Neonatal intestinal obstruction

1. Meconium Disease
Dr. Shirish Silwal
Dept. Of Paediatric Surgery, BSMMU

2. Contents
• What is meconium?
• Common meconium diseases
1. Meconium ileus
2. Meconium plug syndrome

3. Neonatal intestinal obstruction
1. Intestinal atresia
2. Meconium ileus
3.Hirschsprung's disease (HD)
4.Malrotation of the gut with or without volvulus

4. Meconium
Meconium is the First Stool Passed by New-Born

5. • “Meconium” derives from
the Greek word mēkōnion (poppy)
due to its tar like appearance that
resembles raw opium.
• Thick, Sticky and blackish green.
• Unlike later feces, meconium is
composed of materials ingested
during the time the infant spends
in the uterus: intestinal epithelial
cells, mucus, amniotic fluid, bile.

6. NormalPassageOf Meconium
Healthy full term infants:
99% pass meconium within 24 hrs of birth
100% pass meconium within 48 hrs of birth
Preterm infants:
37% pass within 24 hrs
99% pass within 9th day of birth

7. CommonDifferentialsof MeconiumDisease
Meconium ileus
Meconium plug syndrome

8. First sign or symptom that we suspect its a
meconium ileus ??
Neonate born with abdominal distention before
neonate swallows air.

9. Meconium Ileus
Common cause of neonatal intestinal
obstruction
Characterized by extremely viscid, protein-rich,
inspissated meconium in mid ileum causing
obstruction
Earliest manifestation of cystic fibrosis(CF)

12. Incidence
• 9 – 33% of all neonatal intestinal obstruction
• Predominant in white countries where the rate of CF is higher
(1 in 1200 to 1 in 2700 live birth)
• Nearly absent in some Asian people and black Africans
• No difference between sexes

13. Causes Of Meconium Ileus
Pancreatic
insuffienciency
Intestinal
glandular
abnormality
Abnormal
intestinal
motility

14. Composition
• Meconium is thick, viscid, inspissated – due to
• Water: 65% (normal – 75%)
• Lower sucrase & lactase level
• Increased albumin, nitrogen
• Decreased pancreatic enzyme & carbohydrate
• Reduced Na, K, Mg, heavy metals
• Presence of abnormal mucoprotein

15. Clinical features
• Uncomplicated/simple (58%):
• Abdominal distension with palpable doughy
bowel loops (putty sign present)
• Bilious vomiting
• Failure to pass stool
• On DRE, narrowing of anus and rectum, with
only a dense rubberlike gray meconium
sticking to the anal wall

16. Contd.
• Complicated (42%):
• Presents symptoms immediately after birth
due to in utero perforation
• meconium peritonitis
• Signs of peritonitis (abdominal distension,
edema & erythema of abdominal wall,
abdominal tenderness, sepsis)
• NG tube insertion : >20ml bile stained gastric
fluid

17. Investigations
• Imaging :
• Prenatal USG: Done in 3rd trimester
• Hyperechogenic bowel

18. Contd.
• Plain x-ray abdomen:
• Disparity in the size of the
intestinal loops
• No or few air fluid levels on
erect film
• Granular soap bubble
(Neuhauser sign)

19. Contd.
Water soluble contrast
enema:
• Unused or microcolon
often containing small,
inspissated rabbit pellets of
meconium.
• If reflux into the terminal
ileum pellets of meconium
can be seen

20. Contd.
• Laboratory testing:
• Sweat chloride test:
• Sweat collected from forearm, leg or back
• >60mEq/L of chloride diagnostic of CF
• Amniocentesis with fetal DNA restriction
fragment length polymorphism analysis (if
family history of CF)

21. • Albumin concentration in meconium:
• Tetra bromophenolethylester blue detects
albumin >20mg/gm of stool
• Normally meconium contains <5mg/gm
albumin
• In CF: albumin >80mg/gm of stool

22. Contd.
• Stool trypsin & chymotrypsin analysis:
• Trypsin <80mg/gm of stool
• Histopathology:
• Goblet cell hyperplasia
• Accumulation of secretion within crypts or lumen

23. Management
• Non operative
• Operative

24. Non Operative Management
• Neonates should be managed as neonatal intestinal obstruction:
Nothing per oral
Aggressive fluid resuscitation
Nasogastric tube to suction
Mechanical respiratory support
Correction of coagulation disorder
Empirical broad spectrum antibiotic coverage
• Hyperosmolar contrast enema:
• Gastrograffin (standard)

25. Contd.
• Need to fulfill the following criteria before applying such
therapy:
• An initial diagnostic contrast enema should exclude other causes
of distal intestinal obstruction
• The complications of volvulus, atresia, perforation or peritonitis
must be excluded
• Must be performed with careful fluoroscopic control

26. Contd.
• I/V antibiotics should be administered
• Should be attended by a pediatric surgeon
• The patient should have a full fluid resuscitation with fluid given
aggressively during the procedure
• The patient should be prepared for imminent operation should
complication develop

27. Operative Management
• Simple meconium ileus:
• Indications of surgery:
• Inadequate meconium evacuation or a complication from the
contrast enema
• Failure of non-operative treatment with the contrast enema
• An unsuspected associated intestinal atresia
• If the enema failed to promote passage of meconium within 24 to
48 hours
• Two attempts at washout are unsuccessful

28. Contd.
• Operative options:
• Enterotomy and intraoperative saline irrigation for mechanical
separation of the pellets from the bowel wall and evacuation of
the meconium

29. Contd.
• Mikulicz double barreled enterostomy

30. Contd.
• The Bishop-Koop procedure

31. Contd.
• The Santulli procedure

32. Contd.
Complicated meconium ileus:
• Surgery is indicated in complicated MI.
• Surgical management includes:
• Early diagnosis
• Debridement of necrotic material
• Pseudocyst resection
• Diverting stoma’s
• Antibiotics
• Meticulous post operative care

33. Post Operative Management
• Initial management- ongoing resuscitation
• Instillation of 2% or 4% N-acetylcysteine will help solubilize
residual meconium
• Nutritional management- breast milk/infant formula along
with supplemental pancreatic enzyme(2000-4000 unit
lipase/120ml) & vitamins.
• Prophylactic pulmonary care with chest physiotherapy

34. Prognosis
• Current 5 years survival is approaching 100%
• 72% survival at 10 years
• Current operative mortality is reported to be 10-20%
• Current life expectancy for patients with cystic fibrosis is 35
years

35. Meconium Plug Syndrome
• Usually, the terminal 2 cm of neonatal meconium is firm in
texture, forming a whitish cap that is passed before, during or
shortly after delivery.
• 1 in 500 newborns will have a longer, more tenacious
obstructive plug

36. • Failure to pass this plug results in meconium plug syndrome
• Hypothesis- either colonic motility abnormality or the
character of the meconium was altered
• Most of the infants are found to be healthy

37. Causes
• Most common:
• Cystic fibrosis
• Small left colon syndrome
• Hirschsprung disease
• Less common:
• Congenital hypothyroidism
• Maternal narcotic addiction
• Neuronal intestinal dysplasia

38. Clinical Features
• Failure to pass meconium
• Bilious vomiting
• Abdominal distention
• Obstructive pattern on plain abdominal radiograph
• The meconium plug may become dislodged after digital
stimulation of the anus and rectum

39. Diagnosis
• Contrast enema- may be therapeutic as well as diagnostic
• Sweat test for cystic fibrosis
• TSH for hypothyroidism
• A rectal biopsy for HPD

41. Prognosis
• Excellent outcome after relief of the obstruction, and no
further intervention is required

42. ManagementofMeconiumIleus:5years'experienceatDhaka
Shishu(Children)Hospital(2011-2016)
KMNFerdous,MSHasan,KAKabir,MKIslam,TBanu

43. Take Home Message
• Timely passage of the first stool is a hallmark of the well-being
of the newborn infant.
• Early diagnosis is of paramount importance.
• Clinical history and physical examination combined with plain
abdominal radiographs, contrast enema radiographic
examination and rectal examination eventually yield the
diagnosis

44. THANK YOU