Calcified intraluminal meconium in newborn males with imperforate anus. Enterolithiasis in the newborn

A Neonatal Case of Lower Urinary Tract Obstruction and Imperforate Anus: Urethral Decompression Due to Rectourinary Fistula

Lower urinary tract obstruction (LUTO) is a rare fetal condition associated with significant perinatal morbidity and mortality. Herein, we report a neonatal case of LUTO with anal atresia complicated by anhydramnios and pulmonary hypoplasia. After treatment for severe postnatal respiratory distress, the neonate underwent vesicostomy and colostomy. Postoperatively, respiratory status and renal function improved. This case highlights a unique feature where a large rectovesical fistula channeled fetal urine into the colon, which minimized obstructive damage to the urinary tract and preserved renal morphology. Fetal colonic dilatation and numerous enteroliths indicate urine influx into the intestinal tract. Our case suggests the importance of recognizing such exceptions in complete LUTO to predict postnatal outcomes diagnosed in utero.

Prenatal diagnosis of enterolithiasis at 18 weeks: multiple foci of intraluminal calcified meconium within echogenic bowel

Enterolithiasis is an uncommon finding of a dilated hyperechogenic bowel with multiple ball-like echogenic structures at a routine prenatal check-up using ultrasonography. We here report a case of prenatally diagnosed enterolithiasis at 18 weeks of gestation, showing multiple hyperechogenic foci rolling within the bowel fluid after peristalsis. The size of the dilated bowel gradually increased during pregnancy. Magnetic resonance image demonstrated the dilated lower bowel with blind-ending rectum. A postnatal contrast medium study with retrograde urethrography revealed a middle imperforate anus and a rectourethral fistula. A careful examination, even before 20 weeks of gestation, is extremely useful in demonstrating intraluminal coarse calcifications within an echogenic bowel.

Imaging of total colonic Hirschsprung disease

BACKGROUND

Hirschsprung disease (HD) is a functional obstruction of the bowel caused by the absence of intrinsic enteric ganglion cells. The diagnosis of total colonic HD (TCHD) based on contrast enemas is difficult in newborns because radiological findings vary.

OBJECTIVE

To evaluate the radiographic and contrast enema findings in patients with pathologically proven TCHD.

MATERIALS AND METHODS

From 1966 to 2007, 17 records from a total of 31 patients with TCHD were retrospectively evaluated for diameter and shape of the colon, diameter of the small bowel, bowel wall contour, ileal reflux, abdominal calcifications, pneumoperitoneum, filling defects, transitional zones and rectosigmoid index.

RESULTS

Three colonic patterns of TCHD were found: microcolon, question-mark-shape colon and normal caliber colon. Additional findings included spasmodic colon, ileal reflux, delayed evacuation and abdominal calcifications. Colonic transitional zones were found in eight patients with TCHD.

CONCLUSION

The diagnosis of TCHD is difficult to establish by contrast enema studies. The length of the aganglionic small bowel and the age of the patient can influence the radiological findings in TCHD. The transitional zone and the rectosigmoid index can be false-positive in TCHD. The colon can appear normal. Consider TCHD if the contrast enema study is normal but the patient remains symptomatic and other causes of distal bowel obstruction have been excluded.

Imperforate anus: A relatively common anomaly rarely diagnosed prenatally

OBJECTIVE

Despite the relatively common occurrence of imperforate anus, prenatal diagnosis is rarely reported. In this study, we investigated the presence and diagnosis of imperforate anus along with strategies for improving prenatal diagnosis of the condition.

PATIENTS AND METHODS

Fetuses and infants with imperforate anus who had been examined prenatally by ultrasound at the National Center for Fetal Medicine (NCFM) from 1987 to 2004, were evaluated.

RESULTS

Of 69 cases with imperforate anus, only 11 (15.9%) were diagnosed prenatally, at a median gestation of 18 + 4 (range, 15 + 6 to 35 + 6) weeks. In all 11, dilatations of the rectum or lower part of the bowel were seen. Additional anomalies, most of them diagnosed prenatally, were present in 59/69 (85.5%) of the cases. The most frequent additional anomalies were urogenital (53.6%). The karyotype was abnormal in nine cases (13.0%). A retrospective evaluation of available videotapes of 22 cases of imperforate anus that were not diagnosed prenatally revealed that it was possible to suspect the diagnosis in 11/22 (50%) cases. Sixteen infants were born with imperforate anus without prenatal diagnosis of any abnormality. In total, 31/69 (44.9%) cases were terminated, two (2.9%) died in utero and 12 (17.4%) died postnatally. Twenty-four (34.8%) infants survived, including all 10 with isolated imperforate anus and seven of eight cases with only one additional anomaly.

CONCLUSIONS

The prenatal detection rate of imperforate anus was only 15.9%. Imperforate anus is often associated with other anomalies; in this study, 85.5% had additional anomalies. Prenatal diagnosis makes prenatal counseling possible and facilitates optimized postnatal care. We believe that the prenatal detection rate of imperforate anus could be improved. Examiners should intensify their search for typical findings of imperforate anus especially when other anomalies that frequently accompany this condition are present.

Echogenic foci in the dilated fetal colon may be associated with the presence of a rectourinary fistula

Intraintestinal meconium calcification in the fetus and newborn is a rare finding, occurring in patients with intestinal obstruction. The intraluminal location of the enterolithiasis enables differentiation from calcifications that are secondary to bowel perforation and meconium peritonitis. We report on a term male neonate with VACTERL (vertebral defects, imperforate anus, cardiac anomalies, tracheoesophageal fistula, renal anomalies, limb anomalies) association and rectourethral fistula, in whom enterolithiasis was documented by prenatal ultrasound imaging at 21 weeks' gestation. A review of the literature and a summary of all previously described cases of neonates with intraluminal meconium calcifications are provided. Prenatal ultrasonographic detection of enterolithiasis in fetuses with anal atresia may indicate the presence of an enterourinary fistula.

Fetal enterolithiasis: prenatal sonographic and MRI diagnosis in two cases of urorectal septum malformation (URSM) sequence

OBJECTIVES

Enterolithiasis (multiple calcifications of intraluminal meconium) is a rare, prenatal ultrasonographic finding. In this study, our aim was to evaluate the prenatal diagnostic features and discuss the management of the patients.

METHODS

The data of two cases of prenatally diagnosed fetal enterolithiasis were collected from ultrasound scan, magnetic resonance imaging (MRI) and neonatal or postnatal autopsy records. The findings were evaluated in both prenatal and postnatal periods. Chromosomal analysis was performed in one case. An evaluation of primary and secondary malformations was done. Coexisting anomalies were searched for via radiology, neonatal surgery and histopathology.

RESULTS

Malformations in two cases (both males) with partial and complete urorectal septum malformation (URSM) sequence were described. The absence of an anal opening and presence of a fistula between the urinary and gastrointestinal tract were common findings. These features were considered as primary malformations contributing to the formation of enterolithiasis. Secondary anomalies (urinary and gastrointestinal system malformations, pulmonary hypoplasia, genital and other coexisting anomalies) were evaluated.

CONCLUSIONS

The prenatal detection of enterolithiasis carries a poor prognosis. Most of the previously reported cases were invariably associated with major fetal malformations of the urinary and gastrointestinal tract. It is a warning sign for large bowel obstruction with or without enterourinary fistula. Therefore, adequate gastrointestinal and urologic studies must be undertaken after birth for the final diagnosis. There is a high mortality rate in the reported cases, mostly attributed to associated anomalies, and all survivors required neonatal surgery. It is important to differentiate the partial from the full URSM sequence because the prognosis in the partial URSM sequence is generally good, with long-term survival being common.

Infrared spectrophotometry of intraluminal meconium calculi in a neonate with imperforate anus and rectourethral fistula

BACKGROUND/PURPOSE

Intraluminal meconium calculi are a rare cause of neonatal abdominal calcifications in patients with anorectal malformations. To investigate their pathogenesis, we performed infrared spectroscopic analysis of meconium-calcified lesions.

METHODS

Meconium calculi were collected from the colostomy in a newborn patient with imperforate anus and rectourethral fistula. The potassium bromide method was employed to obtain the infrared absorption spectrum of the meconium calculi.

RESULTS

The wavelength pattern of the meconium calculi exhibited 4 specific peaks at 1570, 1390, 1105, and 1005 cm(-1) between 22% and 45% transmittance values. The unique absorption spectrum exclusively indicated ammonium hydrogen urate (C(5)N(5)O(3)H(7)), having the combined constituents of ammonium and uric acid.

CONCLUSIONS

These results suggest that the intraluminal meconium calculi were originally derived from meconium and fetal urine. The stasis of meconium passage and fetal urine mixing through the rectourethral fistula in a low-pH condition was deduced to be the main cause of this rare stone formation.

Neonatal intestinal obstruction simulating meconium ileus in infants with long-segment intestinal aganglionosis: radiographic findings that prompt the need for rectal biopsy

BACKGROUND

The initial clinical presentation and radiographic finding of microcolon in children with long-segment intestinal aganglionosis involving the entire colon, ileum and sometimes the jejunum can mimic meconium ileus. This makes the diagnosis difficult for the radiologist and surgeon.

OBJECTIVE

To document and describe the clinical and radiographic findings in children with long-segment intestinal aganglionosis who are initially thought to have meconium ileus.

MATERIALS AND METHODS

We reviewed the cases of six neonates with long-segment intestinal aganglionosis presenting as meconium ileus at our institutions between 1978 and 2002. We examined the clinical presentation and the radiographic, surgical, and pathologic findings. In addition, 17 cases from the literature were identified and are included in the discussion.

RESULTS

A total of 23 cases were reviewed. Right lower quadrant intraluminal calcifications were noted on abdominal radiographs in all six neonates of our series and were described in 13 of the 17 neonates reported in the literature. Similarly, a microcolon was present in five of the six neonates of our series and in 14 of 16 historical neonates (one not reported).

CONCLUSION

In a neonate with small-bowel obstruction and a microcolon, the presence of right lower quadrant intraluminal calcifications should raise the suspicion of long-segment intestinal aganglionosis even if the operative findings are typical of meconium ileus and a biopsy should be performed.

Intraluminal meconium calcification without distal obstruction

Intraluminal meconium calcification of unknown mechanism is reported in three neonates who did not have distal intestinal obstruction. The condition was benign in all three cases and did not require surgical intervention. This new form of intra-abdominal calcification should be differentiated from other forms that invariably are due to surgical disorders.

Fetal defaecation: is it a normal physiological process?

It has been long known that the late gestation human fetus passes meconium in response to hypoxia. However, there is good evidence, from amniotic fluid studies measuring bile pigment and enteric enzyme content, to suggest that passage of meconium is a normal physiological event in the second trimester. Similarly there is some indirect evidence that fetal defaecation is a normal physiological process in the third trimester. However, this evidence is less strong, and it is safer to assume that in most cases meconium staining of liquor at this time is associated with fetal hypoxia. Dilation of the rectosigmoid portion of the distal bowel found in newborn infants with anorectal malformations supports the hypothesis that fetal colonic peristalsis and defaecation is a normal physiological process.

The prenatal diagnosis of imperforate anus with rectourinary fistula: dilated fetal colon with enterolithiasis

The finding of extraluminal calcifications is commonly reported and usually indicates intrauterine intestinal perforation with intraperitoneal extravasation of meconium, most often associated with intestinal obstruction and/or atresias. Intraluminal calcification of meconium is more rare and appears to result from the mixing of stagnant urine and meconium in utero. The presence of the intraluminal calcifications in a dilated loop of intestine, particularly with an associated urinary tract abnormality, should suggest a rectourinary fistula. Two cases of prenatally diagnosed imperforate anus with rectourinary fistulae are reported.

Intraabdominal calcifications in the newborn: an unusual case with anorectal malformation and other anomalies

Intraabdominal calcifications are an unusual radiographic finding in the newborn and can easily be misinterpreted as meconium peritonitis. The authors refer to a patient with anorectal malformation (ARM), intraluminal calcifications and other anomalies. Careful differentiation of the type of intraabdominal calcifications can suggest the possibility of other initially unsuspected anomalies.

Neonatal abdominal calcification: is it always meconium peritonitis?

Intraluminal meconium calcifications are a rare cause of neonatal abdominal calcifications and can easily be misinterpreted as meconium peritonitis. We report three patients with anorectal anomalies, rectourethral fistula, and intraluminal calcified meconium. Intestinal stasis and mixing of urine and meconium may be predisposing factors for the calcification of meconium. Intraluminal calcifications appear as discrete punctate flecks within the distribution of the bowel, in contrast to meconium peritonitis, where the calcifications are linear and plaque-like, occurring anywhere in the abdominal cavity and scrotum. Careful differentiation of abdominal calcifications will allow more appropriate planning of the need and timing of surgery and can suggest the possibility of other anomalies that may not be suspected initially.

Enterolithiasis with imperforate anus. Report of two cases with sonographic demonstration and occurrence in a female

Enterolithiasis has been previously described as a plain film finding of rectovesical or rectourethral fistula in patients with anorectal malformation. Two cases of enterolithiasis with anorectal malformation are described in which the intraluminal nature of the calcifications was identified using ultrasound. The use of ultrasound for this purpose has not been previously reported to our knowledge. This simple, noninvasive technique permits antenatal differentiation between enterolithiasis and meconium peritonitis in some patients and can suggest the prenatal diagnosis of rectourinary communication when enterolithiasis is present. In addition, one of our cases occurred in a female. The entity of enterolithiasis with imperforate anus in a female has not been previously reported.

Enterolithiasis in two neonates with oesophageal and anorectal atresia

Enterolithiasis in two neonates with oesophageal and anorectal atresia is reported. The features of the two cases and comparison with the literature, the particular appearance of these intracolonic calcifications and the importance of radiological examinations for associated digestive, urinary and pulmonary malformations are presented.

Origin of calcification in healed meconium peritonitis

Calcification is the most characteristic pathologic feature of healed meconium peritonitis. Occurrence of calcification in meconium peritonitis has been reported, but its mechanism has not been discussed. According to our studies, the cause of calcification and giant cell reaction is meconium peritonitis is related to several distinct factors leading to three morphologic presentations described under type I, II and III in this paper. These factors can be traced to components of meconium. These morphologic findings are specific and in the proper context diagnostic of meconium peritonitis.

Rectourethral fistula on the urethrogram

Radiologic demonstration of a rectourethral fistula is of importance in the evaluation of the male neonate with imperforate anus. After pull-through operation a remnant of the fistula may remain as a small unimportant sinus tract or may cause problems.

Genitourinary malformation with calcified intraluminal meconium and pulmonary hypoplasia

Calcified intraluminal meconium is a rare finding in newborn infants that is often associated with communication between the urinary and gastrointestinal tracts. Frequently such infants die because of respiratory problems. An illustrative case is presented, and pulmonary hypoplasia is suggested as an etiology of the respiratory difficulties observed.

Imperforate anus and colon calcification in association with the prune belly syndrome

Two patients with the prune belly syndrome demonstrated colon calcifications and anorectal malformations. Bladder outlet obstruction was present in both cases. Calcifications were also found in the renal collecting system and bladder of one patient. No fistula was demonstrated between the genitourinary tract and bowel in either infant at autopsy. The calcification in the colon and urinary tract is probably secondary to stasis.