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MECONIUM PERITONITIS/ CASE PRESENTATION Presented by dr Farah A- Khawaja DISCUSSED BY: DR. K. GHANDOUR. DR. A. HAM

MECONIUM PERITONITIS/ CASE PRESENTATION Presented by dr Farah A- Khawaja DISCUSSED BY: DR. K. GHANDOUR. DR. A. HAMAM. HISTORY. B/O A was a N/B male baby, diagnosed in utero, at G.A. of 30 weeks to have hydrops fetalis & maternal polyhydramnios.

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MECONIUM PERITONITIS/ CASE PRESENTATION Presented by dr Farah A- Khawaja DISCUSSED BY: DR. K. GHANDOUR. DR. A. HAM

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  1. MECONIUM PERITONITIS/ CASE PRESENTATION Presented by dr Farah A- Khawaja DISCUSSED BY: DR. K. GHANDOUR. DR. A. HAMAM.

  2. HISTORY • B/O A was a N/B male baby, diagnosed in utero, at G.A. of 30 weeks to have hydrops fetalis & maternal polyhydramnios. • He was delivered at 10:00 am on 16/2/2004 by elective C/S, GA=31 weeks.

  3. EXAMINATION AFTER DELIVERY • H.R: 175, R.R: 50, Temp: 37.5, BP: 57/30, O2 sat: 99% (O2 via N/P). • Measurements: Weight= 2.330 Kg, HC= 31 cm, Length= 45 cm.

  4. EXAMINATION/ Cont. • Pink, not jaundiced & having moderate respiratory distress with irregular breathing. • Gross abdominal distension, AG=35 cm, generalized abdominal tenderness.

  5. EXAMINATION/ Cont. • Rest of physical examination was unremarkable.

  6. MANAGEMENT • N/G tube drained greenish material. • Peritoneal tap was performed immediately & a sample was sent for analysis, the fluid came out as yellowish green, 170 ml in the 1st hour with a total of 290 ml at the end of his 1st day.

  7. PERITONEAL FLUIDANALYSIS • Protein=3.1 g/dL, PH=7.5, SG=1010, sugar=44 mg/dL, LDH=430 U/L, • Serum: Protein=3 g/dL, serum LDH=839 U/L, fluid/serum LDH=0.5, sugar=66 mg/dL.

  8. LAB RESULTS • CBC: Hb= 14 g/dL, PCV=41%, WBC=7.7*103 mm3, N=33%, L=55%, M=12%, Plt= 492* 103 mm3 • LFT, KFT: Normal. • TORCH: Negative. • PCR/ Cystic Fibrosis: Negative.

  9. ABDOMINAL US • Diffuse adrenal glands enlargement consistent with diffuse hyperplasia. The gall bladder was slightly distended. Small amount of fluid was seen in the Morison’s pouch.

  10. MANAGEMENT/ Cont. • NPO. • He received Oxygen through N/P. • UAC, UVC were inserted, I.V.Fluids, Ampicillin, Cefotaxime started empirically.

  11. 1ST LAPAROTOMY • Done on the next day. • Indications: Meconium peritonitis , Intestinal obstruction.

  12. 1ST LAPAROTOMY/Intraop Findings • Diffuse meconium peritonitis, jejunal atresia, loss of small bowel, inspissated meconium in terminal ileum. • Segmental SB volvulos, the cause is meconium ileus in utero.

  13. 1ST LAPAROTOMY/ Procedure • Resection with end– end anastomosis. • Length of healthy remaining SB is 70 cm in addition to the ileocecal valve.

  14. 1ST LAPAROTOMY/Cont. • Closure of abdominal wall was performed without stomas or drains. • Metronidazole was added.

  15. COURSE IN HOSPITAL • The baby was kept NPO for 7 days & was receiving intravenous fluids & antibiotics.

  16. COURSE IN HOSPITAL • His N/G tube drainage was not significant during the 7 postop days. • On 22/2/2004 (5th post op) UAC was removed & feeding was started on 23/2/2004 by continuous N/G drip as 1cc/hour G/W 5% then shifted the next day to ½ strength Comformil or Breast Milk with gradual increase.

  17. COURSE IN HOSPITAL • Sucking was started on 25/2/2004 with gradual build up in the amount. Initially there was milk residue in the stomach that decreased over time. The baby was in a stable general condition & was gaining weight & off Oxygen since 23/2/2004. • He was taking 35-40 ml / feed.

  18. 28/2/2004 • UVC was removed, tip was sent for C/S & revealed E.Coli, which was sensitive to Imipenem-Cilastatin, Amikacin, and Piperacillin-Tazobactam but resistant to Ampicillin & Cefotaxime.

  19. Yet, the baby’s general condition was stable, sucking well & was gaining weight so Ampicillin, Cefotaxime, Metronidazole & IVF were discontinued on 2/3/2004.

  20. 5/3/2004 • The baby was noticed to take the Breast Milk adequately but slow in taking the Comformil & so the milk was changed to Similac NeoSure in a trial to take more calories in a smaller volume (NeoSure 0.74 Kcal/ml vs. 0.70 Kcal/ml for Comformil).

  21. 7/3/2004 • The baby developed hypoactivity, intolerance to feed, and abdominal distension as the abdominal girth increased from 27cm to 31cm in the same day. So he was kept NPO, Metronidazole & Piperacillin-Tazobactam started again.

  22. 8/3/2004 • The baby’s general condition deteriorated. • Abdominal XR revealed bowel loops distension with intramural air shadows suggestive of NEC. • A plan for a second laparotomy on the same day was decided.

  23. 2ND LAPAROTOMY • Indications: Suspension of gangrenous SB. • Presumptive diagnosis: Extensive NEC or adhesion obstruction with gangrene.

  24. 2ND LAPAROTOMY/Intraop Findings Extensive NEC involving the remaining small bowel, the small bowel was dusky & didn’t respond to 100% oxygen.

  25. 2ND LAPAROTOMY/Procedure • A small opening was done in the small intestinal wall & irrigation by warm saline done. Peritoneal cavity was irrigated also by warm saline. • Abdominal wall closed with no stomas or drains.

  26. 2ND LAPAROTOMY/Cont. • The baby came from the operative theatre on mechanical ventilator with a plan to maintain him on the ventilator to achieve good oxygen saturation & adequate PaO2.

  27. Lab results post op showed decreasing WBC: 4.3*103 mm3 (preop 11.2). • Platelets 337 * 103 mm3 (532). • Na 129 meq/L (134). • ABGs: PH= 7.3, PaCO2= 31.2mmHg, PaO2= 61.7mmHg, HCO3= 18.4meq/L, BE= - 6.6, Oxygen Sat= 91.8%. • On 9/3/2004 Amikacin was added.

  28. The baby’s condition worsened with increasing abdominal distention & worsening lab results with decreasing Hb, Platelets, WBC, Na, & persistent loop distention by abdominal XR.

  29. Peritoneal tap was done 3 times before the 3rd laparotomy, the fluid came out as dark red to black. • Peritoneal tap cultures.

  30. Elective extubation was done on 12/3/2004 & the baby remained on Oxygen given through N/P. • Tip of ETT C/S revealed E. Coli & Pseudomonas.

  31. 16/3/20043RD LAPAROTOMY • Indications: Suspected gangrene of the SB. • Findings intraop.: Gangrenous SB preserving the proximal 5 cm of jejunum & 5 cm of terminal ileum.

  32. 3RD LAPAROTOMY/Procedure Resection of gangrenous SB with formation of proximal & distal stomas.

  33. 3RD LAPAROTOMY/Cont. • The baby came out from the operative theature on mechanical ventilator but was extubated electively after 9 hours & put on Oxygen given through N/P.

  34. 17/3/2004 • The baby started to have attacks of bradycardia & low oxygen saturation.

  35. 18/3/2004 • He continued to have low oxygen saturation 40s% so he was put on mechanical ventilator . • But he didn’t improve despite being on high setup. He started to develop low BP & was started on Dopamine.

  36. 19/3/2004 • Last CBC: Hb=7.9 g/dL, PCV=24%, WBC=0.69*103mm3, Plt=18*103mm3. • The baby died at 10:00 am.

  37. MEDICATIONS/ SUM. • 1- Ampicillin, Cefotaxime 16/2-2/3/2004. • 2- Metronidazole 17/2-2/3/2004. • 3- Tazobactam/ Piperacillin 7/3-14/3/2004. • 4- Pentaglobin for 5 days 8/3/2004. • 5- Amikacin 9/3/2004. • 6- Imipenem/ Cilastatin 14/3-16/3/2004. • 7- Tazobactam/ Piperacillin 16/3/2004. • 8- Filgrastim 16/3/2004. • 9- PRBCs, Platelets, FFP.

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