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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.

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
  • Abstract Biliary atresia, malrotation, meconium peritonitis and transient hypothyroidism are occasionally seen in neonatal infants.[ncbi.nlm.nih.gov]
Hypotension
  • Additional clinical observations were hypotension and a sudden decrease in end-tidal carbon dioxide with a markedly discrepant high Pco(2), indicating a massive pulmonary gas embolism.[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.
Suppression
  • In five patients who underwent drainage of cysts after birth, systemic inflammation could not be completely suppressed before curative surgery.[ncbi.nlm.nih.gov]
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]
  • Amniocentesis was also performed in patients with polyhydramnios for treatment of preterm labor. These observations suggest that aggressive therapy can prolong the gestation period and improve MP treatment outcomes. (c) 2008 S. Karger AG, Basel.[ncbi.nlm.nih.gov]
  • Treatment was by bowel resection and an ileostomy (and later bowel anastomosis), followed by parenteral nutrition which was complicated by hepatitis. The literature is reviewed and management dilemmas and options are discussed.[ncbi.nlm.nih.gov]
  • Ten weeks following laser treatment, the two fetuses showed intra-abdominal hyperechogenicity and ascites. After birth, the two newborns were surgically managed for peritonitis. We discuss the pathogenesis of this double insult.[ncbi.nlm.nih.gov]
  • Because of failed tocolytic treatment, the fetus was delivered vaginally. Both the mother and fetus received intensive care, and the mother recovered. In contrast, the fetus's course worsened due to progressive abdominal distension.[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]
  • This case increases our understanding of the natural history and prognosis of MP.[ncbi.nlm.nih.gov]
  • CONCLUSION: Recognition of the predisposing factors in fetal meconium peritonitis and immediate referral to a tertiary medical center, where specialists are available, could help physicians determine an accurate diagnosis and might improve prognosis.[ncbi.nlm.nih.gov]
  • With the development of neonatal care, the prognosis of meconium peritonitis improved much. We report our clinical experience.[ncbi.nlm.nih.gov]
  • CONCLUSION: Prenatal diagnosis of meconium peritonitis is possible through careful ultrasonographic examination, and early surgical intervention and intensive postoperative support are required to improve the prognosis.[ncbi.nlm.nih.gov]

Etiology

  • 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.[ncbi.nlm.nih.gov]
  • In addition, depending upon the etiology, ascites, polyhydramnios or fetal bowel distention may be present.[fetalsono.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]
  • 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]
  • The etiology is thought to be the result of a sterile chemical reaction resulting from bowel perforation in utero . The bowel perforates as a result of bowel obstruction, such as an atresia or meconium ileus .[radiopaedia.org]

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]

Prevention

  • We report a case of in utero paracentesis of ascites in a fetus with meconium peritonitis due to volvulus at 34 weeks which resulted in the correction of an abnormal fetal heart rate pattern and enabled vaginal delivery by preventing abdominal dystocia[ncbi.nlm.nih.gov]
  • Repeated paracentesis between 29 weeks and 4 days and 31 weeks and 6 days of gestation prevented the progression to fetal hydrops and hypoplastic lungs, which may occur due to massive meconium ascites with an increased preload index.[ncbi.nlm.nih.gov]
  • After constructing a diversion colostomy, a cutaneous vesicostomy was necessary to prevent recurrent urinary tract infections.[ncbi.nlm.nih.gov]
  • […] parenteral nutrition (TPN) made it difficult to make an early differential diagnosis of biliary atresia because of the presence of TPN-associated cholestatic jaundice, and the Roux-en-Y limb used for hepatic portoenterostomy could not be made long enough to prevent[ncbi.nlm.nih.gov]
  • Urgent abdominal drainage at birth, followed by intestinal diversion of persistent intestinal perforation on the first day of life, may prevent bacterial colonisation and improve prognosis.[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: 2018-06-22 03:40