68 • PERINATOLOGY Vol 24 • No. 1 • May–Aug 2023 Alvarez Saenz MP, et al. Meconium Peritonitis Case Report calcifications, intestinal echogenicity, thick and dilated intestinal walls, polyhydramnios, and pseudocysts.1 The clinical presentation of meconium peritonitis varies from ascites to giant cysts, and it manifests postnatally as respiratory distress, abdominal distension, bile vomiting, and no meconium passage. The main causes of meconium peritonitis are anomalies of the gastrointestinal tract. However, other alterations such as volvulus, intussusception, aganglionic colon, and bile duct atresia also contribute to the condition. Conditions such as cystic fibrosis (CF; in 8%–40% of patients) and perinatal infections such as cytomegalovirus and parvovirus B19 are also reported to contribute to this disease. Surgical management is the treatment of choice in patients in whom the perforation is not sealed off in utero and perpetuates into chemical peritonitis. Clinical observation with conservative ileum management is preferred for stable patients in whom the perforation is self-closed through fibrosis. With an early and comprehensive prenatal diagnosis and postnatal treatment, mortality can be reduced, and complementary studies can be considered based on documented associations.1,2 In this case report, we discuss about a neonate with a meconium peritonitis–type giant cyst who needed urgent surgical management and did not receive early interdisciplinary treatment due to the lack of prenatal diagnosis. Case Description A 25-year-old primiparous woman delivered a male neonate, without adequate prenatal control, through a secondary cesarean section due to severe preeclampsia at 37 weeks of gestation. The weight of the neonate was 2730 g, and the Apgar scores were 3 and 5 at 1 and 5 minutes of life, respectively. The neonate required advanced neonatal resuscitation with orotracheal intubation in the first hour of life. The neonate had significant abdominal distension with blue coloration of the abdominal wall (Figure 1A). He was referred to NICU as a vital emergency due to suspected intestinal obstruction and perforation. On admission to the NICU, after cardiopulmonary stability, a very distended, tense abdomen, with a violaceous abdominal wall, compared with the abdomen at birth, with an absence of peristalsis was noticed (Figure 1B). An abdominal ultrasound was performed, which showed free fluid with multiple interior echoes associated with distension of the proximal thin intestinal loops and a small amount of gas in the ileal and colonic loops. The signs were similar to that of hemoperitoneum, and emergency surgery was performed on day 2 of life. Initially, laparoscopy was performed, and when the port was placed, free hemoperitoneum with clots and fibrous membranes in tension cavity were observed, after which an open laparotomy was performed for cystic cavity resection. A loop exclusion from the midgut due to volvulus was found, with a 20-cm necrosis of the jejunum in that cavity including Morrison’s space and bilateral subphrenic spaces. Approximately 20-mL thick meconium was found in the peritoneal cavity. These findings were consistent with the condition called meconium peritonitis. Toward the pelvis, a distal ileum loop plus appendix was found with nodular impactions of depigmented meconium-like pea-sized sheaths (Figure 2A) and some calcifications. A cavity lavage was performed, during which adherent, thick, and filiform meconium was observed proximal to the jejunum (Figure 2B). A jejunum resection of 22 cm was carried out, and a jejunostomy and an ileostomy were created. Three days later (on day 4 of life), when the loop edema and inflammatory reaction reduced, there was no active bleeding, and there was evidence of a devitalized bowel; hence, a second surgical procedure was performed. An approximate length of 60 cm was measured from the angle of Treitz to the ileostomy and 6 cm from this to the cecum. Diatrizoic acid irrigation was performed to Figure 1. (A and B) The Distended Abdomen and Violaceous Abdominal Wall of the Neonate A B
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