Meconium Plug Syndrome Research Articles

Neonatal meconium-related obstruction: Establishing a research strategy to evaluate an evolving disease

PurposeThe link between prematurity and meconium-related obstruction is understudied. We sought to describe the contemporary spectrum of meconium-related obstruction and to validate the use of ICD-10 codes for the study of this family of diseases. MethodsThis retrospective cohort study included neonates within our health system treated for a radiographically or intraoperatively confirmed meconium-related obstruction from January 2018 to December 2022. We stratified obstructions by type (meconium ileus vs meconium plug syndrome) and need for intervention (contrast enema vs surgery). We evaluated the association of prematurity, cystic fibrosis, and Hirschsprung's disease with disease severity using t-tests, ANOVA, and chi-squared tests. We secondarily evaluated the accuracy of ICD-10 codes at identifying meconium-related obstructions using sensitivity, specificity, and predictive values. ResultsOver five years, 18 infants were treated for meconium-related obstruction. This included five patients (28%) with meconium ileus and 13 (72%) with meconium plug syndrome. Twelve neonates (67%) were preterm, including all five (100%) treated for meconium ileus, none of whom had cystic fibrosis or Hirschsprung's disease. Among infants with meconium plug syndrome, one (8%) had cystic fibrosis and two (15%) had Hirschsprung's disease. Eight (44%) patients required a contrast enema, 5 (28%) multiple contrast enemas, and 5 (28%) surgery. Increasing prematurity was associated with worse disease severity (p<0.001). Diagnosis code P76.0 identified all cases of meconium-related obstruction (sensitivity=100%; specificity=95%). ConclusionsMost meconium-related obstructions were related to prematurity and not cystic fibrosis or Hirschsprung's disease. The use of ICD-10 code P76.0 is a promising research strategy for this evolving condition. Level of evidenceLevel III – retrospective comparative study

Investigations, management and outcome of neonates presenting with distal intestinal obstruction: challenging the need for contrast enemas

PurposeTo characterise the investigations, management and ultimate diagnosis of neonates with distal intestinal obstruction.MethodsRetrospective review of term (> 37 weeks) neonates with admission diagnosis of distal intestinal obstruction over 10 years (2012–2022). Patient pathways were identified and associations between presentations, response to treatments and outcome investigated.ResultsA total of 124 neonates were identified and all included. Initial management was colonic irrigation in 108, contrast enema in 4, and laparotomy in 12. Of those responding to irrigations none underwent contrast enema. Ultimately, 22 neonates proceeded to laparotomy. Overall, 106 had a suction rectal biopsy and 41 had genetic testing for cystic fibrosis. Final diagnosis was Hirschsprung disease (HD) in 67, meconium ileus with cystic fibrosis (CF) in 9, meconium plug syndrome in 19 (including 3 with CF), intestinal atresia in 10 and no formal diagnosis in 17. Median length of neonatal unit stay was 11 days (7–19).ConclusionsInitial management of neonates with distal bowel obstruction should be colonic irrigation since this is therapeutic in the majority and significantly reduces the need for contrast enema. These infants should all have suction rectal biopsy to investigate for HD unless another diagnosis is evident. If a meconium plug is passed, testing for CF is recommended. Evaluation and therapy are multimodal and time consuming, placing burden on resources and families.

Meconium plug syndrome in twins

Meconium plug syndrome in twins

Neonatal Meconium Plug Caused Severe Proximal Small Bowel Dilatation and Made A Misinterpretation of Pneumoperitoneum

&lt;p&gt;There is a high mortality rate for infants with visceral perforations. Clinical imaging of this condition includes free air in the abdomen with abdominal plain radiography or lateral decubitus radiographs. An important disease that is easily ignored in the perinatal period is meconium plug syndrome, which causes functional obstruction in the colon that leads to dilated bowel loops in abdominal plain radiography. We report a female newborn who had a suspected bowel obstruction during prenatal examination because of polyhydramnios. The initial plain abdominal film showed a large volume of air accumulation in the peritoneum. An emergent exploratory laparotomy was performed and it revealed that there was no free a3 ir nor ascites in the peritoneal cavity. The proximal small bowel was severely dilated and a meconium plug at the splenic flexure was found. The image of air in the patient&amp;rsquo;s small bowel and peritoneal cavity in the anterior&amp;ndash;posterior view and image of the left decubitus view of the abdomen were similar in this case to the degree that the clinicians could not differentiate them, leading to an unnecessary exploration laparotomy.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

Contrast Enema: Solving Diagnostic Dilemmas in Neonates With Lower Intestinal Obstruction.

BackgroundAnatomical abnormalities leading to bowel movement failure are the major cause of intestinal obstruction. This study was done to assess the diagnostic efficacy of contrast enema in neonates with lower intestinal obstruction.MethodologyThis prospective study was conducted in The Children’s Hospital and University of Child Health Sciences, Lahore from February 2021 to July 2021. Patients presenting with constipation, abdominal distension, vomiting, and unable to pass meconium, evaluated clinically and by X-rays, were included in the study. Patients with lower intestinal obstruction (i.e., meconium ileus, Hirschsprung’s disease, ileal atresia, meconium plug syndrome, and small left colon) were given contrast enema (gastrografin) after hydration. The radiologist was blinded by the clinical diagnosis or reference standard diagnosis, which was labeled prior to image interpretation. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for major contrast enema diagnosis.ResultsDuring this period, a total of 34 patients were included in the study. The mean age of presentation was 72.0 ± 24 hours. There were 21 (61.8%) boys and 13 (38.2%) girls, representing a male to female ratio of 1.7:1. In four cases, our diagnosis on the basis of contrast enema was proven wrong. Sensitivity, specificity, PPV, and NPV of Hirschsprung’s disease were found to be 93.3%, 50%, 87.5%, and 66.7%, while these were 84.6%, 66.7%, 91.7%, and 50.0%, respectively, for meconium ileus.ConclusionThe diagnostic efficacy of contrast enema was found to be good in neonates with lower intestinal obstruction. The spectrum of intestinal obstruction among neonates shows diversity while contrast enema seems to play a major role in the identification and remodeling of the diagnostic plan in a major proportion of cases.

STUDY OF INTESTINAL OBSTRUCTION AMONG NEONATES

Failure to pass meconium by a full-term neonate within the rst 24 hours should raise a suspicion of bowel obstruction . The commonest reported causes of bowel obstruction in decreasing order includes anorectal malformations, duodenal atresia , jejunoileal atresia , Hirschsprung's disease , meconium ileus and meconium plug syndrome(1) . Other neonatal medical conditions like hypothyroidism , hypokalemia , sepsis and congestive heart failure are also reported to cause bowel obstruction (2). The aim of this observational cross sectional study of 60 patients from Dec. 2016 to June. 2018 was to study the types and clinical features of neonatal intestinal obstruction , various modalities of intervention , to study the prognosis and causes of adverse outcome. The study showed that the most common cause of neonatal intestinal obstruction is seen to be anorectal anomalies, predominantly Anorectal Malformations . The diagnosis of these disorders is done with minimal investigations . These anorectal malformations require initial evaluation to rule out associated anomalies and surgical intervention in the form of either anal cut back or stoma creation

Left Small Bowel Syndrome A Case Report and Literature Review

Left small colon syndrome is a rare cause of neonatal obstruction, favored by the existence of a diabetic mother in 40 to 50% of cases. The diagnosis is evoked by ultrasound and confirmed by an opaque enema with water-solubles. The enema will allow a colonic emptying often accelerating the regression of the digestive symptoms (use of gastrografine if necessary). The prognosis is good with symptomatic and conservative treatment. The meconium plug syndrome can also be compared to this condition, which is also part of the functional occlusive syndromes that resolve.

Gastrointestinal Emergency in Neonates and Infants: A Pictorial Essay.

Gastrointestinal (GI) emergencies in neonates and infants encompass from the beginning to the end of the GI tract. Both congenital and acquired conditions can cause various GI emergencies in neonates and infants. Given the overlapping or nonspecific clinical findings of many different neonatal and infantile GI emergencies and the unique characteristics of this age group, appropriate imaging is key to accurate and timely diagnosis while avoiding unnecessary radiation hazard and medical costs. In this paper, we discuss the radiological findings of essential neonatal and infantile GI emergencies, including esophageal atresia and tracheoesophageal fistula, hypertrophic pyloric stenosis, duodenal atresia, malrotation, midgut volvulus for upper GI emergencies, and jejunoileal atresia, meconium ileus, meconium plug syndrome, meconium peritonitis, Hirschsprung disease, anorectal malformation, necrotizing enterocolitis, and intussusception for lower GI emergencies.

A Case Report of Meconium Plug Syndrome with Intestinal Obstruction in a SGA, Preterm 34 Week Gestation Baby

A Case Report of Meconium Plug Syndrome with Intestinal Obstruction in a SGA, Preterm 34 Week Gestation Baby

Bedside upper gastrointestinal series in the neonatal intensive care unit

BackgroundIn neonatal intensive care unit (NICU) patients with intubation status, fluoroscopic evaluation for the bowel is limited. This study was to evaluate the utility of bedside upper gastrointestinal (UGI) series with delayed radiographs (DR) for assessing duodenojejunal junction (DJJ) and small bowel passage in NICU patients with nonspecific bowel ultrasonography and contrast enema findings.MethodsWe reviewed clinical and imaging data for bedside UGI with DR of NICU patients from 2014 to 2019. Five abdominal radiographs were obtained at fixed time intervals of immediately after, 1 min, 5 min, 1 h, and 2 h following the administration of 5 cc/kg isotonic water-soluble contrast agent via the nasogastric tube.ResultsTwenty bedside UGI with DR were performed in 17 patients (weight range: 520-3620 g, age range: 0–4 months). Confidence identifying the DJJ was either good (n = 7) or equivocal (n = 8) at immediate or 1 min radiographs. The DJJ could not be evaluated in five from four delayed passage (including two meconium plug syndrome and one gastric volvulus) and one inadequate timing. There was only one case of intestinal malrotation, which was not detected on ultrasonography, but detected at the first UGI examination with good DJJ confidence.ConclusionsBedside UGI with DR can evaluate intestinal malrotation using immediate and 1 min delay and small bowel passage using 1 and 2 h delay images in NICU patients with nonspecific ultrasonographic and contrast enema findings. The majority with delayed contrast passages can have bowel pathology. Because of a small number of patients in this study, further studies with more infants are needed.

Ultrasound Guided Hydrostatic Treatment of Meconium Ileus; another Indication for Ultrasound Based Approach to Bowel Obstruction

Dear Editor-in-Chief, The inspissated meconium pellets are a cause or effect of ileocolic obstructions. The present study aimed at explaining our experience of ultrasound-based approach for differentiation and treatment of the inspissated meconium pellets. This study was conducted at Mashhad University of Medical Sciences, Mashhad, Iran, from 2017-2020. Twenty-four neonates (less than 8 days) with inspissated meconium pellets were examined using ultrasound. Moreover, in cases with non-complicated inspissated meconium pellets, ultrasound-guided contrast enema was performed for confirmation of the diagnosis or probable treatment. In ultrasound, the inspissated meconium pellets were observed as uniform hypo- to hyper-echoic tubular or beaded intra-luminal material in ileocolic loops or recto-sigmoid area. These pellets were in five states: simple meconium ileus, localized or generalized meconium, small bowel, meconium plug syndrome, and Hirschsprung's disease. During contrast enema in non-complicated meconium ileus, moving and floating of inspissated meconium pellets was observed during ultrasound scanning, while this issue was not observed in small bowel atresia. The success rates of the hypertonic contrast enema in patients with simple meconium ileus were 80%. The inspissated meconium pellets have an ultrasound appearance. They are mainly observed in patients with simple and complicated meconium obstructions and bowel atresia. Except in complicated meconium obstructions, the ultrasound-guided contrast enema was performed for their differentiation and probable treatment.

Should we look for Hirschsprung disease in all children with meconium plug syndrome?

BackgroundMeconium plug syndrome (MPS) is associated with Hirschsprung disease (HD) in 13–38% of cases. This study sought to assess institutional variation in utilization of rectal biopsy in children with MPS and the likelihood of diagnosing HD in this population. MethodsPatients with MPS on contrast enema in the first 30 days of life from the Pediatric Health Information System database in 2016–2017 were included. Institutional rates of rectal biopsies performed during the initial admission were calculated and then used to predict institutional rates of early HD diagnoses using Poisson regression. ResultsOf 373 newborns with MPS, 106 (28.4%) underwent early rectal biopsy, of whom 43 (40.5%) had HD. Fifty-seven (15.3%) were ultimately diagnosed with HD. Eight (14%) of these patients had a delayed diagnosis. HD rates between institutions did not differ significantly (range 0–50%, p=0.52), but usage of early rectal biopsy did (range 0–80%, p=0.03). Each additional early biopsy increased the early HD diagnosis rate by 35% (β=0.30, 95% CI 0.15–0.45, p<0.0001). ConclusionThe incidence of HD is increased in children with MPS. There is significant hospital variability in the utilization of early rectal biopsy, and opportunity exists to standardize practice.Type of Study: Study of Diagnostic testLevel of Evidence: Level III

Review. Gastrointestinal Surgery in Neonates: Practice, Facts, and Trends

The author presents an overview of the current trends in acute neonatal gastrointestinal surgery. Necrotizing enterocolitis and focal intestinal perforation are disorders of different etiology, appearance, and prognosis. In neonates with focal perforation, a good prognosis can be expected. Primary anastomosis is a valid option for primary surgery. Meconium ileus is based on obstruction of the terminal ileum. Medical treatment is the primary therapeutic option, although surgery may be required. In contrast, meconium plug syndrome is based on stool plugging in the left colon, and surgery is not appropriate. Hirschsprung’s disease is confirmed on the basis of representative biopsy of the rectum just above the dentate line. There is a trend toward a single-step pull-through operation without protective stoma. Open hernia repair in small neonates can be performed via a mini-incision and without opening the external inguinal ring. Laparoscopic hernia repair has some advantages, especially in girls. In infants with pyloric stenosis, laparoscopic pyloromyotomy is a first line option for treatment. There is a general trend toward single-stage procedures and laparoscopic reconstructive surgery for gastrointestinal malformations. With the exception of tracheoesophageal fistula and low bowel obstruction, the vast majority of upper gastrointestinal malformations can be identified using prenatal ultrasound examination. One-stage repair with excellent results is even possible in neonates below 1000 g. Surgery of duodenal or small bowel atresia can be performed following the postnatal adaptation period. For some forms of anorectal malformation, the need for a protective stoma has been questioned in the last decade. Posterior sagittal anorectoplasty remains the standard procedure for the majority of cases. Midgut or segmental volvulus affects different groups of infants. If a neonate is suspected of having any type of volvulus, urgent surgery is required. Intestinal duplication carries a high risk for complications, and surgery should be performed on an elective basis.

Comparative Effectiveness of Imaging Modalities for the Diagnosis of Intestinal Obstruction in Neonates and Infants:: A Critically Appraised Topic

The purpose of this study was to critically appraise and compare the diagnostic performance of imaging modalities that are used for the diagnosis of upper and lower gastrointestinal (GI) tract obstruction in neonates and infants. A focused clinical question was constructed and the literature was searched using the patient, intervention, comparison, outcome method comparing radiography, upper GI contrast study, and ultrasound in the detection of upper GI tract obstruction such as duodenal atresia and stenosis, jejunal and ileal atresia, and malrotation and volvulus. The same methods were used to compare radiography and contrast enema in the detection of lower GI tract obstruction such as meconium plug syndrome, meconium ileus, Hirschsprung disease, and imperforate anus. Retrieved articles were appraised and assigned a level of evidence based on the Oxford University Centre for Evidence-Based Medicine hierarchy of validity for diagnostic studies. There were no sensitivities/specificities available for the imaging diagnosis of duodenal atresia or stenosis, jejunal or ileal atresias, meconium plug, and meconium ileus or for the use of cross-table lateral radiography for the diagnosis of rectal pouch distance from skin in imperforate anus. The retrieved sensitivity for the detection of malrotation on upper GI contrast study is 96%, and the sensitivity for the diagnosis of midgut volvulus on upper GI contrast study is 79%. The retrieved sensitivity and specificity for the detection of malrotation with volvulus on ultrasound were 89% and 92%, respectively. The retrieved sensitivity and specificity for the detection of Hirschsprung disease on contrast enema were 70% and 83%, respectively. The retrieved sensitivity of invertogram for the diagnosis of rectal pouch distance from skin in imperforate anus is 27%. The retrieved sensitivities of perineal ultrasound and colostography for the diagnosis of rectal pouch distance from skin in imperforate anus were 86% and 100%, respectively. There is limited evidence for the imaging diagnosis of duodenal atresia and stenosis, jejunal and ileal atresias, meconium plug, meconium ileus, and imperforate anus, with recommended practice based mainly on low-quality evidence or expert opinion. The available evidence supports the use of upper GI contrast study for the diagnosis of malrotation and volvulus, with ultrasound as an adjunct to diagnosis. Contrast enema is useful in the investigation of suspected Hirschsprung disease, but a negative study does not outrule the condition. Colostography is the investigation of choice for the work-up of infants with complex anorectal malformations before definitive surgical repair.

Efficacy of Ultrasound-guided Contrast Enema on Meconium Plug Syndrome in Preterm Infants

Efficacy of Ultrasound-guided Contrast Enema on Meconium Plug Syndrome in Preterm Infants

MORTALITY RISK FACTORS FOR NEONATAL INTESTINAL OBSTRUCTION

This study aimed to determine the type of neonatal intestinal obstruction, their mortality, and the significance of the direct causes of death. A retrospective study of all neonates managed for neonatal intestinal obstruction (total number studied was 161 child) at Basrah Children's Specialty Hospital (BCSH) between June 2012 and June 2014. Data were collected from patients’ hospital records (neonatal intensive care unit) and analyzed for age, sex, clinical features, diagnosis, surgical procedure performed, prematurity, birth weight, duration of symptoms, complications and their management. The mortality due to neonatal intestinal obstruction is still high in our setting (25.5%). The significant factors associated with mortality were prematurity, birth weight, sepsis; reoperation, short bowel syndrome, and proximal intestinal stoma. Certain causes of neonatal intestinal obstruction were associated with high mortality e.g. jejunoileal atresia (52.6%), meconium ileus (50%), perforated viscus (46%), and duodenal atresia. Male are affected more than female with M:F ratio of 2.4:1. The most common cause of intestinal obstruction in neonates in this series was anorectal malformations (33.5%). Other causes of neonatal intestinal obstruction included Hirschsprung’s disease (24.2%), small intestinal atresias (11.8%), intestinal malrotation with or without volvulus (9.3%), perforated viscus (8.1%), meconium ileus (7.5%), duodenal aresia (2.5%), annular pancreas (1.2%), and meconium plug syndrome, necrotizing enterocolitis and segmental dilatation (0.6%, each). In conclusion, neonatal intestinal obstruction is a common cause of admission accounting for 28.2% of all admission. Mortality from intestinal obstruction is still high in our society and strict measures regarding prenatal, natal and postnatal management should be addressed to save those neonates.

PO-0664 Superglue, A Simple And Effective Method For Sealing An Untight Catheter For Peritoneal Dialysis

Introduction Acute renal failure is a severe complication in neonatal intensive care medicine. The only therapeutic option for renal replacement therapy in small infants or premature babies with acute renal failure is peritoneal dialysis. In this paper two case reports of sealing an untight peritoneal catheter with cyanoacrylate glue will be presented. Patient 1: Premature infant of 34 + 2 weeks gestational age. Dorsal cloaca malformation with megacystis and megaureter, peritoneal dialysis for 13 days. Patient 2: Term neonate of 40 + 4 weeks gestational age with meconium plug syndrome and volvulus, double ileostomy, necrotising enterocolitis and Morbus Hirschsprung. Alagille syndrome with renal malformation, peritoneal dialysis for 46 days. All catheters were extremely untight from the very beginning; effective dialysis was not possible. Sealing with fibrine glue was not efficient. Only sealing of the skin with cyanoacrylate glue allowed for effective peritoneal dialysis. Apart from gradually increasing irritation of the skin no serious side effects occurred. No dialysate entered the surrounding soft tissue although the subcutaneous part of the skin channel was always filled with dialysate. Conclusion It is possible to seal a catheter for peritoneal dialysis quickly and effectively with cyanoacrylate glue without serious complications. The existence of an ileostomy did not interfere with the dialysis.

Renal Excretion of Water-soluble Contrast Media After Enema in the Neonatal Period

When abdominal distention occurs or bowel obstruction is suspected in the neonatal period, a water-soluble contrast enema is helpful for diagnostic and therapeutic purposes. The water-soluble contrast medium is evacuated through the anus as well as excreted via the kidneys in some babies. This study was designed to evaluate the incidence of renal excretion after enemas using water-soluble contrast media and presume the causes. Contrast enemas using diluted water-soluble contrast media were performed in 23 patients under 2 months of age. After the enema, patients were followed with simple abdominal radiographs to assess the improvement in bowel distention, and we could also detect the presence of renal excretion of contrast media on the radiographs. Reviewing the medical records and imaging studies, including enemas and consecutive abdominal radiographs, we evaluated the incidence of renal excretion of water-soluble contrast media and counted the stay duration of contrast media in urinary tract, bladder, and colon. Among 23 patients, 12 patients (52%) experienced the renal excretion of water-soluble contrast media. In these patients, stay-in-bladder durations of contrast media were 1-3 days and stay-in-colon durations of contrast media were 1-10 days, while stay-in-colon durations of contrast media were 1-3 days in the patients not showing renal excretion of contrast media. The Mann-Whitney test for stay-in-colon durations demonstrated the later evacuation of contrast media in the patients with renal excretion of contrast media (p=0.07). The review of the medical records showed that 19 patients were finally diagnosed as intestinal diseases, including Hirschsprung's disease, meconium ileum, meconium plug syndrome, and small bowel atresia or stenosis. Fisher's exact test between the presence of urinary excretion and intestinal diseases indicated a statistically significant difference (p=0.04). The intestinal diseases causing bowel obstruction may increase the water-soluble contrast media's dwell time in the bowel and also increase urinary excretion.

Conjugated Hyperbilirubinemia in Children

A variety of anatomic, infectious, autoimmune, and metabolic diseases can lead to conjugated hyperbilirubinemia, both in the newborn period and later in childhood. The pediatric practitioner is most likely to encounter conjugated hyperbilirubinemia in the neonatal period.It is crucial to maintain a high degree of suspicion for cholestasis in the persistently jaundiced newborn. The goal is recognition of conjugated hyperbilirubinemia between 2 and 4 weeks after birth, allowing for the prompt identification and management of infants who have biliary atresia, which remains the most common cause of neonatal cholestasis.

“Pulling the plug”—Management of meconium plug syndrome in neonates

BackgroundThe significance of meconium plug syndrome (MPS) is unclear but has been associated with Hirschsprung’s disease and magnesium tocolysis. We reviewed our experience to attempt to identify any potential association with these conditions and to review our outcomes. MethodsUsing the International Classification of Diseases, Ninth revision, code for meconium obstruction, patient charts were identified during the 1998–2008 period. A total of 61 cases of MPS were found, after excluding 7 of meconium ileus. Data regarding the hospital course and outcomes were collected and analyzed. ResultsApproximately 30% of patients had spontaneous resolution of the meconium plug without any treatment. Of those patients requiring treatment, contrast barium enema was used, with 97% success. Only 2 patients required surgical intervention owing to worsening distension and subsequent peritonitis. When we stratified the patients according to gestational age of >36 and <36 wk, contrast barium enemas were performed 2.2 ± 1.8 versus 8.6 ± 7.8 d after birth (P = 0.003), respectively, and the lower gestational age patients had a longer length of stay. Contrast barium enema was still successful in 94% of patients with a gestational age of <36 wk. Magnesium tocolysis was noted in 16% of the cases, and Hirschsprung’s disease was only found in 3.2% of patients. ConclusionsPatients with MPS have excellent outcomes, independent of gestational age. Contrast barium enema remains the initial diagnostic and treatment of choice for patients with MPS. Also, although previous reports have shown a link between magnesium tocolysis and Hirschsprung’s disease with MPS, our experience suggests otherwise.