Delayed passage of meconium can be caused by several intestinal obstructions and diseases. It is suspected in full-term infants who do not pass meconium in the first 24 hours and in premature infants who delay passage for over a week. Diagnostic workup includes abdominal x-rays, ultrasound, and contrast studies to locate the obstruction. Management requires gastric decompression, fluid resuscitation to address dehydration, and monitoring of electrolytes and glucose levels which may become imbalanced. The cause is determined based on the presentation and imaging findings, and treatment involves surgery for structural issues or supportive care for medical conditions.

2. Delayed passage of meconium
Dr. Faheem ul Hassan Andrabi
M Ch Pediatric Surgery
Dr. Gowhar Mufti
Assist. Professor
Pediatric & Neonatal Surgery

3. Delayed passage of Meconium
Timely passage of the first stool is a hallmark of the
well-being of the newborn infant.

4. DPM
suspected in any full-term infant who does not pass
meconium in the first 24 hours of life and
in the premature infants who have excessively delayed
the passage of meconium(7–8days)

5. DPM
Delayed passage of meconium is a frequent finding in
patients with distal intestinal obstruction and is
observed in 90% of infants with Hirschsprung’s disease.

6. DPM
The passage of meconium does not indicate that a
complete intestinal obstruction is not present, since
meconium formed distal to an obstruction may be
evacuated.

7. causes
Hirschsprung's disease 1/4,000
Meconium ileus 1/3000
Meconium plug syndrome 1/500 to 1/1,000
Anorectal malformation 1/4,000 to 1/8,000
Small left colon syndrome Rare
Hypoganglionosis Rare
Neuronal intestinal dysplasia Rare
Megacystis-microcolon-I ntestinal
Hypoperistalsis syndrome
Very rare
Distal Ileal or colonic atresia Rare

8. Medical causes of DPM
Infant of diabetic mother
Downs Syndrome
hypermagnesemia
Maternal drugs like opiods
Already passed meconium in utero. Eg Fetal distress
1% normal Term neonates have DPM
5% normal preterm neonates have DPM

9. Presentation
Proximal obstruction presents earlier than the distal
esophageal atresia or gastroduodenal obstruction, usually
present within the first 24 to 48 hours of life.
Distal obstructions, such as ileal or colorectal atresias, may
present a few days after birth,
while functional obstructions, such as Hirschsprung’s disease,
may present later

10. DPM
DPM associated with
Vomiting
Abdominal distension
Poor feeding
Signs of peritonitis and shock

11. Vomiting
Non-bilious or bilious
Non-bilious
Proximal to Ampulla of Vater
Examples are pyloric atresia and pyloric stenosis

12. Vomiting
Bilious
Distal to Ampulla of Vater
Obstruction in
 Duodenum, jejunum, Ileum or colon
Medical conditions, such as GERD, and sepsis, can also cause vomiting,
and these need to be investigated as part of the diagnostic workup.
About 25% of neonates with BV eventually require abdominal surgery.

13. Abdominal distension
The degree of abdominal distention depends on the
level of obstruction.
More distal the obstruction, the greater will be the
distention.
Proximal obstructions, such as duodenal atresia and
malrotation, present with minimal epigastric distention,
whereas ileal and colonic obstructions present with
prominent distention.

14. Abdominal distension
Abdominal distention that is present at birth can result
from
meconium ileus
meconium peritonitis
antenatal intestinal obstruction and perforation usually due to
volvulus & intestinal atresia

15. Abdominal distension
Abdominal masses like
choledochal cyst,
mesenteric cyst,
duplication cyst
ovarian cyst
Hydronephrosis or ascites.
May also present as abdominal distension at birth

16. Abdominal distension
Abdominal distention can develop in the first hours after birth in
neonates with esophageal atresia due to air passing through a
concomitant TEF, particularly if the infant is ventilated
mechanically.
Neonates with malrotation and midgut volvulus also may develop
abdominal distention due to dilatation of a closed segment of
bowel distal to the usual site of duodenal obstruction. (closed loop
Obstruction)

17. Abdominal distension
Abdominal distention usually is delayed in distal or
functional obstructions and may appear 24 hours or
later after birth. (microcolon, ARM, Hirschsprung's
Disease)

18. DPM
The cardinal features of NIO are vomiting, abdominal
distension and failure to pass meconium.
Secondary symptoms such as brady- or tachycardia,
temperature instability, and lethargy are usually a
because of dehydration, electrolyte imbalance, and
sepsis

19. As the patient arrives
Prenatal history forms the cornerstone of diagnosis
History of
Polyhydroamnios
Cystic fibrosis
Drug intake like opoids and MgSO4
Gestational diabetes
Prematurity and fetal distress
Sepsis

20. History
Siblings of children with esophageal atresia may exhibit
features of the VACTERL
family history of epidermolysis bullosa may be observed
in neonates with pyloric atresia.
Almost half of neonates with small left colon syndrome
are infants of diabetic mothers.

21. Assessment
Vital signs
Cry, suck and activity
Signs of hypothermia
HR, RR, CRT and skin turgor
AF, dry mucosae and U.O should be assessed
After proper assessment, appropriate measures should be taken to address the
Issues (like fluid bolus and addressing hypothermia)

22. Abdominal assessment
Color
 Erythema
 blue
 shiny
Size
 distended,
 taut,
 scaphoid
 measurement of girth every 2-4 hourly

23. Abdominal assessment
Visible/prominent vascular markings
Visible bowel loops, peristalsis evident
Tenderness
Temperature
Palpation for masses
Presence/absence of bowel sounds or flatulence

24. Assessment
Color, volume and consistency of NG Aspirate should be
noted (for presence of BBF)
Similarly color, volume and consistency of stools should
be assessed
Daily weight of neonate should be followed

25. Intervention
8–10 French FT should be used to provide adequate
drainage and decompression of the stomach
 to decrease restriction of the diaphragm.
 To decrease the risk of emesis and the potential for
aspiration
Gastric decompression

26. Intervention
Regular flushing of the tube with air & saline ensures
patency.
Accurate measurements of drainage are necessary to
assist with maintaining fluid balance.
Gastric decompression

27. Intervention
Establishing adequate vascular access is essential for
any resuscitative and therapeutic measures to be
successful.
Warming the neonate initially makes vascular access
easy
Vascular access

28. Intervention
The fluids lost in vomitus and gastric aspirates are easily
quantified.
Intraperitoneal, interstitial (“third space”) losses from
the obstructed intestine cannot be easily measured.
In the circumstance of hypovolemic shock, fluid
resuscitation with NS boluses is essential to maintain
blood pressure and adequate perfusion to all vital
organs.
Maintenance of Fluid and Electrolyte Balance

29. Intervention
Gastric losses should be replaced.
maintenance fluid volume needs to be above the norms
(by approximately 10–20 percent) to compensate for
the third space losses
Maintenance of Fluid and Electrolyte Balance

30. Intervention
Immediate measurement of electrolytes is vital when
an obstruction is suspected.
The common practice of waiting to measure
electrolytes until the “obligatory” diuresis phase occurs
in the newborn infant with suspected intestinal
obstruction is unwarranted.
Maintenance of Fluid and Electrolyte Balance

31. Intervention
Clinical presentation, age, duration, location, and
degree of obstruction are key factors in the calculation
of estimated fluid and electrolyte requirements.
Measuring trends over time is essential because
changes in electrolytes also reflect fluid balance.
Maintenance of Fluid and Electrolyte Balance

32. Intervention
Assessing weight, skin turgor, serum electrolytes and
urine output, and renal function helps in estimating
fluid and electrolyte.
Maintenance of Fluid and Electrolyte Balance

33. Intervention
A history of dehydration and inadequate fluid intake
may lead to hypoglycemia.
Conversely, the stress response to sepsis and
obstruction may lead to hyperglycemia.
Frequent measurement of serum glucose is essential.
Maintenance of BS

34. Intervention
Observation for pH imbalance is essential
Both metabolic acidosis and alkalosis may occur with
intestinal obstruction, depending on the level of
obstruction,
Upper GI tract obstruction may lead to a loss of chloride
in the vomitus subsequently resulting in hypochloremic
metabolic alkalosis.
Maintenance of Normal pH Balance

35. Intervention
Acidosis and increased lactate levels are indicators of
shock
Respiratory acidosis may also occur secondary to sepsis
and to the respiratory decompensation due to
abdominal distention and decreased lung volumes
Maintenance of Normal pH Balance

36. Diagnostic work-up (disease-specific)
Polyhydroamnios ( s/o proximal obstruction, EA, PA, DA,
MI)
Echogenic contents of bowel in MI
Double Bubble sign in DA
Presence of other abdominal masses like a Choledochal
cyst or renal mass
Presence of distended bladder in megacystis microcolon
Syndrome
Prenatal USG

37. Diagnostic work-up (disease-specific)
Prenatal ultrasound image shows fluid-filled distended stomach (S) and
duodenal bulb (D),producing prenatal ultrasound double bubble sign
Prenatal USG

38. Diagnostic work-up (disease-specific)
Echogenic bowel (MI)
Free abdominal fluid ( perforation)
Relation of SMA and Vein (in Malrotation)
Distended bowel ( atresia)
Postnatal USG

39. Diagnostic work-up (disease-specific)
Abdominal x-ray with GI tract
anatomic landmarks.
Radiograph (X-Ray)

40. Diagnostic work-up (disease-specific)
Air is generally present in the
stomach of the neonate within 5 minutes of life,
in the jejunum within 15 minutes, and
in the cecum by 2 to 3 hours.
Air usually reaches the sigmoid colon and the rectum
within 6 to 12 hours.
Radiograph (X-Ray)

41. Diagnostic work-up (disease-specific)
Although radiographs permit visualization of the bowel
gas pattern, it is difficult to differentiate between the
small bowel and the colon in a neonate.
Radiograph (X-Ray)

42. Radiograph
Characteristic gas pattern in proximal gut obstruction

43. Radiograph
Gas pattern in mid GIT obstruction

44. Radiograph
Gas pattern in distal GIT obstruction

45. Diagnostic work-up (disease-specific)
Posteroanterior and lateral decubitus abdominal
radiographs should be obtained in all neonates with
suspected intestinal obstruction.
Radiograph (X-Ray)

46. Diagnostic work-up (disease-specific)
Pyloric atresia. Single bubble sign. Epidermolysis bullosa
is an association of PA
Radiograph (X-Ray)

47. Duodenal atresia
Double bubble sign on X-Ray
Distal gas absent in complete atresia

48. Distended stomach and duodenum with traces of
contrast distally. ( Partial obstruction; Duodenal stenosis
and duodenal web)

49. Diagnostic work-up (disease-specific)
UGI depicting malrotation with all of the small bowel on
the right side of the abdomen.
Malrotation

50. Diagnostic work-up (disease-specific)
Upper GI barium study demonstrates the classic
‘corkscrew’ appearance of the duodenum and proximal
jejunum.
Midgut volvulus

51. Diagnostic work-up (disease-specific)
Diagram of small bowel volvulus with secondary ischaemia of the midgut.
UGIS of volvulus showing the characteristic “corkscrew” appearance.
Midgut volvulus

52. Diagnostic work-up (disease-specific)
Jejunal atresia. Triple bubble sign
Radiograph (X-Ray)

53. Diagnostic work-up (disease-specific)
Ileal atresia. Multiple air fluid levels in proximal two-third of abdomen.
No gas in lower abdomen. Note the large AF level in distal most part of
proximal bowel
Ileal Atresia

54. Diagnostic work-up (disease-specific)
Ileal atresia. Contrast enema shows a microcolon but unable to reflux
contrast into the terminal ileum.
Ileal Atresia

55. Meconium Ileus
dilated small bowel loops of
different size,
few air-fluid levels, and a
“ground-glass” or “soap-
bubble”

56. Radiology
Meconium Ileus
There are distended bowel
loops of disparate size,
Few air-fluid levels, and a
“soap bubble” right lower
quadrant appearance.

57. Meconium Ileus
Meconium Ileus
 CE depicting a micro colon
inspissated intraluminal pellets
of meconium are seen

58. MI- Laboratory Testing
Gastrograffin is both diagnostic and therapeutic in MI
Other tests used to diagnose MI are
sweat chloride in excess of 60 mEq/L is diagnostic of CF.
Meconium albumin> of 80 mg/g
genetic analysis for CFTR

59. Diagnostic work-up (disease-specific)
MPS. Contrast enema shows intraluminal filling defect in the
rectosigmoid colon. Patient later passed meconium plug and obstruction
was relieved
Meconium plug syndrome

60. Diagnostic work-up (disease-specific)
MPS. Lateral and frontal images demonstrate a microcolon involving the
entire colon. Inspissated meconium (arrows) is seen throughout the small-
calibered colon
Meconium Plug Syndrome

61. Diagnostic work-up (disease-specific)
Hirschsprung’sDisease. distended loops of intestine with paucity of air in
rectum
Hirschsprung’s Disease.

62. Diagnostic work-up (disease-specific)
Hirschsprung’s Disease. Transition zone at RS junction
Hirschsprung’s Disease.

63. Diagnostic work-up (disease-specific)
Hirscpsrungs Disease

64. Diagnostic work-up (disease-specific)
Colonic atresia

65. Microcolon
Microcolon is a radiographic feature of low intestinal
obstruction that results from underutilization of colon
It is also called “unused colon,”
includes entities in which meconium is not passed
through the colon during in fetal life.

66. Microcolon
Disease entities manifesting as microcolon include.
meconium ileus,
small left colon syndrome,
small intestinal and colonic atresia, and
Hirschsprung disease
Etiology
Microcolon has also been defined by a luminal diameter less than the height of
an upper lumbar vertebral body.

67. There are 4 patterns of contrast enema
Normal (normal length and caliber)
No obstruction.
Microcolon

68. Normal length and small caliber
Normal length and small
caliber
Meconium ileus
Jejuno-ileal Atresia
Total Colonic Aganglionosis
Microcolon

69. Short length and small caliber
Short length and small
caliber
Colonic Atresia
Microcolon

70. Change in Caliber
Change in Caliber
Small Left Colon Syndrome
Hirschsprung Disease
Microcolon

71. A word about Contrast Study
Two types of contrast studies generally rule out
obstruction.
The choice (upper vs lower) and the sequence of
studies are determined by the clinical presentation, the
x-ray findings, and the suspicion of upper vs lower GI
tract obstruction.

72. A word about Contrast Study
If a proximal obstruction such as duodenal atresia or
malrotation is suspected, upper GI series (e.g., ESSB) is
instituted
If a mid to distal obstruction is suspected, the contrast
enema is done first to assess the patency of the distal
bowel.

73. Contrast Study
Traditionally, barium has been used as a contrast
medium.
It is inexpensive, readily available, and provides good
contrast images.
However, disadvantages for its use in the neonate
include aspiration into the lung or solidification in
dilated bowel

74. Contrast Study
In cases of perforation, barium may lead to peritonitis
and granuloma formation.
Preferably, water–soluble, nonionic, or low-osmolar
contrast solutions that, in cases of perforation, are
reabsorbed are used.

75. Algorithm
In cases of perforation, barium may lead to peritonitis
and granuloma formation.
Preferably, water–soluble, nonionic, or low-osmolar
contrast solutions that, in cases of perforation, are
reabsorbed are used.

76. Algorithm
In cases of perforation, barium may lead to peritonitis
and granuloma formation.
Preferably, water–soluble, nonionic, or low-osmolar
contrast solutions that, in cases of perforation, are
reabsorbed are used.

77. Current Diagnostic Protocol - HD

78. Current Diagnostic Protocol - HD
The diagnosis requires histopathological demonstration
of the complete absence of enteric ganglion cells and
presence of hypertrophied AchE-positive nerve trunks
Therefore, rectal biopsies with appropriate processing
and interpretation by an experienced pathologist are
the criterion standard to diagnose HD.

79. Current diagnostic protocol; HD
Anorectal manometry (ARM) may be a confirmatory
investigation or a tool to exclude HD in older children
with a history of constipation from infancy.
A BE but may be indicated in Histologically confirmed
cases to provide information on the length of the
aganglionic bowel.

80. Biopsy-HD
The easiest means of obtaining adequate diagnostic
tissue in rectal biopsies in infants is by rectal suction
biopsy (RSB).

81. Biopsy - HD
Compared with full-thickness rectal biopsies, RSB can
be performed without general anesthesia or even
sedation.
The rates for major complications such as perforation,
bleeding, and infection are between 1.3% and 2.9%

82. Biopsy - HD
An accurate diagnosis is only possible if 2 to 3 suction
biopsies are taken 2 to 3 cm above the dentate line and
if they include sufficient submucosa.
Biopsies taken closer to the dentate line may be
misleading because of a normal zone of submucosal
hypoganglionosis.

83. Biopsy- HD
This zone of hypoganglionosis is 10 mm in neonates to
25 mm in children 3 years old and Older.
If a full-thickness biopsy is obtained, this could be done
as low as 1 cm above the dentate line because the
myenteric plexus extends more distally.

84. Biopsy-HD
Between 9% and 30% of RSBs are inadequate and must
be repeated, primarily because of insufficient
submucosa in the biopsy.
This is particularly a problem in children older than 1
year.

85. Anorectal manometry
ARM assesses the rectoanal inhibitory reflex (RAIR),
which is absent in HD.
Although the absence of the rectoanal inhibitory reflex
is specific for the diagnosis of HD, the role of ARM is still
debated.

86. ARM has the advantages of being a less-invasive
method without the exposure to ionizing radiation.
The limitations include the need for the patient to be in
a normal physiologic and quiet state to avoid possible
artifacts
Anorectal manometry

87. Inconclusive results, however, are more common in
ARM because of patient agitation.
Specificity is lower for ARM compared with RSB.
ARM cannot reliably replace histology and biopsies.
Anorectal manometry

88. ARM should not be used as a sole diagnostic tool for HD
in neonates and infants.
ARM is a useful screening test in older children
presenting with symptoms of HD.
If the RAIR is absent, these patients should be referred
for Bx.
If the rectoanal inhibitory reflex is present, HD could be
reasonably excluded.
Anorectal manometry

89. In comparison with ARM and RSB, BE has a low
sensitivity and specificity for the diagnosis of HD.
The transitional zone is difficult to demonstrate in
young infants.
The technique also fails in children with total colonic
aganglionosis.
Furthermore, BE may not distinguish HD from other
newborn’s pathologies, such as allergic colitis.
Barium enema

90. It is also unreliable in short-segment HD.
If a BE is performed, this should be done without
previous bowel preparation or recent digital rectal
examination
Barium enema

91. DPM

92. Barium Enema
does not represent a valid alternative to RSB or ARM to
exclude or diagnose HD, regardless of age; however,
BE may have some use as an additional investigation in
diagnosed cases to assess the length of the
rectosigmoid aganglionic segment before surgery.

93. Thank You
drfaheemandrabi@gmail.com