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Meconium Peritonitis

Meconium peritonitis is a condition where perforation of the bowel due to a number of congenital pathologies, leads to the introduction of meconium into the peritoneal cavity. This causes a sterile inflammatory reaction.


Presentation

Meconium peritonitis (MP) is a rare condition that results from the development of bowel obstruction in a growing fetus within the uterus. This may lead to perforation of the gut wall, which in turn leads to a leakage of meconium into the peritoneal cavity. Aseptic peritonitis ensues, due to a secondary inflammatory response. The outcome of MP depends to some extent on diagnostic and management approaches, which have greatly improved over the years [1] [2]. Severity and symptomatology of the condition are determined by the gestational age of the fetus, at the time the perforation occurs.

There are many possible causes of bowel obstruction in utero. These range from vascular factors such as mesenteric ischemia, to bowel pathologies such as meconium ileus, intussusception, volvulus, intestinal atresia, Hirschsprung's disease, hernias, and meconium plugs [3]. In addition to these, congenital infections, particularly parvovirus B19, rubella and cytomegalovirus, have been shown to be predisposing factors in the occurrence of MP [4]. There is an established association between MP and cystic fibrosis [5]. Polyhydramnios, jejunoileal atresia, and other gastrointestinal malformations have also been linked to MP.

There are three main classes of MP, the first being fibro-adhesive. This results in calcification and tissue deposition on the area of perforation, producing a mass that seals the defect. Most perforations are closed off before birth. The other types of MP are cystic and generalized. Additional effects of the inflammatory changes that may occur include ascites, fibrosis and intraperitoneal meconium calcifications.

Anemia
  • A 33-year-old primigravida at 26 weeks gestation presented with fetal hydrops and fetal anemia following prior parvovirus B19 infection. The fetus required two intrauterine transfusions of packed red cells.[ncbi.nlm.nih.gov]
  • He had a prenatal history of dilated bowel loops and hydrops on ultrasonography, as well as fetal anemia requiring an intrauterine blood transfusion 18 days prior to delivery.[jmedicalcasereports.biomedcentral.com]
Neonatal Intestinal Obstruction
  • The water-soluble enema will also exclude other causes of neonatal intestinal obstruction.[clinicalgate.com]
Multiple Congenital Anomalies
  • Two of the three children survived postoperation, one died 3 hours later after induction out at 31 weeks of gestational age due to multiple congenital anomalies.[ncbi.nlm.nih.gov]
Recurrent Urinary Tract Infection
  • After constructing a diversion colostomy, a cutaneous vesicostomy was necessary to prevent recurrent urinary tract infections.[ncbi.nlm.nih.gov]
Transient Hypothyroidism
  • Biliary atresia, malrotation, meconium peritonitis and transient hypothyroidism are occasionally seen in neonatal infants.[ncbi.nlm.nih.gov]
Bilious Vomiting
  • Six fetuses showed abdominal distension, bilious vomiting, and no normal meconium at birth; they underwent exploratory laparotomies and subsequently, survived and prospered.[ncbi.nlm.nih.gov]
  • vomiting Imaging Findings On conventional radiographs Meconium, being fluid density, is normally invisible on radiographs In meconium ileus, there may be dilated loops of bowel (small bowel) typically without air-fluid levels because of the viscosity[learningradiology.com]
  • Failure to pass meconium (stool) may lead to bilious vomiting and abdominal distention.[surgery4children.com]
  • Clinical presentation included abdominal distension, bilious vomiting, and failure to pass meconium. In two recent cases, prenatal ultrasonography detected a mass with proximal bowel distension indicative of cystic meconium peritonitis.[link.springer.com]
Pelvic Mass
  • RESULTS: The prenatal US and/or MRI findings showed fetal ascites, a multicystic pelvic mass, oligohydramnios, and bilateral hydronephrosis in 5 of 11 patients with cloacal malformations.[ncbi.nlm.nih.gov]
Hypertension
  • A 3-day-old premature infant with meconium peritonitis, periventricular leukomalacia, and pulmonary hypertension died with respiratory insufficiency.[ncbi.nlm.nih.gov]
  • Apply new evidence-based management options to treat genetic and constitutional factors leading to a high-risk pregnancy (such as diabetes, obesity, hypertension, and cardiac disease) through new and expanded coverage of these increasingly common presentations[books.google.com]
Hydrops Fetalis
  • The association of meconium peritonitis with hydrops fetalis was through different mechanisms in each patient.[ncbi.nlm.nih.gov]
  • Investigation for hydrops fetalis was performed and immune and… CONTINUE READING[semanticscholar.org]
  • The baby was born with severe anoxia, hydrops fetalis and with intense ascites leading to breathing difficulties. She was submitted to a procedure in order to drain the ascites, in the neonate resuscitation room, to allow for adequate respiration.[omicsonline.org]
Reduced Fetal Movement
  • The clinical utility of this report is the recognition that meconium peritonitis (MP) may be diagnosed in the acute phase with typical ultrasound features, and should be considered in the differential diagnoses of cases presented with reduced fetal movements[ncbi.nlm.nih.gov]

Workup

The diagnosis of meconium peritonitis can be made either in utero or after birth. Some features of the disease can spontaneously resolve before birth. It may be beneficial to test for cystic fibrosis, as there is a strong correlation between the two conditions.

During the prenatal period, imaging techniques are used to assess the fetal abdomen. These are:

  • Ultrasound: A snowstorm appearance of the abdomen may be visualized, as well as focal calcifications that appear hyperechoic [6]. Some of the other likely findings on ultrasound examination are fetal ascites, wide abdominal circumference and polyhydramnios [7]. Distended bowel loops may also be present. The use of ultrasound may be instrumental in predicting the overall outcome of the newborn. Furthermore, information gained from imaging can predict the likelihood of surgery during the neonatal period. Some literature classifies ultrasound findings in MP into types I to III, which correspond to: massive ascites, giant pseudocysts and small pseudocysts or calcifications [8] [9]. Types I and II were shown to be predictive of poor outcomes in the neonatal period. In addition, if such features persist, surgery is usually required in the postnatal period [10].
  • Xray: This may show peritoneal or scrotal calcifications (in cases of a patent processus vaginalis), and an intraabdominal mass, which is often a meconium pseudocyst.
Gliosis
  • Brain parenchyma surrounding occluded cerebral vessels showed infarct and gliosis.[ncbi.nlm.nih.gov]

Treatment

  • Surgical treatment and management of meconium peritonitis depend on the clinical presentation of the newborn.[ncbi.nlm.nih.gov]

Prognosis

  • Establishing clear postnatal treatment and prognosis is difficult because of the heterogeneity of the results obtained by ultrasound.[ncbi.nlm.nih.gov]
  • Prognosis: In case of simple peritonitis the outcome is good and surgical intervention is not necessary. In case of complex peritonitis (associated with bowel dilatation, ascites) the prognosis is poor and neonatal mortality is 50%.[fetalmedicine.org]

Etiology

  • The purpose of this article is to review a case of meconium peritonitis while considering its etiology, diagnosis, management, and multidisciplinary team care.[ncbi.nlm.nih.gov]
  • In addition, depending upon the etiology, ascites, polyhydramnios or fetal bowel distention may be present.[fetalsono.com]
  • Etiology fetal intestinal perforation Cystic fibrosis digestive cystic fibrosis fetal intestinal tumors jejunal congenital fibrosarcoma ( 12776248 ) Complications disseminated intravascular meconium meconium per vagina References Meconium peritonitis[humpath.com]
  • Prenatal ultrasound findings were compared with postnatal etiology, intraoperative findings, and postnatal outcome of the patients. Results: Antenatal MP was diagnosed in 14 fetuses between 18 and 38 weeks' gestation.[degruyter.com]

Epidemiology

  • The epidemiology of tracheo-oesophageal fistula and oesophageal atresia in Europe: EUROCAT Working Group. Arch Dis Child 1993;68:743-8. [ PUBMED ] 3. Spitz L. Esophageal atresia: Lessons I have learned in a 40-year experience.[afrjpaedsurg.org]
Sex distribution
Age distribution

Pathophysiology

  • The pathophysiologic progression of this condition is demonstrated by serial ultrasound examinations. Neonatal radiologic confirmation of the diagnosis is also presented.[ncbi.nlm.nih.gov]
  • Newborn Surgery, Third Edition provides a comprehensive compendium of the pathophysiology, investigation and management of neonatal disorders.[books.google.com]
  • […] rather than pulmonary complaints. 4 However, there is no evidence of distinct allelic frequencies or haplotypic variants in CF patients with MI compared with those without 22 or in CF patients with significant liver disease. 23, 24 Gastrointestinal Pathophysiology[clinicalgate.com]

Prevention

  • After constructing a diversion colostomy, a cutaneous vesicostomy was necessary to prevent recurrent urinary tract infections.[ncbi.nlm.nih.gov]

References

Article

  1. Nam SH, Kim SC, Kim DY, et al. Experience with meconium peritonitis. J Pediatr Surg. 2007 Nov;42(11):1822-1825.
  2. Kuroda T, Kitano Y, Honna T, Sago H, Hayashi S, Saeki M. Prenatal diagnosis and management of abdominal diseases in pediatric surgery. J Pediatr Surg. 2004;39(12):1819-1822.
  3. Chan KL, Tang MH, Tse HY, Tang RY, Tam PK. Meconium peritonitis: Prenatal diagnosis, postnatal management and outcome. Prenat Diagn. 2005;25(8):676-682.
  4. Schild RL, Plath H, Thomas P, Schulte-Wissermann H, Eis-Hubinger AM, Hansmann M. Fetal parvovirus B19 infection and meconium peritonitis. Fetal Diagn Ther. 1998;13(1):15-18.
  5. Hamada T, Hirose R, Kosaka T, et al. Giant cystic meconium peritonitis associated with a cloacal anomaly: Case report. J Pediatr Surg. 2008;43(3):E21-23.
  6. Berrocal T, Lamas M, Gutieérrez J et-al. Congenital anomalies of the small intestine, colon, and rectum. Radiographics. 1999;19(5):1219-1236.
  7. Mcnamara A, Levine D. Intraabdominal fetal echogenic masses: a practical guide to diagnosis and management. Radiographics. 2005;25(3):633-645.
  8. Kamata S, Nose K, Ishikawa S, et al. Meconium peritonitis in utero. Pediatr Surg Int. 2000;16(5-6):377-379.
  9. Zangheri G, Andreani M, Ciriello E, Urban G, Incerti M, Vergani P. Fetal intra-abdominal calcifications from meconium peritonitis: sonographic predictors of postnatal surgery. Prenat Diagn. 2007;27(10):960-963.
  10. Shyu MK, Shih JC, Lee CN, Hwa HL, Chow SN, Hsieh FJ. Correlation of prenatal ultrasound and postnatal outcome in meconium peritonitis. Fetal Diagn Ther. 2003;18(4):255-261.

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Last updated: 2019-07-11 21:09