*2.5.3 Treatment algorithm*

Diatrizoate meglumine (GastrografinRx) is a hyperosmolar, water-soluble, radiopaque solution containing 0.1% polysorbate 80 (Tween 80) and 37% organically bound iodine with osmolarity of 1900 mOsm/L. Success rate of 63–83% have been reported for gastrografin enemas for patients with uncomplicated meconium ileus [31].

Noblett's criteria for nonoperative gastrografin enema therapy [30]:


To carry out the enema, a two-way Foley's catheter is inserted into the rectum through which a 25–50% solution of gastrografin is slowly infused at low hydrostatic pressure under fluoroscopic control. The balloon of the catheter should not be inflated to minimize the risk of rectal perforation. Upon instillation, fluid is drawn into the intestinal lumen by osmosis, and this hydrates and softens the meconium mass. For very inspissated meconium, 1% N-acetylcysteine may be added to the enema solution for better deconcentration. The procedure is usually followed by rapid passage of loose meconium (liquefied to some extent), and this continues for the next 24–48 hours.

**77**

*Meconium Ileus*

and ischemia.

difficulty [32].

cystic fibrosis.

*2.5.4 Surgical treatment*

surgery is always indicated.

• Persistent bowel obstruction

• Enlarging abdominal mass

• Intestinal atresia

• Volvulus

• Perforation

• Bowel necrosis

*DOI: http://dx.doi.org/10.5772/intechopen.85548*

Although the perforation that occurs during enema administration can usually be seen on fluoroscopy, it is important to obtain an immediate abdominal radiograph after completion of the gastrografin enema to rule out bowel perforation and a late abdominal radiograph (8–12 hours later or as clinically indicated) to confirm

Sometimes a second gastrografin enema or serial gastrografin enemas can be performed at 6–24 hour intervals if evacuation is incomplete or if the first attempt at gastrografin evacuation does not reflux contrast into dilated bowel. Administration of a 10% N-acetylcysteine solution (5 mL q6h) through a nasogastric tube to liquefy upper gastrointestinal secretions as suggested by Noblett is also useful in such cases [30]. The potential complications associated with the gastrografin enema procedure include perforation, hypovolemic shock,

The risk of perforation during the procedure increases with repeated enemas. Late perforations, usually occurring 12–48 hours after the enema, may be due to direct injury to the bowel mucosa by the contrast medium, severe bowel distention

Nonoperative treatment can be done for infants with peritoneal (or scrotal) calcifications on radiography who are presumed to have had meconium peritonitis in utero but who show no signs of obstruction and are passing meconium without

In nonoperative management, if the enema was successful and the features of bowel obstruction have resolved, usually within 48 hours, the infant is commenced on feeds with pancreatic enzyme supplements added for infants with confirmed

In uncomplicated meconium ileus, surgical exploration is indicated when there is progressive distention or signs of clinical deterioration or peritonitis despite multiple enemas. Whereas in complicated cases (e.g., meconium peritonitis, ileal atresia or stenosis, ileal perforation, and volvulus with or without pseudocyst formation),

Indications for surgical management in meconium ileus [31]:

• Conditions associated with cystic fibrosis and meconium Ileus

• Persistent or worsening abdominal distension

• Meconium cyst formation with peritonitis

by fluid osmotically drawn into the intestine, or extensive bowel necrosis.

evacuation of the obstruction and to exclude late perforation [31].

### *Meconium Ileus DOI: http://dx.doi.org/10.5772/intechopen.85548*

*Pediatric Surgery, Flowcharts and Clinical Algorithms*

Diatrizoate meglumine (GastrografinRx) is a hyperosmolar, water-soluble, radiopaque solution containing 0.1% polysorbate 80 (Tween 80) and 37% organically bound iodine with osmolarity of 1900 mOsm/L. Success rate of 63–83% have been reported for gastrografin enemas for patients with uncomplicated meconium ileus [31].

• Other causes of neonatal distal intestinal obstruction must first be excluded.

• There should be no clinical or radiologic signs of complications like volvulus,

• Ensure adequate fluid and electrolyte replacement and correction of hypother-

• Provision for adequate resuscitation and hydration in anticipation of transient

• Assurance of close surgical supervision from the initial evaluation through the

To carry out the enema, a two-way Foley's catheter is inserted into the rectum through which a 25–50% solution of gastrografin is slowly infused at low hydrostatic pressure under fluoroscopic control. The balloon of the catheter should not be inflated to minimize the risk of rectal perforation. Upon instillation, fluid is drawn into the intestinal lumen by osmosis, and this hydrates and softens the meconium mass. For very inspissated meconium, 1% N-acetylcysteine may be added to the enema solution for better deconcentration. The procedure is usually followed by rapid passage of loose meconium (liquefied to some extent), and this continues for the next 24–48 hours.

Noblett's criteria for nonoperative gastrografin enema therapy [30]:

gangrene, perforation, peritonitis, and atresia of the small bowel.

osmotic fluid losses associated with the hyperosmolar enema.

• The enema must be carried out under fluoroscopic guidance.

• Intravenous antibiotics should be administered to the infant.

mia as preparatory measures before the enema.

*2.5.3 Treatment algorithm*

**76**

hospital course.

Although the perforation that occurs during enema administration can usually be seen on fluoroscopy, it is important to obtain an immediate abdominal radiograph after completion of the gastrografin enema to rule out bowel perforation and a late abdominal radiograph (8–12 hours later or as clinically indicated) to confirm evacuation of the obstruction and to exclude late perforation [31].

Sometimes a second gastrografin enema or serial gastrografin enemas can be performed at 6–24 hour intervals if evacuation is incomplete or if the first attempt at gastrografin evacuation does not reflux contrast into dilated bowel. Administration of a 10% N-acetylcysteine solution (5 mL q6h) through a nasogastric tube to liquefy upper gastrointestinal secretions as suggested by Noblett is also useful in such cases [30]. The potential complications associated with the gastrografin enema procedure include perforation, hypovolemic shock, and ischemia.

The risk of perforation during the procedure increases with repeated enemas. Late perforations, usually occurring 12–48 hours after the enema, may be due to direct injury to the bowel mucosa by the contrast medium, severe bowel distention by fluid osmotically drawn into the intestine, or extensive bowel necrosis.

Nonoperative treatment can be done for infants with peritoneal (or scrotal) calcifications on radiography who are presumed to have had meconium peritonitis in utero but who show no signs of obstruction and are passing meconium without difficulty [32].

In nonoperative management, if the enema was successful and the features of bowel obstruction have resolved, usually within 48 hours, the infant is commenced on feeds with pancreatic enzyme supplements added for infants with confirmed cystic fibrosis.
