Meconium Ileus: a demonstration of the ileal meconium mass by barium enema examination.

Abstract

Examination of the colon in patients with suspected meconium ileus is often incomplete, since the examiner is usually satisfied with demonstration of the microcolon indicative of small-bowel obstruction. It may be possible, by pursuing filling of the small bowel by reflux, to demonstrate the meconium mass and thus permit a more definitive diagnosis. There is, to date, one published case where this has been accomplished (1). In addition, Caffey, in the new fifth edition of his book, illustrates a case of meconium ileus in which barium outlined inspissated meconium in the distal ileum by reflux (2). This report relates our experience with similar circumstances to illustrate the value of examination of the distal small bowel and the characteristic findings which are obtained. The patient, a 24-hour-old, white, full-term female, was referred to the University of Virginia Hospital with a history of abdominal distension noted six hours after birth and, six hours later, the onset of vomiting bile-stained material. Physical examination on admission was not remarkable except for abdominal distension with hyperactive bowel sounds. Roentgenograms of the abdomen showed multiple dilated loops of bowel without air-fluid levels. The typical small bubble pattern of meconium ileus was not evident (Fig. 1). Barium-enema examination showed a microcolon of normal length. The distal ileum was visualized by reflux and was filled by meconium masses, made evident by a thin layer of surrounding barium. The small bowel, more proximally, was air-filled and dilated (Fig. 2). Because of the similarity of these masses to the meconium plug of the colon, it was suggested that surgery be postponed for twenty-four hours to determine if the meconium masses would pass spontaneously. A radiograph of the abdomen obtained twenty-four hours later showed that the barium in the colon was partially evacuated, but the meconium in the ileum was unchanged (Fig. 3). The diagnosis of meconium ileus was therefore believed confirmed, and laparotomy was performed on the same day. At surgery, the distal portion of the ileum was filled with hard, grayish-white, inspissated meconium appearing as multiple small nodules approximately 1 cm in diameter, rather than solid blocks. The ileum proximal to this area was grossly dilated, dark in color, and filled with tenacious greenish-black meconium. The small bowel proximal to this meconium-filled segment appeared dilated, but otherwise normal. The hard concretions in the distal ileum were expressed into the colon through the ileocecal valve. The segment of bowel containing the viscid meconium, approximately 30 cm in length, was resected, and an end-to-side anastomosis was performed. Postoperatively, the patient passed several meconium stools spontaneously but unfortunately did not survive the postoperative period and died on the ninth postoperative day. Autopsy showed evidence of pancreatic fibrosis, confirming the suspicion that the infant had mucoviscidosis.