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and abdominal scarring. Infants with meconium peritonitis and signs of intestinal
obstruction often require exploratory laparotomy.
Meconium plug syndrome is thought to occur because of colonic hypomotility,
and is commonly seen in preterm infants and infants of diabetic mothers. Similar
to meconium ileus, neonates typically present with failure to pass meconium
within the first few days of life and progressive abdominal distention. Contrast
enema is often diagnostic and therapeutic, with much higher success rate of fully
evacuating the meconium than with meconium ileus. The need for surgical
evacuation of the meconium is uncommon; however, meconium plug syndrome
may be associated with Hirschsprung disease and cystic fibrosis, so patients
should be evaluated for both.
Hirschsprung Disease
Hirschsprung disease results from an aganglionic segment of the colon that
results in a distal intestinal obstruction. Up to 90% of infants present in the
neonatal period with abdominal distention, emesis, and failure to pass meconium.
The abdomen is often soft, and a digital rectal examination may result in
explosive stool. Contrast enema can be diagnostic in up to 80% of cases when a
transition zone is identified. Definitive diagnosis is achieved by identification of
complete aganglionosis on a biopsied specimen. Eight percent of cases will have
total colonic Hirschsprung. Hirschsprung-associated enterocolitis occurs in up to
10% of cases but can be life threatening if unrecognized. Treatment for
enterocolitis requires emergent decompression of the rectum and broad-spectrum
antibiotics. Definitive treatment of Hirschsprung disease requires surgical
resection of the aganglionic segment.
Anorectal Malformations
Anorectal malformations leading to intestinal obstructions include the
imperforate anus. Most patients have associated fistulas that result in some
meconium passage that can delay diagnosis. In males, the fistulas can occur
between the rectum and urinary tract, and in females between the rectum and
perineum, vestibule, or bladder. Clinicians should examine the perineum closely
and look for associated malformations of the sacrum, spine, spinal cord, and

genitourinary tract. Treatment requires surgical correction of the malformation,
which may include primary repair or colostomy, depending on the presence of
associated anomalies.
Adhesions