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:

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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

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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