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Clinical Radiology (1997) 52, 477-479

Case Report: Antenatal Sonographic Diagnosis of Meconium Peritonitis and Subsequent Evolving Meconium Pseudocyst Formation Without Peritoneal Calcification
W. T. YANG, S. S. Y. HO* and C. METREWELI t

Department of Diagnostic Radiology, *Department of Diagnostic Radiology and Organ Imaging and ~Department of Diagnostic Radiology and Organ Imaging, Chinese University of Hong Kong Prince of Wales Hospital, Shatin, Hong Kong
A case of giant meconium pseudocyst secondary to rupture from intestinal obstruction diagnosed by in utero sonography is presented_ The diagnosis of intestinal obstruction was made in the late second trimester before development of polyhydramnois, and the diagnosis of meconium cyst made in the third trimester despite the absence of intra-abdominal calcification. Exploratory laparotomy immediately after birth revealed a giant pseudocyst at the site of rupture immediately proximal to distal ileal atresia with associated in utero volvulus. Conventional radiographic features of meconium peritonitis with secondary meconium cyst formation are well described [1-6]. With the advent of high resolution real time ultrasound (US), the special role of sonography in detecting congenital malformations in utero has been established. We present a case in which sonographic diagnosis of intestinal obstruction was made at 27 weeks gestation before the development of polyhydramnois, and a sonographic diagnosis of meconium pseudocyst was made at 36 weeks gestation despite the absence of intra-abdominal calcification.
Laparotomy at 10 h of life confirmed ileal atresia with associated volvulus and a large pseudocyst at the rupture site in the distil ileum. Small bowel resection and anastomosis were performed after 500 ml of greenish brown fluid were drained fi'om the pseudocyst. Pathology of the resected small bowel specimen did not reveal any calcification intraluminally or on the serosal surface. The baby recovered well postoperatively and has achieved normal developmental milestones. Subsequently, a sweat test was normal.

Discussion
The incidence of congenital small bowel atresia is 0.38 in 10 000 newborns [7] and the prevalence of neonatal meconium peritonitis is estimated at one in 30 000 live births [8]. On sonography, fetal bowel obstruction characteristically consists of dilated sonolucent masses occupying the fetal abdominal cavity asymmetrically, with associated polyhydramnois [7]. The differential diagnosis includes a distended urinary bladder, usually in the middle of the lower abdomen, and mesenteric and ovarian cysts, usually located to one side of the abdominal cavity. Dilated loops filling the abdominal cavity suggest obstruction of the small bowel.

Case Report
A 31-year-old Chinese gravida 2 para I with an uneventful previous pregnancy and delivery, who was visiting Hong Kong presented to the antenatal US screening clinic at 27 weeks gestation for fetal anomaly screening. An isolated markedly dilated bowel loop was seen in the midabdomen of the fetus without associated ascites or polyhydramnois (Fig. 1). The rest of the examination was normal. The diagnosis was small bowel obstruction secondary to either ileal atresia, meconium ileus or small bowel volvulus, with a high risk of intestinal perforation. A follow-up US at 29 weeks gestation showed significant increase in size of the dilated segment of bowel, with associated ascites and polyhydranmois (Fig. 2). The diagnosis at this time was probable intestinal rupture and meconium peritonitis. The third follow-up US at 36 weeks gestation showed a large cystic collection in the abdomen with well defined echogenic walls (Fig. 3), which was separate from the bowel loops and most likely represented a meconium pseudocyst. An active 3400 g male infant was delivered at 38 weeks gestation by elective caesarian section. Physical examination revealed gross abdominal distension, more significant on the fight The abdominal wall was intact and anus patent. Both testes were descended without associated scrotal swelling or inguinal herniae_ Abdominal radiographs at 5 h of life showed a large soft tissue mass occupying the right hemiabdomen causing displacement of bowel loops to the left_ There was no radiograplucally demonstratable calcification (Fig. 4). US demonstrated a predominantly right sided cystic abdominal mass with well circumscribed echogenic walls filled with echogenic viscid content and a solitary echogenic focus with posterior acoustic shadowing within (Fig. 5). There was no sonographically visible calcification of the periphery or rim. The hepatobiliary system, adrenals and kidneys were normal. The most likely diagnosis was a meconium pseudocyst secondary to in utero bowel rupture. Correspondence to: Dr W.T. Yang, Department of Radiology, Prince of Wales Hospital, Shatin, NT, Hong Kong. 1997 The Royal College of Radiologists, Clinical Radiology, 52, 477 479. Fig. 1 - Transverse scan of the fetal abdomen at 27 weeks gestation shows an isolated markedly dilated small bowel loop (arrowheads). No ascites or polyhydrarnnois is present.

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(a)

Fig. 3 - Follow-up transverse scan of the fetal abdomen at 36 weeks gestation shows a well defined intraperitoneal cystic collection with echogenic walls (marked within calipers) separate from bowel. Note intraluminal calcification (arrow).

perforation, healed fibroadhesive (plastic) meconium peritonitis with calcification which occurs when the perforation seals off before birth and an abdominal meconium pseudocyst which results when the perforation occurs in utero but remains open allowing communication with the cystic cavity [10,11]. The latter is often a large meconium filled cyst lined by a thick membrane containing multiple calcium deposits and plaques; is usually secondary to a prenatal volvulus with perforation [8]; and accounts for 14% of sonographic findings in meconium peritonitis [14].

(b)
Fig. 2 - Transverse abdominal scan at 29 weeks gestation shows the dilated bowel loop (arrowheads) with associated polyhydramnois (a) (arrows) and ascites (b) (asterisk)

Extension of loops into the pelvis is indicative of large bowel obstruction. In this case, the presence of dilated loops in the mid abdomen pointed toward small bowel obstruction. The diagnosis was made at 27 weeks gestation before the development of polyhydramnois, as compared with other reported cases, where the diagnosis was made at 31 weeks gestation and after [7,9]. Meconium peritonitis is a sterile chemical peritonitis secondary to passage of meconium into the peritoneum after gut perforation [10]. The most common cause is intestinal obstruction due to meconium ileus, atresia, or volvulus. Rarely no obstruction is found [ 11,12]. Meconium ileus due to cystic fibrosis, which accounts for 25% to 40% of meconium peritonitis in the West [11], is uncommon in Asians [13]. The three main types of meconium peritonitis include a generalized meconium ascites from a recent open

Fig. 4 - Abdominal radiograph at 5 h of life shows a large soft tissue opacity in the right hemiabdomen displacing bowel loops to the left. There is no evident intra-abdominal or scrotal calcification. 1997 The Royal College of Radiologists, Clinical Radiology, 52, 477-479.

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the third antenatal ultrasound was performed soon after the development of the pseudocyst and before calcification had been deposited in sufficient quantity to be visible radiographically or echographically. Although calcification may develop within days histologically, radiographic and sonographic evidence of calcification usually requires weeks [4,21]. In conclusion, the diagnosis of meconium pseudocyst should be considered in the setting of fetal bowel obstruction with sequential polydramnois, ascites and cyst formation, even in the absence of intra-abdominal calcification.

REFERENCES

Fig. 5 - Transverse abdominal ultrasound scan at 5 h of life shows a large cystic well circumscribed mass with echogenic walls and echogenic content but no demonstrable calcification peripherally or intraperitoneally. The solitary echogenic focus within the cyst (arrow) represents intracystic meconium calcification, also seen in Fig. 3.

Less than 10 cases of prenatally diagnosed meconium peritonitis have been reported in the literature [14-20]. The sonographic diagnosis of meconium peritonitis should be considered in the presence of a fetal intra-abdominal hyperechoic mass, particularly if associated with ascites and polyhydramnois. Isolated ascites may occasionally be the only finding. When ascites develops suddenly in a fetus with bowel obstruction, as in our patient, the diagnosis of meconium peritonitis should be strongly suspected. The sonographic features of a meconium cyst are a thickened, well circumscribed, echogenic cyst wall with areas of focal calcification and echogenic viscous content [8]. Calcification of meconium peritonitis is usually linear in appearance as opposed to intraluminal meconium calcification which appears as punctate echogenic foci in the bowel lumen, as seen in our patient (Figs 3 & 5) [8]. Peritoneal calcification is the most common and characteristic finding of meconium peritonitis on both prenatal sonography and postnatal radiography [8]. The differential of a large intraperitoneal bowel related cystic mass with echogenic content includes a duplication cyst, which was unlikely in view of our initial finding of bowel obstruction. Other non urinary or bowel related cystic masses in the fetal abdomen which enter the differential list include an haemorrhagic ovarian cyst, mesenteric and omental cysts (usually lymphangiomas) and choledochal cysts (usually in the fight upper quadrant) [8]. Awareness of the site, prevalence and usual sonographic appearances help suggest the most likely diagnosis. Despite the absence of calcification in the cyst wall, peritoneum or scrotal sac in our patient, the prenatal diagnosis of a meconium cyst was made because of the evolution of abnormalities on follow-up. It is possible that

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1997 The Royal College of Radiologists, ClinicalRadmlogy, 52, 477-479.