A 4-day-old newborn weighing 2.8kg, presented with abdominal distension, respiratory distress with non-passage of meconium. Examination showed grossly distended and resonant abdomen with dilated veins on the surface. Anal opening was normal and a 10 size red rubber catheter could be passed without difficulty. There was no visible bowel loops or palpable mass. Nasogastric tube drained no aspirate. Clinically a diagnosis of neonatal bowel perforation was made. X-ray abdomen showed large gas and fluid level with deviation of nasogastric tube to right side (Fig. 1A). There was no rectal gas shadow. Possibility of gastric perforation or meconium cyst with communication with bowel was kept in mind. Fluoroscopic water soluble contrast gastrography was done on table that showed normal stomach with flow of contrast to small bowel ruling out gastric perforation. Contrast enema was done to look for microcolon assuming that meconium cyst as a possibility. It showed enhancement of the gas filled structure (Fig. 1B). A diagnosis of either meconium cyst, duplication cyst with communication and contained perforation was considered.
Laparotomy was done via right upper transverse incision. The stomach and small bowel were normal looking. The incision was extended across the midline to deliver a spherical shaped large dilated segment measuring 17 cm x15 cm involving most of the colon except for the normal sized proximal 4 cm of ascending colon and distal rectum from the level of S3 vertebrae (Fig. 2A, 2B). The appendix was single and normal. The blood supply for the dilated part was from ileocecal artery. The inferior mesenteric artery was found running along the mesenteric side as an arcade and branching dichotomously on either side, to supply the bowel wall. There were no creeping or serpentine blood vessels on the antimesenteric side as in pouch colon. Malrotation was present with cecum in the left hypochondrium and thick Ladd’s bands.
Figure 1: Plain X- ray abdomen showing large gas shadow with fluid level with deviation of nasogastric tube (A) and Contrast enema fluoroscopic image showing enhancement of gas filled structure (B).
Figure 2: Per-operative picture showing near total segmental dilatation of colon (A) and the line diagram showing the extent of dilatation (B).
The colon was divided at the junction of ascending colon and dilated segment and proximal end colostomy was done. In view of near total colonic involvement, the dilated distal part was subjected to colorraphy and brought out as distal stoma. Ladd’s bands were divided and appendicectomy done. The excised part of the dilated colon and appendix were sent for biopsy which showed normal ganglion cells and muscle layer. Post operatively the proximal stoma functioned well.
After 3 months, to assess the function of distal preserved colon, rectal biopsy, anorectal manometry and transit study were done. For transit study 10 capsules were loaded with barium into the distal stoma. X-ray abdomen was taken every 2 hour. All the capsules were expelled out of anus within 6 hours. Distal cologram showed normal caliber colon of adequate length with no retention of barium in 24 hours film. There was no recurrence of dilatation. The rectal biopsy and anorectal manometry were normal. Colostomy closure was then performed. In the post operative period baby passed liquid stool in 48 hours and then breast feeding was started. There was no constipation or other symptoms at one year follow-up. Repeat barium enema done at 6 months showed normal caliber colon.