Text Book Reading

Dr. Iwan S.

MECONIUM ILEUS
Pediatric Surgery
Jay L. Grosfeld

MECONIUM ILEUS

Landsteiner (1905): observasi obstruksi

usus halus penderita dg kelainan pankreas
ada hubungan dengan def enzim
cystic fibrosis
20,8% penderita di AS
Etiologi unknown genetic

PATHOGENESIS

Mulai terjadi di intrauterin sebagai

hasil akumulasi mekonium viskositas
tinggi dan padat:
Defisiensi enzim pankreas dan
sekresi mukus
yang kental oleh
kelenjar usus abnormal akumulasi
dan
obstruksi
mekonium
intraluminal komplikasi

GAMBARAN KLINIK

Uncomplicated meconium ileus

Segera setelah lahir, ditandai dgn
distensi abdomen, mekonium yang
kental menyumbat usus, muntah
hijau, tidak bisa BAB.

Complicated mec ileus,

Intrauterin atau setelah lahir
perforasi dan atau nekrosis usus:
gambaran kalsifikasi berbentuk bulan
sabit atau butiran-butiran intra abd,
peritonitis, eritem atau edema ddg abd
dan atau nyeri tekan abd.
Simple mec ileus

Bayi atau dewasa muda mec ileus

equivalent or distal ileal
obstruction syndr

Riwayat CF 10%-33%, amniosintesis

accurate diagnosis

Serial USG intrauterin intestinal

obstr of mec ileus (about 20% of the
CF population) with or without a
complicating meconium cyst.

Polihidramnion menggambarkan
adanya mekonium ileus intrauterin,
yang berasal dari obstruksi usus
berat.

simple atau uncomplicated:

peritonitis (-)

Pemeriksaan fisik
Distensi abdomen pada saat bayi
lahir
Peristaltik usus terlihat dan teraba,
kadang terlihat gambaran usus
PUTTY SIGN; palpated mass
RT: Tidak ada mekonium yang keluar
Teraba massa, perubahan warna
ddg abd, dan tanda-tanda peritonitis
Hypovolemia
NGT kehijauan > 20 ml

RADIOLOGI

USG: Echogenic bowel wall in the third

trimester
Plain abdomen, supine and erect films:
a. Perbedaan ukuran lekukan usus
b. No or few air-fluid levels
c. Gambaran butiran, soap bubble or
ground-glass sering terlihat pada abd
kanan.
Contrast enema (barium, gastrografin, or
any water-soluble)microcolon or unused
colon

Laboratorium

Analisa tripsin dan chymotrypsin

feses
Trypsin < 80 mg/g
CF immunoreactive trypsinogen
darah

DIFF DIAG
Neonatal intestinal obstruction:
Ileal atresia
Hirschsprungs disease
Neonatal small left colon
Meconium plug syndrome

MANAGEMENT
Non operative

Tergantung dari inspissated intraluminal

meconium dan patensi dari ileokolon.
Noblett described :
1. contrast enema distal intestinal obst
2. comp of
volvulus,atresia,perforation,peritonitis
excluded
3. enema with careful fluroscopic control
4. Intravenous antibiotic
5. Pediatric surgeon
6. full fluid resuscitation
7. Should be prepared for imminent
operation

Gastrografin enema meglumine

ditriazone(tween 80),40% sodium
diatrizoat

solubilizing enema treatment guidelines

Noblett
fluoroskopic
guidance
dan
pemberian larutan gastrografin 50% dalam
air abdominal radiograph diulang dalam
8-12 jam obstruksi (-)

The success of nonoperative treatment is

variable

Operative management
Simple Meconium Ileus

a.
b.
c.
d.
e.

Tujuan menghilangkan obstruksi:

evakuasi mekonium atau reseksi
bagian yang mengandung inspissated
material
Enterotomies with irrigation coupled
with a limited resection
The Miculicz resection and
enterestomy
The Bishop-koop resection and
enterostomy
The Santulli enterostomy
Tube enterestomy

Kriteria Bishop-koop prosedur

1. Limit intaoperative bowel trauma
2. Resect disparately ileal loop
3. Create appropriately sized end to
side anastomosis
4. Inserting catheter into distal
bowel
5. Enterostomy closure by ligation
chimney stoma

Santulli
a proximal chimney enterostomy,
an operation that in essence is the
reverse of the resection coupled
with a distal chimney enterostomy

Complicated Mec Ileus

Hampir selalu dgn operasi
Indikasi : persisting intestinal obst,
enlarging abdominal mass, sign
of peritonitis, dan clinical and lab
sign of ongoing sepsis

 Meconium peritonitis meconium

accumulating in peritonial cavity
A calcified pseudocyst fibrous wall
and spared bowel loop
At operation mandatory asses
residual intestinal length

Postoperative management
Support of the infants
general physiologi

Komplikasi
Gasrointestinal
a. Intussuception
b. Rectal prolapse
c. Colonic stricture

Pulmonary
a. Bacterial sepsis
b. Bronchopnemonia

Inguinoscrotal Disease
a. Hernia and hydrocele
b. Cryptorchidism

TERIMA KASIH