Barthel et al. Journal of Medical Case Reports 2012, 6:229 http://www.jmedicalcasereports.com/content/6/1/229 Page 2 of 3 Figure 1 Initial radiographic image and photograph taken after patient’s second operation. (A) Plain abdominal radiograph showing bilateral eggshell calcifications consistent with giant cystic meconium peritonitis (GCMP, arrows). (B) Photograph taken at the patient’s second operation, where the peritoneal drain was removed and an ileostomy was brought out. The remnant of the original meconium pseudocyst can be seen at the bottom of the figure (arrow). precluded the identification of intestinal loops for safe stoma formation. Bilateral Penrose drains were therefore placed as a temporizing measure to allow decompression of the meconium from his abdomen. Although our patient’s sepsis improved with source control, he remained obstructed with a high nasogastric output. He also had persistent impairment of his pul- monary function from the obstruction and abdominal distension. Therefore, he was taken for a second oper- ation one month later. In this procedure, an extensive lysis of adhesions was performed, revealing a meconium cyst remnant (Figure 1B). His distal microcolon was also visualized, and an ileostomy was brought out at this time. Feeds were started on postoperative day 11 and were slowly advanced over the next four weeks to goal. Our patient was discharged and continued to gain weight appropriately at home. A screening chloride sweat test for cystic fibrosis was performed at four months of life and was negative. He was brought back in for elective ileostomy closure at seven months of life, at which time he was thriving on oral feeds and was weaned off parenteral nutrition. We also note that, to date, he has had no episodes of adhesive bowel obstruc- tion or any evidence of blind loop syndrome. Discussion Broadly, the meconium syndromes constitute a spectrum of diseases, all of which can present with neonatal bowel obstruction [7]. These may include meconium ileus, which is often associated with cystic fibrosis and can be amenable to nonoperative management with saline, con- trast or N-acetylcysteine enema administration, but requires surgical intervention if such measures fail [8]. In fact, it has recently been reported that contrast enema therapy for a simple meconium ileus has become less successful over time, requiring more frequent operative intervention. These authors attribute this effect to the changing practice pattern of radiologists and differing properties of various enema agents that have been employed [9]. Meconium plug syndrome is a related but distinct entity characterized by colonic obstruction by inspissated meconium. It is usually benign, resolves with contrast enema administration, and is not usually asso- ciated with cystic fibrosis [10]. In turn, a distinction must be made between this condition and small left colon syndrome, which is associated with maternal dia- betes, but also typically resolves with rectal contrast ad- ministration [11]. The defining characteristic of meconium pseudocyst and meconium peritonitis, which distinguishes these conditions from meconium ileus or meconium plug syn- drome, is intrauterine perforation with extralumenal leakage of enteric material into the peritoneal cavity [12]. Outcomes for neonatal meconium peritonitis have improved over time, with relatively high mortality rates reported from the 1950s improving to a survival rate of about 90% with modern advances in pediatric surgery and perinatology [13]. Surgery remains the definitive treatment, but there is a lack of standardization in the literature. Multiple drainage procedures, stoma creation and final ostomy closure are still common [14]. Of note, a recent retrospective series of 38 patients demonstrated improved survival with primary anastomosis, except for low birth weight babies [9]. Our patient had extensive soilage and adhesions that required a temporary