Ileus

By Peter Galvin, MD

Today’s column involves a case study from Centre Hospitalier Universitaire Saints-Justine in Montreal. A full-term baby boy was transferred to a tertiary care neonatal intensive care unit (NICU) at 30 hours of age because of abdominal distention and failure to pass meconium. Meconium is the first stool passed after birth. It contains cellular debris and dead red blood cells from the birth process. Before being transferred, the baby had fed poorly and regurgitated colostrum. Colostrum is the first milk produced by a mother immediately post-delivery. It is thinner than normal milk, yet it contains antibodies, immune and growth factors, and other bioactives essential to a newborn. It also contains laxatives that encourage the baby to pass meconium. Bovine colostrum is available should the mother decide not to breast-feed.

A naso-gastric tube had been placed and had drained yellow fluid. An abdominal radiograph showed dilated loops of bowel (see Panel A) indicating a bowel obstruction. On arrival at the NICU the baby was irritable, with abdominal distention and was vomiting bilious material. A bedside abdominal sonogram showed possible reversal of the superior mesenteric vessels (these supply blood to the upper intestines). This raised concern for intestinal malrotation, a birth defect, and a midgut volvulus, which is a twisting of the intestines that causes a bowel blockage. The presence of a volvulus is usually a surgical emergency, so an urgent laparotomy (abdominal exploration) was performed.

Considerable distention of the small bowel caused by thick meconium – rather than a midgut volvulus – was found. An enterotomy (opening of the bowel) was performed and thick, almost rigid, meconium was removed (see Panel B). On postoperative genetic testing, the baby was found to be homozygous for a mutation in CFTR, the gene encoding cystic fibrosis transmembrane conductance regulator. A final diagnosis of meconium ileus (bowel blockage or paralysis) due to cystic fibrosis was made. After a 23-day hospital stay, the baby was discharged.

Approximately 15 to 20% of infants born with cystic fibrosis will have a meconium ileus, which is usually treated with serial enemas. This is because one of the hallmarks of cystic fibrosis is thickened secretions, and this includes not just lung secretions but meconium as well. It also includes sweat, which is saltier than normal and often can be detected by kissing the infant and noting a saltier than normal taste.

This case study was published in March in the New England Journal of Medicine. Please direct questions or comments to editor@rockawaytimes.com