> For the complete documentation index, see [llms.txt](https://thisispiggy.gitbook.io/my-wiki/llms.txt). Markdown versions of documentation pages are available by appending `.md` to page URLs; this page is available as [Markdown](https://thisispiggy.gitbook.io/my-wiki/02-step-2/pediatrics/03-failure-to-pass-meconium.md).

# 03 Failure To Pass Meconium

## Overview

Newborn constipation has to causes:

* Failure to pass meconium: nothing comes out in **first 24 - 48 hrs**
  * Biliary emesis: anything obstructing
  * Imperforate anus
  * Meconium Ileus
  * Hirschsprung: can present in either first 48 hrs or yr 2
* Constipation in general: decrease in frequency, increase in difficulty/hardness in **year 2**
  * voluntary holding
  * medication SE
  * diet
  * anatomy
  * neurologic problems (rare)

## Imperforate anus

* Path: part of VACTRL
* symptoms: no hole, maybe stool if fistula present
* diagnosis: xray (cross table)
* treatment
  * Mild: anus where it supposed to be but not connected. Surgery now
  * Severe: anus pouch far from skin. Wait for baby to get bigger with more colon. Colostomy now and fix later
  * Watch out for VACTERL

cross table X-ray:

![\_](https://i.imgur.com/PXEdAn0.png)

### VACTERL

Prepare for intubation vs surgery. See if heart and tracheal look good

* Vertebral: US sacrum
* Anal: X-Ray
* Cardiac: Echocardiogram
* TracheoEsophageal: Catheter with X-ray from nostril to stomach. Coiled up
* Renal: VCUG
* Limb: X ray wrist

### Colostomy

a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon.,

## Meconium Ileus

* path: CF
* Demographics: infant failure to pass meconium with prenal screen positive or no prenatal care
* diagnosis: x-ray show transition point and gas filled plug. **Echogenic bowel on prenatal ultrasound** can be an early hint.
* treatment: 
  * water-enema to diagnose and dissolve plug
  * CF: sweet chloride test to confirm, ADEK supplement, pancreatic enzyme, pulmonary toilet to prevent respiratory infections

![\_](https://i.imgur.com/NvcrJTj.png)

![\_](https://i.imgur.com/lBKe4Ci.png)

## Hirschsprung

* path: failure of migration of Auerbach and Meissner plexus inhibitory neurons that allow relaxation. Fails to innervate distal colon
* demographics: 
  * 90%: failure to pass meconium: palpable colon, distended, explosive diarrhea on digital rectal exam
  * 10%: chronic diarrhea with overflow incontinence. Enough good colon push liquid part of stool around obstruction = watery diarrhea
* diagnosis
  * Step 1: xray. Bad colon normal. Good colon dilated
  * 90%: contrast enema to see transition point
  * 10%: anal rectal manometry: increased tone
  * best test: biopsy show no plexus
* treatment: surgical resect bad colon

## Voluntary holding

* path: fear of pain, defecation, embarrassment. Water absorbed as stool sits = hard stool = constipation
* demographics: cognitive impaired higher risk
  * begin toilet training and going to school for first time
  * voluntary holding at first turn involuntary
  * overflow incontinence: water
  * encopresis: stooling in bed. Liquidy stool comes out
* diagnosis: clinical. Bowel habits
* treatment
  * bowel regiments. Stool softeners, motility agents, behavior modification
  * disimpaction: under anesthesia unlike adults