!8>*,'&08!',18/39!!Le lavement aux hydrosolubles! )-+! 3C! )'*,1)! &':&-4)'-/?3)! C! 6&->)! :&/;',-+&50)! )+H,0!
+7>1/4)0+&50)9!A3!)-+!*,'+1)=&':&50>!)'!*/-!:)!4')08,4>1&+,&')!,0!:)!-&;')!*3&'&50)!:%)'+>1,*,3&+)9 !4. Diagnostic étiologique !4.1. Les occlusions hautes (Tableau 1) !$)-!,?-+10*+&,'-!:0,:>'/3)-!-,'+!1)3/+&6)8)'+!.1>50)'+)-I!)33)-!4)06)'+!B+1)!-,&+!&'+1&'-<50)-!4/1!
/+1>-&)!,0!:&/471/;8)I!-,&+!)@+1&'-<50)-!4/1!6,36030-!-01!8/31,+/+&,'I!?1&:)!4>1&+,'>/3)I!:043&*/+&,'!:0,:>'/3)!,0!6)&')!4,1+)!41>!:0,:>'/3)9!!
4.1.1. Atrésie ou diaphragme duodénal !L'atrésie duodénale! *,11)-4,':! C! 0')! &'+)1104+&,'! *,843<+)! :)! 3/! 308&<1)! &'+)-+&'/3)9! A3! 4)0+!
-G/;&1!-,&+!:G0')!-,30+&,'!:)!*,'+&'0&+>!:&;)-+&6)!/6)*!0'!*,1:,'!43)&'!,0!0'!6>1&+/?3)!7&/+0-!)'+1)!3)-!J!-);8)'+-!:0,:>'/0@I!-,&+!:G0'!:&/471/;8)!*,843)+!E1)43&!8050)0@!/''03/&1)!4)14)':&*03/&1)!C!3/!4/1,&!:0,:>'/3)F!-&>;)/'+!3)!430-!-,06)'+!/0!'&6)/0!:)!KJI!4/1.,&-!:)!KL!EM&;9NF9!!
La sténose duodénale!*,11)-4,':!C!0'!:&/471/;8)!-&>;)/'+!/0!'&6)/0!:)!KJ!,0!:)!KL!/6)*!0'!4)1+0&-! *)'+1/3! :,'+! 3)! */3&?1)! :>+)18&')! 3/! 41>*,*&+>! :)-! -O84+28)-9! ! $G/?,0*7)8)'+! :)! 3/! 6,&)!?&3&/&1)!-)!./&+!-01!3/!+1/'*7)!8B8)!:0!:&/471/;8)!,0!&88>:&/+)8)'+!)'!/8,'+9!P)-! /',8/3&)-! -)1/&)'+! )'! 1/44,1+! /6)*! 0'! :>./0+! :)! 1)*/'/3&-/+&,'! :)! 3/! 308&<1)! :&;)-+&6)I!
+1/'-&+,&1)8)'+! ,**04>)! 4/1! :)-! *)3303)-! >4&+7>3&/3)-! (0-50GC! 3/! Q<8)=R<8)! -)8/&')-! :)! 6&)!)8?1O,''/&1)9! ! S33)-! -%/--,*&)'+! C! :)-! /',8/3&)-! ?&3&,4/'*1>/+&50)-I! )'! 4/1+&*03&)1! /0! 4/'*1>/-!/''03/&1)9!T'!/'')/0!:)!+&--0!4/'*1>/+&50)!)*+,4&50)!)-+!-,06)'+!,?-)16>!/0!'&6)/0!:)!3%,?-+/*3)9!!!S'!1<;3)!3)!:&/;',-+&*!:G,?-+/*3)!:0,:>'/3!/!>+>!./&+!avant la naissance!)+!3)!',06)/0='>!)-+!41&-!
)'!*7/1;)!)'!-/33)!:G/**,0*7)8)'+!/6/'+!3G/44/1&+&,'!:)!+,0+!-O84+28)9!Cliniquement,! )'! 3%/?-)'*)! :)! :&/;',-+&*! 41>'/+/3I! 3)! +/?3)/0! )-+! *)30&! :G0')! ,**30-&,'! 7/0+)!
/6)*!6,8&--)8)'+-!+1<-!41>*,*)-!E:<-!3)!41)8&)1!(,01!:)!6&)!,0!:<-!3)!41)8&)1!?&?)1,'!4/1.,&-!8B8)!/6/'+!+,0+)!/3&8)'+/+&,'F9!A3-!-,'+!3)!430-!-,06)'+!+)&'+>-!:)!6)1+!,0!')++)8)'+!?&3&)0@!EUQV!:)-!*/-FI!4/1.,&-!*3/&1-!ENQV!:)-!*/-F!-&!3%,?-+/*3)!)-+!-0-=6/+>1&)'9!$)!:&/;',-+&*!:,&+!B+1)!41>*,*)!4,01!>6&+)1!3%/44/1&+&,'!:%0')!:>-7O:1/+/+&,'I!:)!+1,0?3)-!8>+/?,3&50)-!6,&1!:%0'!*7,*!7O4,6,3>8&50)9!!Les anomalies associées! -,'+! 4/1+&*03&<1)8)'+! .1>50)'+)-! W! *71,8,-,8&50)-! E+1&-,8&)! JNFI!
*/1:&/50)-I!:&;)-+&6)-!E/+1>-&)!:)!3GX-,47/;)!,0!:0!;1B3)I!8/3.,18/+&,'!/',1)*+/3)FI!;>'&+,01&'/&1)-I!6)1+>?1/3)-! ,0! :)-!8)8?1)-9! P)-!8/3.,18/+&,'-! 4)06)'+! )'+1)1! :/'-! 3)! */:1)! :G0'! -O':1,8)! :)!YZ[S\!,0!:)!YZP[S\$9!!Radiologiquement,! 3G&8/;)! )'! double bulle! E*,11)-4,':/'+! 3%0')! C! 3%)-+,8/*! )+! 3%/0+1)! /0!
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$%).%'7! +1! 6%+51/! %+'7! 2%! 21449)%)! *81/'%)A%/'15/! 2%! 0&%*0&%+! =%&)%+! +5&+! :5&A%)'! 28&/%! -+$1)-'15/!>-+')10&%?! @**%! 12%/'141%! &/%! -/5.-*1%! -++5:19%! 2%! *-! )5'-'15/! 1/'%+'1/-*%! B.9+%/'C)%! :5..&/!:5.$*%'!5&!.-*)5'-'15/D?!@**%! )%:5//-1'! $)9:5:%.%/'! le type de l'obstacle7! complet -A%:! &/%! A-:&1'9! '5'-*%! 2&! >)(*%!
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2%+! A5.1++%.%/'+! :*-1)+?! K%! :&*! 2%! +-:! +&$9)1%&)! %+'! =-&'! +1'&97! +8-))('-/'! %/! )%>-)2! 2%! *-! )9>15/!=9$-'561*1-1)%?! L*!/8-!$-+!2%!:5/'1/&1'9!-A%:! *%!+%>.%/'!+5&+GJ-:%/'!0&1!$-)-P'!29:-*9?!Q5&'%451+!&/!:&*!2%!+-:!')C+!21+'%/2&!$%&'!+%!$)5J%'%)!$*&+!6-+!-A%:!&/%!1.$5)'-/'%!21+$-)1'9!2%!:-*16)%?!!Une opacification barytée par voie haute!%+'!/9:%++-1)%!*5)+0&%!.-*>)9!&/!21->/5+'1:!-/'9/-'-*!
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%'!+%+!-::5*%.%/'+!;!*-!$-)51!$5+'9)1%&)%!BU1>?VD?!@/!%44%'7 l'anse intestinale primitive!+&61'!2C+!*-!41/!2%! *-!$=-+%! %,')-:<*5.10&%7!V! )5'-'15/+!2%!WXY! :=-:&/%7!2-/+!&/! +%/+! -/'1! =5)-1)%7! -&'5&)!2%!*8-,%!2%!*8-)'C)%!.9+%/'9)10&%?!K8-))('!-$)C+!*-!$)%.1C)%!)5'-'15/!BWXYD!2941/1'!*%!.9+%/'C)%!:5..&/!2-/+!*%0&%*! *%!>)(*%!%+'!+1'&9!;!2)51'%!2%!*-!*1>/%!.921-/%!%'! *-!'5'-*1'9!2&!:H*5/!;!>-&:=%!-A%:!&/!:Z:&.!2-/+!*-!45++%!1*1-0&%!>-&:=%?!![/! -))('! 2%! *-! )5'-'15/! ;! #\XY! )-$$)5:=%! *%! :Z:&.! 2&! 2&529/&.?! F%+! 6)12%+! .-*45).-'1A%+!
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2=;3-0!=73;8+,23O.*!30,*2<3,!%8!/3+.8%3+8,3-0!<*+!/83++*8.P!6=+*0,=23O.*+9!>%%*!+*!583,!<*!72=5=2*01*!782!%C30,*26=<3832*!<*!%8!+-0<*!;8+,23O.*$!1*!O.3!7*26*,!%8!2=8+7328,3-0!<.!72-<.3,!<*!1-0,28+,*9!>%%*!2=/@%*!.0*!!7-+3,3-0!80-268%*6*0,!48++*!*,!6=<380*!<*!%C80;%*!<*!Q2*3,R!*,!%*+!+732*+!<*!,-2+3-0!<*+!72*63@2*+!80+*+!S=S.08%*+!O.3!72*00*0,!.0!8+7*1,!*0!G!,32*!4-.1E-0!I9!!!:*! /-%/.%.+! +.2! 68%2-,8,3-0! *+,! une! urgence chirurgicale extrême! 1-67,*! ,*0.! <.! 23+O.*!
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=/-18,231*9!!A l'échographie,! 3%! +&8;3,! <&.0*! +,2.1,.2*! %3O.3<3*00*!<*!6-27E-%-;3*! 822-0<3*$! 8/*1!.0*!782-3!
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4.1.4. Autres causes !:*+!8.,2*+!18.+*+!<&-4+,2.1,3-0!*P,230+@O.*!<.!<.-<=0.6!1-66*! %8!/*30*!7-2,*!72=!<.-<=08%*!
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4.2. Les occlusions du grêle (Tableau 2) !J*/80,! .0*! -11%.+3-0! 48++*$! %8! <=,*1,3-0! <C.0! 6312-1V%-0! ,=6-3;0*! <C.0! -4+,81%*! 1-67%*,!
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4.2.3 La péritonite méconiale !
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4.2.4. L'iléus du prématuré !
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4.2.8. Les invaginations néonatales !<=.1)+>.1+&.'1!0(!7$2:+&($2!%,&!%;-%7&.'11%**%4!?**%!%,&!@+A.&(%**%:%1&! .0.'7+&@./(%!%&!,'()%1&!
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H%-I%*F!0(7*.-+&.'1!0.>%,&.)%F!@2&2$'&'7.%J4!!
4.3. Les occlusions coliques (Tableau 3) !K.! *='1! %;-*(&! *%,!:+*6'$:+&.'1,! +1'$%-&+*%,F! *%,! -+(,%,! '$>+1./(%,! 03'--*(,.'1,! -'*./(%,! ,'1&!
%;-%7&.'11%**%,4!<+!0(7*.-+&.'1!IL,&./(%!-'*./(%!'(!-'*'$%-&+*%F!7+$6'.,!,(,7%-&2%!%1!+1&21+&+*F!7%(&!8&$%! +66.$:2%!7+$! *32-@'>$+7@.%4!<3+&$2,.%! -'*./(%! ,.2>%+1&! *%!7*(,! ,'()%1&! ,($! *%! -'*'1!0$'.&! 7%(&!:.:%$!(1!'A,&+-*%!>$8*%4!<%!*+)%:%1&!%1!6+.&!*%!0.+>1',&.-!%&!7$2-.,%!,'1!1.)%+(4!!<%,! 'A,&+-*%,! 6'1-&.'11%*,! ,'1&! @+A.&(%**%:%1&! %1! -+(,%F! *%! 7*(,! 6$2/(%1&! %,&! *+! :+*+0.%! 0%!
M.$,-@,7$(1>F! *3.::+&($.&2! -'*./(%! &$+1,.&'.$%! G'(! A'(-@'1! :2-'1.+*J! 2&+1&! 7*(,! $+$%4! N*,! 13'1&!@+A.&(%**%:%1&!+(-(1%!%;7$%,,.'1!+1&21+&+*%4!
L’échographie et/ou l’indispensable lavement aux hydrosolubles 7%$:%&&%1&! 0%! ).,(+*.,%$!*3+A,%1-%!0%!:.-$'-O*'1!-':7*%&4!<%!-'*'1!6'1-&.'11%*!7%(&!8&$%!0%!7%&.&!-+*.A$%F!'(!A.%1!0%!&+.**%!1'$:+*%!'(!+(>:%1&2%F!:+.,!.*!-'1&.%1&!(1!:2-'1.(:!1'$:+*!7*(,!'(!:'.1,!7'1-&(2!0%!A(**%,!03+.$4!!
4.3.1 La maladie de Hirschsprung recto-sigmoidienne !<+!026.1.&.'1!0%!*+!maladie de Hirschsprung GHMJ!%,&!@.,&'*'>./(%!P!-=%,&!*=+A,%1-%!-'1>21.&+*%!
0%,! -%**(*%,! >+1>*.'11+.$%,! 0+1,! *%,! 7*%;(,! 1%$)%(;! ,'(,D:(/(%(;! %&! .1&$+:(,-(*+.$%,4! B%&&%!+1':+*.%! %,&! $%,7'1,+A*%! 0%! *=+A,%1-%! 0%! 72$.,&+*&.,:%! @+$:'1.%(;! %&! %66.-+-%! 0+1,! *%! ,%>:%1&!7+&@'*'>./(%! +A'(&.,,+1&! E! (1%! 0.*+&+&.'1! ! 0(! ,%>:%1&! 0=+:'1&4! <=+1':+*.%! -'1-%$1%! &'(Q'($,! *%!,[email protected]&%$! .1&%$1%!0%! *=+1(,!%&! ,=2&%10!)%$,! *=+:'1&!0=(1! ,%(*! &%1+1&F! *+! *.:.&%! ,(72$.%($%! $%:'1&+1&!7*(,!'(!:'.1,!@+(&4!La forme rectosigmoïdienne %,&!0%!*'.1!*+!7*(,!6$2/(%1&%F!$%7$2,%1&+1&!7$9,!0%!R!0%,!-+,4!!Cliniquement, .*!,3+>.&!*%!7*(,!,'()%1&!0% >+$S'1,F!12,!E!&%$:%!G*+!7$2:+&($.&2!%,&!&$9,!$+$%J4!<+!
HM! 0'.&! 8&$%! ,(,7%-&2%! 0%)+1&! *3%;.,&%1-%! 03(1! $%&+$0! 032*.:.1+&.'1! 0(!:2-'1.(:! +(D0%*E! 0%! *+!).1>&D/(+&$.9:%! @%($%F! 03(1! A+**'11%:%1&! +A0':.1+*! @':'>91%! %&! *3+77+$.&.'1! 0%! )':.,,%:%1&,!A.*.%(;4! <%! &%,&! E! *+! ,'10%! $%-&+*%! 7$')'/(%! 7+$6'.,! *=2*.:.1+&.'1! T!%;7*',.)%!U! -+$+-&2$.,&./(%! 0(!:2-'1.(:!%&!0%,!>+C4!B%7%10+1&! *3.:+>%$.%!0'.&!8&$%!$2+*.,2%!,.!7',,.A*%!+)+1&!'(!E!0.,&+1-%!03(1!7+,,+>%!0%!,'10%4!!
L’ASP!:'1&$%! &L7./(%:%1&! (1%! +2$+&.'1! >*'A+*%! 0(!>$8*%! %&! 0(! -'*'1! +)%-! (1%! 0.,&%1,.'1! 0(!,.>:'V0%F! 0(! -O*'1! >+(-@%! %&! 0(! &$+1,)%$,%! %1! +:'1&! 03(1! $%-&(:! ).0%4! <+! 0.,7+$.&2! 0%! -+*.A$%!$%-&',.>:'V0.%11%!%,&!7+$6'.,!A.%1!).,.A*%!0%!7$'6.*!+)%-!-%!,.:7*%!-'1&$+,&%!+2$./(%4!<3WKX!E!$+L'1!@'$.C'1&+*!2*.:.1%!(1!71%(:'72$.&'.1%!%1!$+77'$&!+)%-!(1%!7%$6'$+&.'1!0.+,&+&./(%!'(!,%-'10+.$%!+(!7+,,+>%!03(1%!,'10%F!/(.!-'1&$%D.10./(%$+.&!*%!*+)%:%1&4!!A l'échographie,! *%! $%-&(:! %&! *%! -O*'1! ,'1&! 0%! &+.**%! 1'$:+*%! '(! +(>:%1&2%F! -'1&%1+1&! (1!
:2-'1.(:! @L7'2-@'>91%! 7*(,! '(! :'.1,! 7'1-&(2! 0%! A(**%,! +2$./(%,4! <%! -+*.A$%! $%-&'-'*./(%! %,&!@+A.&(%**%:%1&! (1.6'$:%F! +(! 1.)%+(! 0%,! Y! ,%>:%1&,! 6+-.*%:%1&! :%,($+A*%,4! 5$9,! $+$%:%1&F!*=2-@'>$+7@.%!.0%1&.6.%!(1%!0.,7+$.&2!0%!-+*.A$%!%1&$%!(1!$%-&(:!0%!&+.**%!1'$:+*%!%&!(1!-O*'1!>+(-@%!7*(,!)'*(:.1%(;4!!<+!7$2,%1-%!03(1%!0.*+&+&.'1!(1.6'$:%!0(!>$8*%!GZ[!E!Z\!::JF!*./(.0.%11%!%&!+2$./(%F!+,,'-.2%!E!
(1!27+1-@%:%1&!.1&$+72$.&'12+*!%,&!*%!,%(*!&2:'.1!0%!*3'--*(,.'14!!
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,)!(,0'!'/0-)%.!&$*4%/'.$20)5!!6,!7/%.8)!1,*''$20)7)%.9!'08!,)!(8/3$,9!0%)!disparité de calibre brutale située sur le sigmoïde,!
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
(*'!)%1/8)!/84*%$'A)9!%/.*77)%.!&*%'!,)'!3/87)'!1/08.)'5!F)1$!%A1)''$.)!(*83/$'!,*!8A*,$'*.$/%!&:0%!&)0G$B7)!,*-)7)%.5!!!!?)! &$*4%/'.$1! &)! ,*! 7*,*&$)! 8)(/')! *-*%.! ./0.! '08! la biopsie rectale! 7)..*%.! )%! A-$&)%1)!
,:*+')%1)! &)! 1),,0,)'! 4*%4,$/%%*$8)'9! ,:>H()8.8/(>$)! &)'! (,)G0'! '/0'I7020)0G! ).! ,:A,A-*.$/%! &)!,:*1.$-$.A!*1A.H,1>/,$%)'.A8*'$20)5!!?)!%08'$%4!()0.!()87)..8)!&)!,)-)8!.)7(/8*$8)7)%.!,:/11,0'$/%9!&:A-$.)8!,*!1/,/'./7$)!&:*7/%.!).!
&)! &$33A8)8! ,:$%.)8-)%.$/%! &A3$%$.$-)5! J0! 1/08'! &)! 1),,)I1$9! ,)'! +$/('$)'! A.*4A)'9! 40$&A)'! (*8! ,)!,*-)7)%.9!()87)..8/%.!&)!(8A1$')8!,*!@/%)!&)!.8*%'$.$/%5!!
4.3.2. Formes longues de maladie de Hirschsprung !!!Dans les formes longues,! ,*! ,$7$.)! '0(A8$)08)!&0! ')47)%.! *4*%4,$/%%*$8)! 8)7/%.)! '08! ,)! 1/,/%!4*01>)!/0!'08!,)!.8*%'-)8')5!F)'!3/87)'!'/%.!+)*01/0(!(,0'!8*8)'5!!!!!Le tableau clinique! )'.! ()0! &$33A8)%.! &)! 1),0$! &)'! 3/87)'! 8)1./I'$47/<&$)%%)'5! ?:*+')%1)! &)!&A+K1,)!38*%1>)!*0!(*''*4)!&)!,*!'/%&)!8)1.*,)!()0.!/8$)%.)8!-)8'!0%)!3/87)!,/%40)5!!!!!Le lavement opaque! /+D)1.$-)! 0%)! &$'(*8$.A! &)! 1*,$+8)! '08! ,)! 1/,/%! 4*01>)! /0! ,)! .8*%'-)8')!(/0-*%.!3*$8)!A-/20)8!,)!&$*4%/'.$1!&)!+/01>/%!7A1/%$*,!7*$'!,)!')47)%.!(*.>/,/4$20)!)'.!&)!.*$,,)!%/87*,)!/0!*047)%.A)!à l’échographie.! !?:*+')%1)!&)!8)(8$')!&)!.8*%'$.!*(8B'!,*-)7)%.!&/$.!3*$8)!8A*,$')8! 0%)! +$/('$)! 8)1.*,)5! ?:$%.)8-)%.$/%! *-)1! )G*7)%'! >$'./,/4$20)'! )G.)7(/8*%A)'! ()87)..8*!0%)!&A8$-*.$/%!)%!@/%)!'*$%)5!!!
4.3.3. La maladie de Hirschsprung colique totale !
La forme colique totale!8)(8A')%.)!LM!N!&)'!7*,*&$)'!&)!O$8'1>'(80%45!?*!@/%)!*4*%4,$/%%*$8)!'PA.)%&!'08!,*!./.*,$.A!&0!1Q,/%9!).!()0.!7E7)!$%.A8)'')8!,*!3$%!&0!48E,)5!?)'!3/87)'!3*7$,$*,)'!'/%.!(,0'!38A20)%.)'!&*%'!,)'!3/87)'!,/%40)'!*-)1!0%)!*047)%.*.$/%!&0!(/081)%.*4)!&)'!3$,,)'!*..)$%.)'5!!!!L’ASP! 7/%.8)! 0%)! &$,*.*.$/%! 4,/+*,)! '/0-)%.! 0%$3/87)! &0! .0+)! &$4)'.$3! 8)%&*%.! ,*!
&$33A8)%1$*.$/%!)%.8)!,)!1Q,/%!).!,)!48E,)!'/0-)%.!$7(/''$+,)5! L’échographie 8A-B,)! ,)! (,0'! '/0-)%.! ;RST! &)'! 1*'=! 0%)! &$'(*8$.A! &)! 1*,$+8)! 38*%1>)! )%.8)! 0%!
8)1.07!).!0%!1Q,/%!4*01>)!&)!.*$,,)!%/87*,)!/0!&$'18B.)7)%.!&$,*.A'!).!0%!1Q,/%!&8/$.!&$'.)%&0!&/%.!,)! &$*7B.8)! )'.! 70,.$(,$A! (*8! 0%! 1/)33$1$)%.! *,,*%.! &)! L5U! V! T5! ?)! 1/,/%! ()0.! E.8)! &)! 1*,$+8)!>/7/4B%)9!&)!.*$,,)!%/87*,)!/0!&$'18B.)7)%.!*047)%.A)5! !
!!!Le lavement opaque! )'.! '/0-)%.! .8/7()085! ?)! 1Q,/%! ()0.! E.8)! &)! .*$,,)! %/87*,)! ).! &)! 1*,$+8)!8A40,$)85!6,!()0.!E.8)!1/08.9!'$7(,$3$A!).S/0!(8A')%.)8!0%)!7/8(>/,/4$)!)%!(/$%.!&P$%.)88/4*.$/%!*-)1!0%!*'()1.!*88/%&$!&)'!*%4,)'!1/,$20)'!'08!,)'!1,$1>A'!)%!8A(,A.$/%5!!W%!8)3,0G!7*''$3!&0!(8/&0$.!&)!1/%.8*'.)!&*%'!,)!48E,)!()0.!E.8)!/+')8-A5!C)'!(')0&/I&$'(*8$.A'!&)!1*,$+8)!()0-)%.!3*$8)!A-/20)8!V!./8.!0%)!3/87)!7/$%'!A.)%&0)5!!!!!?/8'!&)! ,:$%.)8-)%.$/%9! la biopsie d’appendice!7/%.8*%.!0%)! *+')%1)!&)!1),,0,)'!4*%4,$/%%*$8)'!%/87*,)'!)'.!3/%&*7)%.*,)5!!
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,-)'+.(,!'(!8!(+!9:1;'+)2.'++%,%+2!25/+1.2'.5%!9(!2(&%!9.<%12.;=!!!Cliniquement,! .0! 1>/<.2! ?'0'+2.%51! 9>(+! %+;/+2! 9%! 3%2.2! 3'.91! 9%! +/.11/+)%@! 9>(+! 35-,/2(5-! '(!
9>(+! &-&-! 9%!,45%! 9./&-2.6(%=! $%! 35%,.%5! 1:,32A,%! %12! 0>/&1%+)%! 9>-0.,.+/2.'+! 9(!,-)'+.(,=!B5'<5%11.?%,%+2!1>.+12/00%!(+!&/00'++%,%+2!/&9',.+/0@!0>-2/2!<-+-5/0!%12!?'0'+2.%51!1/2.1;/.1/+2=!!!L’ASP ,'+25%!(+%!9.12%+1.'+!5-<(0.45%!(+.;'5,%!9(!<570%!%2!9(!)'0'+!6(.!+%!1'+2!1'(?%+2!3/1!
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%12!9%!3%2.2%! 2/.00%! CH!,,!8!#!,,!9%!9./,425%G! 1(5! 2'(2%! 1/! 0'+<(%(5! CI!1:+95',%!9(!3%2.2! )'0'+!</()*%!JG@!1(5!1/!,'.2.-!'(!1(5!1'+!2.%51!9.12/0=!$/!!9.13/5.2-!9%!)/0.&5%!%12!5-<(0.45%!%+25%!0%!)'0'+!</()*%!9.12/0!9%!3%2.2%!2/.00%!%2!0%!)'0'+!35'K.,/0!6(.!/(<,%+2%!35'<5%11.?%,%+2!9%!?'0(,%=!L/+1!MEF!9%1!)/1@!0%!)'0'+!%12!*','<4+%@!9%!2/.00%!+'5,/0%!'(!9.1)542%,%+2!9.0/2-=!L/+1!2'(1!0%1!)/1@!0%!)'0'+!)'+2.%+2!(+!,-)'+.(,!9>-)*'<-+.).2-!+'5,/0%!30(1!'(!,'.+1!3'+)2(-!9%!&(00%1!9>/.5=!!Le lavement aux hydrosolubles! '3/).;.%! (+%! /,3'(0%! 5%)2/0%! 9%! )/0.&5%! +'5,/0! &.%+!
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’amélioration clinique est spectaculaire!%2!9-;.+.2.?%!/3541!0%!0/?%,%+2=!L/+1!0%!)/1!)'+25/.5%!
(+%!&.'31.%!5%)2/0%@!(+%!5%)*%5)*%!9%!,()'?.1).9'1%!'(!9>*:3'2*:5'N9.%!1'+2!.+9.6(-1=!!!!!!4.3.5. Tableau d'occlusion basse révélateur d'un volvulus sur malrotation
!Cliniquement,! 0/! ;'5,%!+-'+/2/0%!<5/?%! /11').%!9%1!?',.11%,%+21!?%521! /?%)!(+!-2/2! 9%! )*')!
30(1! '(!,'.+1! ,/56(-@! 9%1! 5%)2'55/<.%1@! %2! (+! ,-2-'5.1,%! 30(1! '(! ,'.+1! .,3'52/+2=! P%! 2/&0%/(!9>'))0(1.'+!&/11%!/?%)!5%)2'55/<.%1@!9'.2!;/.5%!-?'6(%5!3/5!35.+).3%!(+!?'0?(0(1!/.<(!9(!<570%=!Q!l’échographie,!0>%K.12%+)%!.1'0-%!'(!/11').-%!9>(+%!9.0/2/2.'+!0.6(.9.%++%!'))0(1.?%!9(!<570%@!
9>(+!-3/.11.11%,%+2!9.<%12.;!/?/1)(0/.5%@!9>(+%!/&1%+)%!9%! ;0(K!%+!L'330%5!)'(0%(5!9/+1! 0/! 13.5%@!9>(+! -3/+)*%,%+2! -)*'<4+%@! 25/9(.2! (+%! 1'(;;5/+)%! ?/1)(0/.5%=! P>%12! 9/+1! )%1! ;'5,%1! 6(>(+%!*:3%5/-5/2.'+!+'+!)',35%11.&0%!9%!0/!5-<.'+!-3.</125.6(%@!3%(2!5%+95%!0%1!?/.11%/(K!,-1%+2-5.6(%1!.+/))%11.&0%1=!!
L’opacification par voie haute!%12!+-)%11/.5%!3'(5!)'+;.5,%5!0%!9./<+'12.)=!!Le lavement,! 1>.0! %12! 35/2.6(-@!,%2! %+! -?.9%+)%!(+!)R)(,! 5%)'(5&-! %+!*/,%S'+!?%51! 0/! 0.<+%!
,-9./+%!2-,'.<+/+2!9>(+%!&5.9%!9%!$/99!%+!;/?%(5!9(!9./<+'12.)=!!T0!1>/<.2!9>(+%!extrême urgence chirurgicale.!!
!4.3.6. Sténose post-entérocolite !!!!La sténose colique! 3'12U%+2-5')'0.2%! %12! (+%! )',30.)/2.'+! )0/11.6(%! 9%! 0>%+2-5')'0.2%!(0)-5'+-)5'1/+2%!9(!35-,/2(5-@!5%+)'+25-%!9/+1!%+?.5'+!(+!6(/52!9%1!)/1=
Le tableau d’occlusion ou de subocclusion 1(5?.%+2! /3541! (+! .+2%5?/00%! /00/+2! 9>(+%! 8! 25'.1!1%,/.+%1!C3/5;'.1!30(1G!/3541!0>-3.1'9%!9>%+2-5')'0.2%=!!
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L’échographie!$%&! %'! ()*+%',%! -'%! .&('/.%! -'*0-%! /-!$-1&*21%3! 2456/*.! %'! 7!,842%1%&!9! 4)%,!5(&5(,*..%$%'&!+%!14!1-$*:5%!,%'&541%!0-*!%.&!%'&/-5(%!+;-'!$4',8/'!(,8/<:'%!(24*.3!!8=2%58($*0-%!4-!.&4+%!*'614$$4&/*5%>!?%!$4',8/'!14*..%!214,%!@!-'%!245/*!1*..%!%&!5*<*+%3!4)4.,-14*5%!4-!.&4+%!+%!6*A5/.%>!!!!
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