visual diagnosis
Day-Old Newborn With
Abdominal Distension
To submit cases for the NeoReviews Visual
Diagnosis column, please e-mail a short summary
of the case to NeoReviewsEditorial@aap.org,
where your summary will be forwarded to the
appropriate editor. Be sure to include “VisDx”
in the subject line of your email.
Figure 1.
Author Disclosure
Drs Prasanth, Wu, and Rastogi have disclosed no financial
relationships relevant to this article. This commentary does
not contain discussion of unapproved/investigative use of
a commercial product/device.
*John H Stroger, Jr, Hospital of Cook County, Chicago, IL.
Downloaded from http://neoreviews.aappublications.org/ at Indonesia:AAP Sponsored on September 22, 2019
Kaninghat Prasanth, MD, DCH, MRCPCH,* Shou-Yien Wu,
MD,* Alok Rastogi, MD, MRCP*
The Case
A 1-day-old newborn presents with abdominal distension
(Figure 1).
Prenatal and Birth Histories
• 21-year-old G2P1 African American mother
• Estimated gestational age: 37 weeks
• Spontaneous vaginal delivery in hospital
• Nonconsanguineous parents
• Routine antenatal screen negative
• Apgar scores 9 and 9 at 1 and 5 minutes of age
• Birthweight: 4,150 g
• Male infant
Presentation
The infant was active and feeding well initially. At 6 hours
after birth, the infant developed abdominal distension and
had two episodes of projectile vomiting. The vomitus was
nonbilious and non–blood stained. He was transferred to the
neonatal intensive care unit (NICU) for further evaluation.
Case Progression
Vital Signs
• Temperature: 98.7°F (37.1°C)
• Heart rate: 120 to 150 beats per minute
• Respiratory rate: 30 to 50 breaths per minute
• 99% oxygen saturation on room air
• Blood pressure on right hand by cuff method: 65/51
Physical Examination
• Large for gestational age.
• Head: Normocephalic; normal, open, flat fontanelles;
symmetric facies; patent nares; intact palate.
• Ears: Normal-shaped pinna bilaterally.
• Neck: Normal.
• Oral cavity: Pink mucosa, intact palate, no lymphade-
nopathy, normal sucking and rooting reflex.
• Lungs: Clear, equal breath sounds; no respiratory distress.
• Cardiovascular: Normal S1 and S2; regular rate and
rhythm; no murmurs or gallops.
NeoReviews Vol.15 No.9 September 2014 e419
visual diagnosis

• Abdomen: Distended, engorged veins, tender, bowel Actual Diagnosis

sounds absent. Intestinal perforation due to spontaneous perforation of
• Genitourinary: Normal-term female genitalia; patent anus. Meckel diverticulum (MD).
• Skeletal: Spine appears normal.
• Skin: No icterus, birthmarks, or other rashes.
The Experts
• Neurologic: Symmetric Moro, normal strength and tone.
MD is the most common congenital anomaly of the gastro-
intestinal tract. (1) MD arises from the persistence of the
Investigations
embryonic yolk sac, which is also called the omphalomes-
• White blood cell count: 7.3  103/mL (7.3  109/L)
enteric duct or vitelline duct. It occurs in roughly 2% to
with 25% neutrophils, 75% lymphocytes
3% of the general population and it is an ileal outpouching
• Red blood cell count: 2.63  103/mL (2.63  109/L)
measuring w3 to 6 cm and w50 to 75 cm from the ileocecal
• Hemoglobin: 7.7 g/dL (77.0 g/L)
valve. It is considered to be a true diverticulum, as it con-
• Platelet count: 41  103/mL (41  109/L)
tains all the layers of the intestine. MD derives its blood
• Blood and urine cultures: negative
supply from the superior mesenteric artery. (2)
Symptomatic MD in the neonatal period presents
Radiographs
most commonly as bowel obstruction (50%). (3) Other
presenting symptoms are pneumoperitoneum (38%) or
bleeding per rectum. (3) Differential diagnosis includes
necrotizing enterocolitis, spontaneous intestinal perfora-
tion, sepsis, and other abnormalities of the gastrointesti-
nal tract, such as atresia and volvulus.
Perforation of MD in the neonatal period is extremely
rare. The causes of MD perforation can be bowel atresia,
duplication, meconium ileus, meconium plug, micro-
colon of prematurity, small left colon syndrome, and
Hirschsprung disease. (4) Ectopic gastric or pancreatic
mucosa or inflammatory diverticulitis may lead to spon-
taneous perforation of MD. A focal congenital muscular
defect coupled with an elevation in the intraluminal pres-
sure also has been postulated as a possible mechanism.
Figure 2. (5) The diagnosis of perforated MD is almost always
made intraoperatively. Treatment consists of surgical re-
section, and prompt management is associated excellent
prognosis.
The rarity of the condition, coupled with the fact that
MD can mimic other causes of surgical abdomen, can
present a diagnostic challenge to the caregiver. Perforated
MD should be borne in mind as a possible cause in any
neonates presenting with bleeding per rectum or signs
of bowel obstruction or perforation.

American Board of Pediatrics Neonatal-Perinatal

Figure 3. Medicine Content Specifications
• Know the morphogenesis of the
Differential Diagnosis gastrointestinal tract and factors that lead
• Intestinal perforation to congenital malformations.
• Know the differential diagnosis of bilious
• Malrotation
and nonbilious vomiting and abdominal
• Necrotizing enterocolitis distention in the neonate.
• Sepsis

e420 NeoReviews Vol.15 No.9 September 2014

Downloaded from http://neoreviews.aappublications.org/ at Indonesia:AAP Sponsored on September 22, 2019
 visual diagnosis

2. Elsayes KM, Menias CO, Harvin HJ, Francis IR. Imaging

• Know the pathogenesis of atresias, stenosis,
diverticulae, and duplications of the small
intestine, including those associated
with annular pancreas.
References
1. Mackey WC, Dineen P. A fifty year experience with Meckel’s
diverticulum. Surg Gynecol Obstet. 1983;156(1):56–64
manifestations of Meckel’s diverticulum. AJR Am J Roentgenol.
2007;189(1):81–88
3. Aguayo P, Fraser JD, St Peter SD, Ostlie DJ. Perforated Meckel’s
diverticulum in a micropremature infant and review of the literature.
Pediatr Surg Int. 2009;25(6):539–541
4. Sy ED, Shan YS, Yang YR, Tsai HM, Lin CH. Hirschsprung’s
disease, a rare precipitating factor in neonatal perforated Meckel’s
diverticulum. J Pediatr Surg. 2006;41(7):1319–1321
5. Chang Y-T, Lin JY, Huang Y-S. Spontaneous perforation of
Meckel’s diverticulum without peritonitis in a newborn: report of
a case. Surg Today. 2006;36(12):1114–1117

Answer Key for September 2014 NeoReviews:

Outcomes in the Era of Therapeutic Hypothermia: 1. B; 2. E; 3. D; 4. C; 5. A.
Chest Compression and Ventilation in Delivery Room Resuscitation: 1. B; 2. B; 3. C; 4. D; 5. E.

NeoReviews Vol.15 No.9 September 2014 e421

Downloaded from http://neoreviews.aappublications.org/ at Indonesia:AAP Sponsored on September 22, 2019
 Day-Old Newborn With Abdominal Distension
Kaninghat Prasanth, Shou-Yien Wu and Alok Rastogi
NeoReviews 2014;15;e419
DOI: 10.1542/neo.15-9-e419

Updated Information & including high resolution figures, can be found at:
Services http://neoreviews.aappublications.org/content/15/9/e419
References This article cites 5 articles, 0 of which you can access for free at:
http://neoreviews.aappublications.org/content/15/9/e419.full#ref-list-
1
Permissions & Licensing Information about reproducing this article in parts (figures, tables) or
in its entirety can be found online at:
https://shop.aap.org/licensing-permissions/
Reprints Information about ordering reprints can be found online:
http://classic.neoreviews.aappublications.org/content/reprints

Downloaded from http://neoreviews.aappublications.org/ at Indonesia:AAP Sponsored on September 22, 2019

 Day-Old Newborn With Abdominal Distension
Kaninghat Prasanth, Shou-Yien Wu and Alok Rastogi
NeoReviews 2014;15;e419
DOI: 10.1542/neo.15-9-e419

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://neoreviews.aappublications.org/content/15/9/e419

Neoreviews is the official journal of the American Academy of Pediatrics. A monthly publication,
it has been published continuously since 2000. Neoreviews is owned, published, and trademarked
by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,
Illinois, 60007. Copyright © 2014 by the American Academy of Pediatrics. All rights reserved.
Online ISSN: 1526-9906.

Downloaded from http://neoreviews.aappublications.org/ at Indonesia:AAP Sponsored on September 22, 2019