Patient Case Discussion
Case Summary
29-day-old premature male with a history of premature birth at 27 weeks was discussed, focusing on the baby's abdominal distension and the possibility of intestinal obstruction or pseudo-obstruction. The team analyzed a radiograph and performed a contrast enema to gather more information, concluding that the radiograph could represent a pseudo-obstruction. The conversation ended with a discussion on the pathology of the case, the examination of a resected segment of small bowel, and the rare condition of segmental intestinal dilatation.
Premature Baby's Meconium and Abdominal Distension
Baby was born via C-section due to maternal fever and tachycardia, and there was a significant amount of meconium in the amniotic fluid. Baby had not passed meconium by day 4, which was initially concerning. However, it was clarified that premature babies often have dysmotility and may not pass meconium for days. The concern was raised about other symptoms, such as abdominal distension and bile. Baby was fed starting at 2 ml/h, but was stopped because of abdominal distension. The general surgery team was consulted due to these concerns.
Premature Baby's Condition and Radiology Interpretation
The discussion revolved around the examination and diagnosis of a premature baby. The initial impression was not particularly concerning, with vital signs and labs appearing normal. However, there was a change in the baby's condition over the course of 24 hours, with significant distension observed. The radiology team was consulted to interpret the films, with the first film showing dilated bowel loops and the second film showing a different pattern. The team was not overly concerned with the first film, but the second film prompted further action. The radiology team was asked to provide their interpretation of the second film.
Interpreting Radiograph and Considering Pseudo-Obstruction
Discussion revolved around the interpretation of a radiograph and the subsequent steps taken. The radiograph showed significant distension of the bowel loops, suggesting a distal bowel obstruction. The team considered the possibility of meconium obstruction of prematurity or atresia, particularly in premature babies where atresia can present subtly. A contrast enema was performed to gather more information, which showed the colon was patent and there was no abrupt cut-off or filling defect suggesting a blockage. The team concluded that the radiograph could represent a pseudo-obstruction, especially in a premature baby.
Neonatal Intestinal Dilatation Diagnosis and Management
The team discussed management of a neonatal case involving intestinal dilatation. The team considered various possibilities, including segmental intestinal dilatation, meconium ileus, and Hirschsprung disease. They also discussed the use of water-soluble enemas in neonatal care, with a focus on the prematurity of the patient. The team agreed on the need for further investigation, such as a contrast enema, to determine the cause of the dilatation. The consensus was that the patient was stable enough for the procedure, and the team planned to monitor the situation closely. The conversation ended with a discussion on the urgency of the situation and the potential risks of the procedure.
Free Air and Perforation Analysis Meeting
The focus now was on the analysis of a patient's condition, specifically the presence of free air. The radiology team confirmed the presence of a large amount of free air and suggested that the contrast could have contributed to the perforation, although it was not definitively ruled out. The surgical team then shared their findings from the operating room, revealing a segmental dilation at the terminal ileum with pneumatosis and a small perforation. The bowel wall was found to be significantly thinned out, with the Serosa intact. The patient is currently doing well on full feeds and enteral feeds. The pediatric pathologist discussed the pathology of the case.
Resected Small Bowel Examination and Histology Discussion
Examination of a resected segment of small bowel was discussed. They highlighted the thinning of the wall and the lack of a definitive perforation. The speaker also compared the normal enteric mucosa of a premature or term baby with the abnormal mucosa of the resected bowel. They noted the abnormal appearance of the muscularis propria, the submucosal hemorrhage, and the thinning of the deeper smooth muscle bundle. The speaker concluded by describing the histology of the area that was observed intraoperatively, noting the absence of normal mucosa, submucosa, and smooth muscle. The pathologic features were consistent with segmental absence of the intestinal musculature.
Segmental Intestinal Dilatation and Spontaneous Perforation
The speakers discussed the rare condition of segmental intestinal dilatation and its association with spontaneous intestinal perforation. They noted that this condition is more common in preterm infants with low birth weight and that the pathogenesis is not yet fully understood. The speakers also suggested that segmental intestinal dilatation and segmental absence of intestinal musculature might be two different entities, with the former being more prone to dilatation. They agreed to keep an open mind about the pathogenesis of these conditions as more cases are studied.