Bilious Emesis and Failure to Pass Meconium in the Nursery

Introduction: In this case we review important newborn nursery management strategies and unique surgical diagnostic measures in a severe case of intestinal obstruction due to small left colon syndrome (SLCS) – illustrating an impressive relationship between intestinal dysmotility and meconium plug formation that increases risk of intestinal perforation in the newborn.

Case Description: We present a case of an infant born to a mother with symptomatic COVID-19, who at 24 hours of life was treated for failure to pass meconium with a glycerin suppository and went on to develop bilious emesis and severe abdominal distention as feeding continued over the next several hours. After a normal upper GI, a barium enema identified a distal obstruction and the pediatric surgical team used rectal irrigation to remove a large meconium plug which mimicked the appearance of the descending colon on plain film, ultimately leading to the diagnosis of SLCS. The infant went on to stool normally after removal, however due to the severity of his initial clinical picture, a multi-disciplinary team was consulted, and concluded that given the severity of the meconium plug, a workup for cystic fibrosis was indicated, but deferred a rectal biopsy for Hirschprung disease due to normal return of bowel function upon removal of the obstruction.

Discussion: Meconium plug syndrome is a transient distal GI obstruction in the lower colon or rectum with thick meconium and is thought to be due to poor intestinal motility. A contrast enema is typically diagnostic, showing a decrease in bowel caliber distal to the plug, and therapeutic, as the plug is often passed during the procedure. A sharp transition zone at the splenic flexure followed by a narrow descending colon on imaging is consistent with SLCS with a meconium plug at the transition zone. Infants presenting with both meconium plug syndrome and SLCS may require an evaluation for an underlying diagnosis of cystic fibrosis or Hirschprung disease. Delayed meconium passage is present in 11.9% of infants diagnosed with cystic fibrosis, while 15% of infants with meconium plugs have an aganglionic segment on rectal biopsy, indicative of Hirschprung disease. The decision to perform additional tests in an infant with SLCS should be guided by the patient’s clinical course and in conjunction with a pediatric surgical team.

Conclusion: Although intestinal obstruction in the newborn is rather rare, it is imperative that it is promptly diagnosed and treated to avoid negative outcomes. Despite being considered a mild form of obstruction due to its transient nature, meconium plug syndrome can lead to an impressive clinical illness and urgent consultation with a surgical team is vital due to the risk of intestinal perforation if the obstruction is not relieved.