0:00

This is Pediatrics case number two and the

0:03

diagnosis we're looking at is meconium Ilias.

0:07

And meconia Milius is really one of a series of diagnoses that

0:10

deal with newborn bowel obstruction.

0:13

So the first Imaging that is typically going to be obtained is

0:16

a frontal radiograph. Maybe an abdominal radi graph

0:19

maybe a whole body because the field of view is quite

0:22

small on a newborn and we can see on this image here,

0:25

which is the first of a contrast enema

0:28

not a barium enema because we don't use barium in

0:31

newborns and children it can be toxic and it's contraindicated.

0:34

We use water soluble contrast. And the first thing

0:37

that we can see on this image.

0:39

Is all of this lucency all

0:42

of these gas-filled Loops of bowel that

0:45

are sort of out of the field of view, but they would have been the initial area

0:48

of concern on the X-ray that was

0:51

obtained before this enema. So we know that there's something

0:54

wrong with the bowel. It's obstructed. We don't know where

0:57

it's probably not very high because we

1:00

would only see maybe just a single or a double or

1:03

a triple bubble like with duodenal atresia gastric

1:06

atresia, things like that.

1:08

In this case, there are multiple Loops of bowel. So

1:11

the obstruction is probably further down and there's a

1:14

differential for obstruction in a newborn. It could be a complete obstruction

1:17

like a anatomic abnormality

1:20

and atresia could be a a volvulus which

1:23

isn't quite anatomic but it is mechanical and

1:26

then it could be a functional abnormality especially

1:29

in children who are born prematurely. It

1:32

could be a meconium plug syndrome, which

1:35

is functional immaturity of the colon. So we're going

1:38

to perform a contrast enema to see if we can identify the level and

1:41

type of obstruction.

1:43

The main decision point at stake here

1:46

is can this be repaired with an enema? Can

1:49

we draw water into the colon and help the neonate

1:52

to pass these obstructing plugs on their own

1:55

or is this a mechanical or anatomic problem

1:58

and surgery is necessary. So we're going to

2:01

put our catheter, of course into the anus in a newborn especially

2:04

in a premature newborn. I will not

2:07

use a catheter with a balloon tip like a fully

2:10

catheter some people like to use that because it

2:13

seals quite well and you don't have to worry about contrast

2:16

leaking but I think that it can obscure your

2:19

diagnosis and more importantly cause harm in a very small patient

2:22

with a very small rectum. So we'll put in a catheter

2:25

no balloon or keep the balloon deflated. We'll tape it

2:28

in place. We'll begin to a fuse water soluble contrast and

2:31

here you can see the patient is in lateral position. Here's the

2:34

vertebral column on one side of

2:37

our image and you can see contrast has begun to be infused into

2:40

the anus and rectum and I'm just gonna scroll

2:43

through

2:43

A few of these images and we can see how the

2:46

contrast progresses. So here it is moving retrograde up

2:49

into the sigmoid colon. Now remember most patients

2:52

will be in prone position when this exam is

2:55

performed. So you're going to see the reverse of the course

2:58

of colon, you would expect if we were looking at an anatomic

3:01

review So the patient's prone so the

3:04

sigmoid goes over to this side.

3:08

And we can see it move around. There's usually a little redundancy of

3:11

the sigmoid colon in neonates, and then it's going to shoot up.

3:15

Towards the spleen.

3:16

Here it goes up towards the spleen now across to

3:19

the midline and we're seeing just a few small Lucent regions

3:22

where contrast is not going. Those

3:25

are filling defects. Something is inside the colon and

3:28

notice also the uniform caliber of the

3:31

colon. There aren't focal areas of dilatation and and

3:35

Stenosis, it's more of an uniform but

3:38

narrowed or small appearance of

3:41

the colon. It comes across the midline here. Now, we're over

3:44

to the hepatic side. Remember the patient is prone and

3:47

now

3:49

We're going to see it terminate approximately where the

3:52

cecum is or wherever it can.

3:55

Hit some sort of obstruction. So it seems

3:58

as we get to the end of this exam that we see that

4:01

the contrast isn't really progressing retrograde much Beyond

4:04

this portion of the body of

4:07

the abdomen right where the liver would be. And so that's either where

4:10

the secum is or where the obstruction is.

4:12

We don't see any areas of leaking or

4:15

fistula. That's good. We don't see anything like

4:18

a mass obstructing but we

4:21

did see multiple filling defects. There are

4:24

some small ones here and there are some larger ones

4:27

here all of these Lucent areas where contrast doesn't

4:30

feel so we know something is inside the colon

4:33

and we also know that contrast can't progress Beyond this

4:36

point and this uniform microcolon we

4:40

would call it is a sign that it's not just

4:43

a functional immaturity. It's not just a plug

4:46

syndrome that's usually called small left

4:49

colon syndrome because it's only one side of

4:52

the colon that is

4:54

In question, in this case, we have a uniform

4:57

micro-colon and there's a small differential for this

5:00

hirschsprung disease in rare cases can include the

5:03

entire colon, but that's less common more common

5:06

is meconia Milius and this is a situation where

5:09

many of the patients have cystic fibrosis. Their chloride

5:12

Transporters are abnormal the meconium the

5:15

first stool that comes out in the initial days

5:18

of life is thick and tenacious almost black

5:21

and tari and it doesn't flow like it

5:24

would in a normal newborn so you see it.

5:27

Kind of blocking up in small little Focus

5:30

areas inside the colon and usually

5:33

obstructing. So sometimes you'll see an increased collection

5:36

of those filling defects here at the proximal colon.

5:39

Maybe you'll be able to go back into the terminal ileum.

5:42

We didn't do that in this case. There was just too much

5:45

blockage, but the other important factor is meconium Ilias,

5:48

which has all of this tenacious meconium

5:51

blocking is highly associated with anatomic abnormalities

5:54

like an allele atresia. If

5:57

it's an atresia, we can't fix that with contrast. We

6:00

need surgery or all of those obstructing filling

6:03

defects and the colon can be a lead

6:06

point and you can have a volvulus. So the question that

6:09

we really need to determine is this meconium Ilias

6:12

uncomplicated in which case you can use contrast agents

6:15

sometimes multiple times and depending

6:18

on the osmolarity or the osmolality you can draw

6:21

water into the colon and maybe resolve the problem or is

6:24

this complicated meconia Milius with

6:27

Freesia or a volvulus for which surgery is necessary

6:30

in this case. This was an ileal atresia.

6:34

Complicating the meconium ileus the patient had to

6:37

go to surgery have the atretic section of bowel resected.

6:40

And then they went on to do very well. So this

6:43

enema can be very important. Sometimes a

6:46

second enema might be required. Maybe you refluxed it

6:49

back as far as you could and you weren't sure was that

6:52

just because we were having trouble that day or is that truly the

6:55

end? Maybe you try a second time but

6:58

repeated enemas over and over are not gonna help a

7:01

case with

7:03

An ileal atresia or maybe a jejunal atresia notice

7:06

that the contrast never made it to these very dilated gas-filled

7:09

Lucent Loops of bowel. So we have

7:12

not reached the obstructed bowel and that's

7:15

because there is a complete obstruction.

7:17

That's the end of the case.