The newborn was resuscitated with intravenous infusion. A nasogastric tube was passed and gastric aspiration done. The neonate was given injection Vit. K and intravenous antibiotics started. X-ray abdomen showed dilated bowel loops. Contrast x-rays with gastrografin enema delineated a small caliber colon with filling defects as of meconium beads (Fig. ​(Fig.1).1). As condition of the baby did not improve an exploratory laparotomy was performed. At laparotomy volvulus of distended small bowel found. The colour of the involved segment was dark and appeared congested (Fig. ​(Fig.2).2). The volvulus was corrected by untwisting the mesentery. The involved gut was hugely distended due to the presence of thick tenacious meconium. The thick meconium was concentrated in distal small bowel whereas the colon was packed with small beads. An enterotomy was made at the most distended portion (distal ileum) and irrigated with diluted gastrografin. Gentle milking was then performed to remove the meconium. The large gut also washed in the similar way. Bishop Koop chimney was made after resecting a small portion of small bowel which was of doubtful viability.

Meconium ileus can be uncomplicated (simple meconium ileus) or complicated. Uncomplicated meconium ileus presents at birth with abdominal distension and failure to pass meconium. Less than half of them present with complications. The complications in meconium ileus may occur either prenatally or postnatally. In-utero complications include volvulus with perforation, meconium peritonitis, giant meconium cyst or atresia etc. Due to massive bowel distension volvulus, perforation and peritonitis can also occur in the postnatal period [2, 3]. In our case patient initially suspected to have simple meconium ileus which then got complicated. The ex-utero volvulus is a rare event.

A non-operative management with gastrografin enema is often successful. This technique is useful in evacuating the thick and sticky meconium from the gut under fluoroscopy. In complicated meconium ileus and in cases where simple meconium ileus does not resolve or complicates an immediate surgery is advised [1, 4]. We initially tried gastrografin enema but due to progressive abdominal distension and rapid deterioration of the clinical condition an emergency laparotomy was performed.