GIANT MECONIUM HYDROCELE: A RARE PRESENTATION OF ANTENATAL GASTROINTESTINAL PERFORATION

Abstract

Dear Editor, Meconium peritonitis is a sterile chemical peritonitis due to leakage of meconium from the bowel in utero. Perforation usually results from obstruction, which can be due to volvulus, intestinal atresia or inspissated meconium associated with cystic fibrosis or vascular compromise of the gut. Occasionally the perforation is idiopathic; gastrointestinal disorder is evident at birth.1 Although the processus vaginalis is still patent in 80–90% of full-term babies, extension of intra-abdominal pathology into the scrotum is relatively rare.2 The processus vaginalis forms by the sixth foetal month and enters the scrotum by the seventh month. Subsequently the testes descend into the scrotum. The processus vaginalis remains patent until birth or shortly thereafter, leaving the residual tunica vaginalis. Following an in utero bowel perforation, a fluid meconium-filled ‘hydrocele’ may thus be present at birth.1 We present a typical giant meconium hydrocele with ascitis of unknown aetiology not reported in our country. A full-term, 1-day-old male baby weighing 2.7 kg presented to us at 36 h after birth with bilateral scrotal swelling of 8 × 6 × 5 cm; soft, cystic, normal colour of overlying mature scrotal skin; no impulse on crying; non-compressible, positive transillumination in the root of scrotum and negative below that (Fig. 1). The baby passed urine normally on the first day of life but had not passed meconium since birth. Abdomen was distended and free fluid was present. The general condition was poor and respiratory rate was high. The baby was put on intravenous fluid and antibiotics. X-ray of the abdomen was suggestive of pneumoperitonium with opacity of scrotum. Abdominal paracentesis drained 100 ml of meconium stained fluid following which explortory laparotomy was done. On exploration, the peritoneum was filled with liquefied meconium, which was communicated with scrotum via the inguinal canal but the perforation site was not detected in the whole gastrointestinal tract. The peritoneal cavity was cleaned by normal saline and antibiotics solution and the bilateral inguinal ring was closed by absorbable suture after aspiration of fluid from the scrotal sac. The abdomen was closed after placement of a drain in the pelvis. The baby passed stool after 3 days and the drain was removed after 5 days. Oral feed was allowed on the seventh day and the baby was discharged well on the 10th day. The baby was well in the follow-up. Bilateral giant meconium hydrocele. A patent processus vaginalis in the male foetus may lead to the migration of meconium into the scrotum, and these infants can present with soft meconium-filled hydrocele at birth. Local tissue reaction during the first several weeks of life results in calcification of this hydrocele into hard, tumour-like lesions that may mimic testicular neoplasia. The simple bilateral hydrocele can be differentiated from meconium hydrocele and testicular neoplasia clinically, in the form of the fluctuation and transillumination test and also by ultrasonological examination of the scrotum. Tanaka et al.3 noted that operation of meconium peritonitis was difficult because the patient's general condition was poor, and dissection of the adhesion was difficult, owing to severe inflammation and bleeding. The patient undergoing an ultrasound-guided drainage of the cystic meconium peritonitis before surgery had better outcome.3 In our case, the cause of bilateral meconium hydrocele may be an antenatal perforation in the gastrointestinal tract due to unknown cause becomes sealed off in later period of gestation. It is mandatory to rule out this life-threatening condition by antenatal sonography, post-natal clinical examination and radiological study to confirm the diagnosis of gastrointestinal perforation.