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Calcified meconium pseudocyst: X-ray diagnosis of meconium peritonitis at birth Gabrielle Shu-yi Lee,1 Suresh Chandran,1,2,3 Victor Samuel Rajadurai1,2,3 1
Department of Neonatology, KK Women’s and Children’s Hospital, Singapore 2 Yong Loo Lin School of Medicine, National University of Singapore, Singapore 3 Duke- NUS Graduate Medical School, Singapore Correspondence to Dr Suresh Chandran, [email protected] Accepted 22 June 2015
DESCRIPTION An infant girl was born at term to a mother diagnosed antenatally to have a fetal abdominal cyst and polyhydramnios. At 32 weeks, fetal imaging showed a calcified lesion (4.5×6.2 cm) in the central abdomen. At birth, a calcified cystic lesion suggesting a meconium pseudocyst (MPC) was noted in the X-ray of the abdomen (figure 1). Abdominal ultrasound scan confirmed a large calcified cyst in the central abdomen. The infant underwent laparotomy due to increasing bilious aspirate. Intraoperatively, they found a large MPC with extensive interloop adhesions and ileal atresia with perforation requiring stoma creation. Histopathological report showed ileal atresia with perforation and a large MPC. The child recovered well and underwent stoma closure at 3 months of age.
Fetal meconium peritonitis (MP) is a sterile chemical peritonitis following bowel perforation.1 Cystic type of MP occurs when the inflamed intestinal loops become fixed, leading to formation of an intraperitoneal cyst with a fibrous wall. When the extruded meconium becomes walled off, it can form a cystic, rim-calcified mass reflecting the normal intra-abdominal healing process to confine the perforation.2 MPC, a rare presentation of MP, has thinning of the intestinal wall with a smooth muscle layer connecting the cyst to normal intestine and it lacks epithelium due to inflammation.3 Fetal ultrasonography showing ascites, calcification and bowel dilation strongly indicate MP. In neonates with MPC, X-ray of the abdomen often reveals calcified pseudocyst. X-ray findings in MPC is suggestive but differentiated from cystic type of MP with per-operative findings and histopathology.3
Learning points ▸ Meconium peritonitis (MP) is rare. Fetal scan showing meconium pseudocyst (MPC), calcification and bowel dilation strongly suggests MP. ▸ MPC formation is rare in MP. More than 85% cases of pseudocyst can be diagnosed as calcified cyst in roentgenogram. ▸ X-ray findings alone are not diagnostic in MPC, per-operative findings and histopathology help to differentiate the cystic form of MP from MPC.
Contributors GSL drafted the initial manuscript, edited the manuscript and reviewed the literature for references. SC and VSR edited the manuscript, reviewed the literature for references and approved the final manuscript. Competing interests None declared. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
To cite: Lee GS-yi, Chandran S, Rajadurai VS. BMJ Case Rep Published online: [ please include Day Month Year] doi:10.1136/ bcr-2015-211052
Figure 1 Chest and abdominal radiograph showing the presence of intra-abdominal calcification distributed throughout the abdomen, especially in the central location where there is peripheral calcification of a meconium pseudocyst. Punctate calcifications are noted over the liver in the right upper quadrant of the abdomen and in the left upper quadrant where there is linear calcification.
REFERENCES 1
2 3
Eckoldt F, Heling KS, Woderich R, et al. Meconium peritonitis and pseudocyst formation: prenatal diagnosis and postnatal course. Prenat Diagn 2003;23:904–8. Yao-Chou L, Chau-Jing C. Meconium pseudocyst: a classical and successfully treated case. J Formos Med Assoc 2009;108:247–57. Minato M, Okada T, Miyagi H, et al. Meconium pseudocyst with particular pathologic findings: a case report and review of the literature. J Pediatr Surg 2012;47:e9–12.
Lee GS-yi, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2015-211052
1
Images in… Copyright 2015 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
2
Lee GS-yi, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2015-211052
Calcified meconium pseudocyst: X-ray diagnosis of meconium peritonitis at birth Gabrielle Shu-yi Lee,1 Suresh Chandran,1,2,3 Victor Samuel Rajadurai1,2,3 1
Department of Neonatology, KK Women’s and Children’s Hospital, Singapore 2 Yong Loo Lin School of Medicine, National University of Singapore, Singapore 3 Duke- NUS Graduate Medical School, Singapore Correspondence to Dr Suresh Chandran, [email protected] Accepted 22 June 2015
DESCRIPTION An infant girl was born at term to a mother diagnosed antenatally to have a fetal abdominal cyst and polyhydramnios. At 32 weeks, fetal imaging showed a calcified lesion (4.5×6.2 cm) in the central abdomen. At birth, a calcified cystic lesion suggesting a meconium pseudocyst (MPC) was noted in the X-ray of the abdomen (figure 1). Abdominal ultrasound scan confirmed a large calcified cyst in the central abdomen. The infant underwent laparotomy due to increasing bilious aspirate. Intraoperatively, they found a large MPC with extensive interloop adhesions and ileal atresia with perforation requiring stoma creation. Histopathological report showed ileal atresia with perforation and a large MPC. The child recovered well and underwent stoma closure at 3 months of age.
Fetal meconium peritonitis (MP) is a sterile chemical peritonitis following bowel perforation.1 Cystic type of MP occurs when the inflamed intestinal loops become fixed, leading to formation of an intraperitoneal cyst with a fibrous wall. When the extruded meconium becomes walled off, it can form a cystic, rim-calcified mass reflecting the normal intra-abdominal healing process to confine the perforation.2 MPC, a rare presentation of MP, has thinning of the intestinal wall with a smooth muscle layer connecting the cyst to normal intestine and it lacks epithelium due to inflammation.3 Fetal ultrasonography showing ascites, calcification and bowel dilation strongly indicate MP. In neonates with MPC, X-ray of the abdomen often reveals calcified pseudocyst. X-ray findings in MPC is suggestive but differentiated from cystic type of MP with per-operative findings and histopathology.3
Learning points ▸ Meconium peritonitis (MP) is rare. Fetal scan showing meconium pseudocyst (MPC), calcification and bowel dilation strongly suggests MP. ▸ MPC formation is rare in MP. More than 85% cases of pseudocyst can be diagnosed as calcified cyst in roentgenogram. ▸ X-ray findings alone are not diagnostic in MPC, per-operative findings and histopathology help to differentiate the cystic form of MP from MPC.
Contributors GSL drafted the initial manuscript, edited the manuscript and reviewed the literature for references. SC and VSR edited the manuscript, reviewed the literature for references and approved the final manuscript. Competing interests None declared. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
To cite: Lee GS-yi, Chandran S, Rajadurai VS. BMJ Case Rep Published online: [ please include Day Month Year] doi:10.1136/ bcr-2015-211052
Figure 1 Chest and abdominal radiograph showing the presence of intra-abdominal calcification distributed throughout the abdomen, especially in the central location where there is peripheral calcification of a meconium pseudocyst. Punctate calcifications are noted over the liver in the right upper quadrant of the abdomen and in the left upper quadrant where there is linear calcification.
REFERENCES 1
2 3
Eckoldt F, Heling KS, Woderich R, et al. Meconium peritonitis and pseudocyst formation: prenatal diagnosis and postnatal course. Prenat Diagn 2003;23:904–8. Yao-Chou L, Chau-Jing C. Meconium pseudocyst: a classical and successfully treated case. J Formos Med Assoc 2009;108:247–57. Minato M, Okada T, Miyagi H, et al. Meconium pseudocyst with particular pathologic findings: a case report and review of the literature. J Pediatr Surg 2012;47:e9–12.
Lee GS-yi, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2015-211052
1
Images in… Copyright 2015 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
2
Lee GS-yi, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2015-211052
