7 INTESTINAL OBSTRUCTION ESCAPED SURGERY: MECONIUM PLUG Oluwayemi IO 1 *, Ade-Ojo IP 2, Olofinbiyi BA 2 1. Department of Paediatrics, Ekiti State University Teaching Hospital, Ado-Ekiti, Ekiti State, Nigeria 2. Department of Obstetrics and Gynaecology, Ekiti State University Teaching Hospital, Ado-Ekiti, Ekiti State, Nigeria Correspondence: Dr. Isaac Oluwayemi. Department of Paediatrics, Ekiti State University Teaching Hospital, Ado-Ekiti, Ekiti State, Nigeria Email: dareoluwayemi@gmail.com Oluwayemi IO, Ade-Ojo IP, Olofinbiyi BA. Intestinal obstruction escaped surgery: meconium plug syndrome. ABSTRACT We report a case of meconium plug syndrome that presented with classical clinical and radiological features of acute intestinal obstruction in a newborn. However, while on conservative management in preparation for surgical intervention, the baby passed thick gelatinous mucoid material (the meconium plug) followed by copious passage meconium with consequent complete resolution of all features of intestinal obstruction. Key words: Meconium plug syndrome, intestinal obstruction, newborn INTRODUCTION Intestinal obstruction occurs in approximately 1 in 1/1500 live births. Obstruction may be complete or partial and may arise from extrinsic or intrinsic abnormality of the gut 1.Obstruction can be further classified as simple or strangulating: simple obstruction is associated with failure of progression of aboral flow of luminal contents while strangulating obstruction is associated with impaired blood flow to the intestine in addition to obstruction of the flow of the luminal content 1. Timely passage of meconium is one of the features of well-being in newborn. Failure of a full-term newborn to pass meconium in the first 24 hours of life may be a pointer to intestinal obstruction 2. In 99% of healthy term newborn meconium is passed within the first 24 hours 3,4. Among premature infants however, passage of meconium may be delayed for a week or more after delivery 4,5. CASE REPORT Baby A.M. is a live male neonate delivered via emergency lower segment caesarean section to a 36yr old unbooked Para 3+1 (3 alive) woman at GA 38 weeks on Saturday, 10 th September 2011. Indication for C/S was previous scar and fetal distress. Apgar score 7
8 was 8 at 1 minute and 10 at 5 minutes. Birth weight was 2.8 kg; he was commenced on artificial milk soon after delivery at 28mls 3 hourly prior the time mother will be strong enough to breastfeed. At 20 hour of life child was noticed not to be tolerating feeds, was vomiting bilious effluent, had abdominal distension and yet to pass meconium, though making urine. An initial diagnosis of presumed sepsis and intestinal obstruction, finding for cause was made. Baby had sepsis work-up, was placed on nil per oral, I.V fluid (1/5 th normal saline in 10% Dextose water), I.V. Cefuroxime 150mg 12hourly, I.V. Gentamycin 10mg 12hourly, NG tube inserted to decompress the bowel. Temperature was within normal limit, Normal umbilical vascular complement (2 arteries and 1 vein), Abdominal girth 35cm, distended abdomen with dilated abdominal veins, bowel sound hypoactive, normal male external genitalia, testes descended (Figure 1 and 2); thermometer inserted into the anus to ascertain patency was slightly stained with meconium; HR=120/minute; RR= 48/minute; OFC=34.4cm. Primitive reflexes were present and normal. Full Blood Count: PCV 54%; WBC total=17,500; lymphocytes 60%, Neutrophils 30%, Eosinophils 3%, Basophils 4%, monocytes 3%. (Suggestive of sepsis for age) Electrolytes, Urea & creatinine: HCO3 24, Cl 107.9, K 3.4, Na 137.5; Urea 5.5; Creatinine 101.9 (all within normal limit) Plain abdominal X-ray erect and supine shows gaseous distension of the bowel loops and multiple air-fluid levels suggestive of intrinsic intestinal obstruction (Figure 3 and 4). Figure 1. General appearance of the case. 8
9 Figure 2. Clinical presentation. Figure 3. Plain abdominal X-ray. 9
10 Figure 4. Plain abdominal X-ray. Patient was reviewed by a surgeon who also agreed with diagnosis and scheduled patient for exploratory laparatomy; however because of financial constraint, baby was managed conservatively till the 4 th day of life when parents were able to gather enough fund for surgery; early morning on the 4th day of life, baby was noticed to have passed little meconium with thick gelatinous mucoid substance followed by three more episodes of passage of copious meconium with consequent reduction in abdominal girth from 35cm to 32cm, normal bowel sounds, vigorous sucking attempts by baby. Gastric lavage was done, NG tube removed and baby put to breast. He sucked very well, tolerated the feeds and moved bowel normally; temperature remained within normal limit. I.V cefuroxime was changed to oral to complete one week and baby discharged to parents. In retrospect, a diagnosis of Intestinal obstruction secondary to meconum plug was made. Baby has been doing well thereafter. A review on follow up 1 week after dissharge showed a thriving baby with no abnormality. 10
11 DISCUSSION Meconium plug syndrome is the mildest and commonest form of functional distal obstruction in the newborn 2,6. It is a transient form of distal colonic or rectal obstruction caused by a tenacious mass of mucus in the distal colon or rectum preventing the passage meconium from the proximal part of the colon. Meconium plug occurs in 1/500 1/1000 live births 7. The etiology of this disorder is unclear 2. Clinical presentation of meconium plug syndrome include: failure to pass meconium, progressive abdominal distension, refusal to feed and bilious vomiting 2. Plain abdominal radiograph often reveals gracious distension of intestinal loops of small and large bowel filling the entire abdomen. Contrast enema is diagnostic showing the outline of the meconium plug and is also therapeutic if the plug is passed afterward. In some newborn rectal stimulation with thermometer, rectal examination or a saline enema induces passage of the plug. After the plug is passed, bowel movements are normal, and all symptoms resolve 2,8. After discharge, patient must be followed up to ensure there is no recurrence or associated intestinal disorder that will need further definitive management. Our patient continued to pass stool and grow normally 1,2,8. Differential diagnosis of conditions that may be associated with delayed or failure to pass meconium in the newborn include: Hirschsprung s disease, meconium plug syndrome, meconium ileus, anorectal malformation, small left colon syndrome, hypoganglionosis, neuronal intestinal dysplasia, and megacystis-microcolon-intestinal hypoperistalsis syndrome 1,2,7. CONCLUSION Meconium plug syndrome is a known cause of transient intestinal obstruction in newborn; this should be excluded before surgery is undertaken in suspected neonatal intestinal obstruction. CONSENT The patient has consented to the publication of this case. COMPETING INTERESTS The authors declare that they have no competing interests. REFERENCES 1. Willie R. Intestinal atresia, stenosis, and malrotation. In: Nelson textbook of Paediatrics, 18 th ed. Philadelphia: Saunders, 2007:558-562 2. Loening-Baucke V, kimura k. Failure to pass meconium: diagnosing neonatal intestinal obstruction. Am Fam Physician. 1993;60:2043-50. 3. Clark DA. Times of first void and first stool in 500 newborns. Pediatrics. 1977;60:457-9. 11
12 4. Ameh N, Ameh E.A. Timing of passage of first meconium and stooling pattern in normal Nigerian newborns: Ann Trop Paediatr. 2009;29:129-33. 5. Weaver LT, Lucas A. Development of bowel habit in preterm infants. Arch Dis Child. 1993;68:317-20. 6. Dillon PW, Cilley RE. newborn surgical emergencies. Gastrointestinal anomalies, abdominal wall defects. Pediatr Clin North Am. 1993:40:1289-314. 7. Gryboski JD. The colon, rectum and anus. In: Grybosky JD. Gastrointestinal problems in infants. Philadelphia: saunders, 1975:499-564. 8. Ceunca AG, Ali AS, Kays DW, Islam S. Pulling the plug - Management of meconium plug in neonates. J Surg Res. 2012;175:e43-6.Epub 2012 March 10. 12