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Duodenal ulcer with intestinal obstruction in anewborn child
D U O D E N A L U L C E R W I T H I N T E S T I N A L OBSTRUCTION IN A NEWBORN CHILD CHARLES H. FLOYD, CAPTAIN, MC, USA ~~ EL PASO, TEXAS L T H O U G H peptic ulcers may occur at any age, and have been observed in stillborn infants, intestinal obstruction secondary to a duodenal ulcer in the neonatal period is rare. In 1941, Bird, Limper, and Mayer ~ reviewed the literature on peptic ulcers of the stomach and duodenum in infants and children. T h e y found only one case of obstruction resulting from a peptic ulcer in a child less than 14 days of age. This is the only such case reported in the English language literature.
indirect 0.2 mg., direct 3.9 rag. Bleeding and clotting times were not'mal. B y 8 hours of age, the hemoglobin had dropped to 13.5 Gin. Two hours later the patient began to pass bright and dark red blood per rectum. This blood contained hemoglobin which was alkaline resistant. At 11 hours of age the baby was transfused with 50 ml. of whole 1)Ioo(l. Esophagoscopy, done by the otol a r g y n g o l o g y service, revealed a normal esophagus. The first feeding (an e v a p o r a t e d milk formula) was given at 13 hours of age. The i n f a n t began to vomit one h o u r later and continued to vomit CASE R E P O R T frequently. The vomitus contained a few flecks of blood. At 24 hours of A white boy was born by spontaage he again passed two large bloody neous delivery at William Beaumont stools. Twelve hours later he was A r m y Hospital a f t e r an uncompli- given an additional 30 ml. of whole cated p r e g n a n c y and labor to a 40- blood. B y 72 hours after birth, the year-old mother. The m o t h e r was vomiting became infrequent and was blood group A, Rh positive, and had free of blood. On the n e x t d a y the a negative serologic reaction for lues. stools were grossly normal. The i n f a n t ' s birth weight was 6 D u r i n g the entire period of hospipounds, 11 ounces (3,060 grams). talization, the abdomen remained soft. One hour and thirty-five minutes a p p a r e n t l y nontender, and was never a f t e r birth a small a m o u n t of b r i g h t abnormally distended. The infant red blood was seen oozing from the did not show any signs of r e s p i r a t o r y baby's mouth, and it was noted t h a t or central nervous disease, trod was he was jaundiced. At 5 hours of age discharged six days after delivery in the infant appeared pale. At this good condition. His hemogloMn at time the hemoglobin was 19.1 Gin. and hematocrit 59 per cent. The in- the time of discharge was ] 7.5 Gin. He was r e a d m i t t e d to the hospital fant was blood group A, Rh positive, at the age of 28 days with a history of and the direct Coombs test on the infant's blood was negative. Total having vomited a f t e r e v e r y feeding serum bilirubin was 4.1 rag. per cent, for the 10 days prior to admission. The vomitus was said to have been From the Pediatric Service, William Beaufree of gross blood or bile. The mont Army Hospital. *Present address: U n i v e r s i t y of C o l o r a d o stools, which had been normal in conM e d i c a l C e n t e r , 4200 E a s t N i n t h A v e . , D e n sistency and frequency, had also 1)eeu vet', Colo. 369
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free of gross blood. Physical examination on admission revealed an icteric infant in no distress who weighed 7 pounds, 3 ounces (3,260 grams). He was having projectile vomiting, and peristaltic waves, coursing from left to right on the anterior abdominal wall, were seen after feeding. No abnormal abdominal mass was felt. Roentgenograms of the abdomen were interpreted as showing signs of obstruction and revealed very little gas in the intestines. The stomach, visualized by barium given by nasogastric tube, did not empty completely in three hours, at which time only a small amount of the barium was seen in the jejunum. The complete blood count and bleeding and clotting times were normal. Reticuloeyte count was 1.4 per cent, total serum b i l i ~ b i n 9.45 mg. per cent, direct 0.31 mg., indirect 9.1 mg. Alkaline phosphatase was 6 Bodansky units. Gastric fluid obtained by lavage contained a small amount of blood. At 30 days of age an exploratory laparotomy was performed through an upper abdominal midline incision. The gall bladder was found to be adherent to the anterior portion of the duodenum, and cicatricial scarring was present about the first part of the duodenum. On opening the stomach in the antral area, a bleeding ulcer was seen on the anterior wall of the duodenum. Edema and scar tissue in the wall of the duodenum had produced almost complete obstruction. The liver and extra hepatic biliary system appeared normal. An anterior gastrojejunostomy was performed. The infant received whole blood and intravenous fluids during the operation and withstood the procedure well. The postoperative course was uneventful except for occasional episodes of vomiting. L yt r e n was given orally 24 hours after surgery. Within 48 hours feedings of skimmed milk were started. Two weeks after surgery roentgenographic study of the upper gastrointestinal tract showed that barium entered the jejunum
OF P E D I A T R I C S
through the gastrojejunostomy. Barium was also seen to enter a normalappearing duodenal bulb. Three weeks later, at the time of discharge, the jaundice had completely cleared, the baby was symptom free and weighed 8 pounds, 1 ounce (3,650 grams). He was taking a diet of evaporated milk formula, strained meats, and cereal. At the age of 80 days the patient weighed ]2 pounds, 1 ounce (5,500 grams). No vomiting had been noted since leaving the hospital. At this time roentgenograms of the upper gastrointestinal tract showed the gastrojejunostomy to be closed with all of the barium passing in a normal fashion through the duodenum, which was radiographically normal. At 12 months of age the infant weighed 24 pounds, 11 ounces (11.25 kilograms). He had not had any f u r t h e r gastrointestinal symptoms and was developing normally. DISCUSSION
This patient was noted to have bleeding from the gastrointestinal tract and jaundice 95 minutes after delivery. The hemorrhage continued until 3 days of age and was severe enough to necessitate two transfusions. He was discharged from the hospital at the age of 6 days, and remained asymptomatic until the eighteenth day of life when he again began to vomit. At 30 days of age laparotomy was performed and a duodenal ulcer was found to be producing duodenal obstruction. A gastrojejunostoniy was performed. The subsequent course was uneventful. The jaundice, which persisted until the age of 35 days, may have resulted from the absorption of Mood from the bleeding duodenal ulcer. Hematemesis and melena in the newborn period in most instances is due to blood that has been ingested
FLOYD:
DUODENAL ULCER WITH INTESTINAL OBSTRUCTION
either at the time of delivery or subsequently from a bleeding nipple while nursing at the breast. However, in those instances where the hemoglobin, e x t r a c t e d from the blood being passed orally or rectally, is found to be alkaline resistant, the blood can be assumed to be from h e m o r r h a g e and not ingested blood. 2 About 0.2 per cent of infants studied at autopsy have peptic ulcers2 They have been f o u n d in stillborns2 In one case p e r f o r a t i o n occurred during the intrauterine period. ~ However, intestinal obstruction resulting from a duodenal ulcer is e x t r e m e l y rare in the neonate. Disorders of the r e s p i r a t o r y or central nervous systems, burns, septicemia, and external t r a v m a have all been implicated as causes of peptic ulcers in the neonate. These conditions are more commoniy associated with gastric ulcers t h a n duodenal ulcers.a, 5, ~ The increased o u t p u t of hydrochloric acid shortly after birth ~, 8 m a y play some role in producing a greater incidence of ulcers at this age as compared with l a t e r infancy. ]n young children the t h e r a p y of peptic ulcers and their complications should be as conservative as possible. This is particularly t r u e in the newborn period since newborn infants recovering from peptic ulcers rarely
~71
have a recurrence. If s u r g e r y becomes necessary because of bleeding, gastrectomy should be avoided and the bleeding site should, when practical, be attacked directly. Gastrojejunostomy is the t r e a t m e n t of choice if s u r g e r y is r e q u i r e d for obstructionP SUMMARY
A case of duodenal ulcer producing intestinal obstruction during the neonatal period has been presented. I wish to t h a n k Dr. Itenry K. Silver for his assistance in preparation of the manuscript. REFERENCES 1. Bird, C. E., Limper, M. A., a n d Mayer, 5. 1~I.: Surgery in P e p t i c U l c e r a t i o n s of Stomach and Duodenum in I n f a n t s and Children, Ann. Surg. 114: 526, 1941. 2. Apt, L., and Downey, W . S . : C ' M e l e n a " N e o n a t o r u m : The Swallowed Blood Syndrome, J. PEDIAT. 47: 6, 1955. 3. Lusztig, G., Traub, A., and Korpassy, B.: On t h e P a t h o l o g y of Duodenal and Gastric Ulcers in I n f a n c y , A e t a Morph. hung. 4: 187, 1957. 4. Lee, W. E., and Wells, J. J.: Perforation in U t e r o of a Gastric Ulcer, Ann. Surg. 78: 36, 1923. 5. 1VicAleese, J. J.: The Surgical Problem P r e s e n t e d b y Peptic Ulcer of t h e Stomach and Duodenum in I n f a n c y a n d ChUdhood, Ann. Surg. 137: 334, 1953. 6. Hollander, M. 1:[., and Stark, IV[. W.: Duodenal Ulcers in I n f a n c y W i t h Present a t i o n of a Case, P e d i a t r i c s 6: 676, 1950. 7. l~[iller, R. A.: Gastric A c i d i t y in the F i r s t M o n t h of Life, Arch. Dis. C h i l d hood 16: 22, 1941. 8. Friedman, M. It. F.: Gastric Secretion in Newborn, Am. J. Digest. Dis. 9: 275, 1942.
indirect 0.2 mg., direct 3.9 rag. Bleeding and clotting times were not'mal. B y 8 hours of age, the hemoglobin had dropped to 13.5 Gin. Two hours later the patient began to pass bright and dark red blood per rectum. This blood contained hemoglobin which was alkaline resistant. At 11 hours of age the baby was transfused with 50 ml. of whole 1)Ioo(l. Esophagoscopy, done by the otol a r g y n g o l o g y service, revealed a normal esophagus. The first feeding (an e v a p o r a t e d milk formula) was given at 13 hours of age. The i n f a n t began to vomit one h o u r later and continued to vomit CASE R E P O R T frequently. The vomitus contained a few flecks of blood. At 24 hours of A white boy was born by spontaage he again passed two large bloody neous delivery at William Beaumont stools. Twelve hours later he was A r m y Hospital a f t e r an uncompli- given an additional 30 ml. of whole cated p r e g n a n c y and labor to a 40- blood. B y 72 hours after birth, the year-old mother. The m o t h e r was vomiting became infrequent and was blood group A, Rh positive, and had free of blood. On the n e x t d a y the a negative serologic reaction for lues. stools were grossly normal. The i n f a n t ' s birth weight was 6 D u r i n g the entire period of hospipounds, 11 ounces (3,060 grams). talization, the abdomen remained soft. One hour and thirty-five minutes a p p a r e n t l y nontender, and was never a f t e r birth a small a m o u n t of b r i g h t abnormally distended. The infant red blood was seen oozing from the did not show any signs of r e s p i r a t o r y baby's mouth, and it was noted t h a t or central nervous disease, trod was he was jaundiced. At 5 hours of age discharged six days after delivery in the infant appeared pale. At this good condition. His hemogloMn at time the hemoglobin was 19.1 Gin. and hematocrit 59 per cent. The in- the time of discharge was ] 7.5 Gin. He was r e a d m i t t e d to the hospital fant was blood group A, Rh positive, at the age of 28 days with a history of and the direct Coombs test on the infant's blood was negative. Total having vomited a f t e r e v e r y feeding serum bilirubin was 4.1 rag. per cent, for the 10 days prior to admission. The vomitus was said to have been From the Pediatric Service, William Beaufree of gross blood or bile. The mont Army Hospital. *Present address: U n i v e r s i t y of C o l o r a d o stools, which had been normal in conM e d i c a l C e n t e r , 4200 E a s t N i n t h A v e . , D e n sistency and frequency, had also 1)eeu vet', Colo. 369
A
370
THE
JOURNAL
free of gross blood. Physical examination on admission revealed an icteric infant in no distress who weighed 7 pounds, 3 ounces (3,260 grams). He was having projectile vomiting, and peristaltic waves, coursing from left to right on the anterior abdominal wall, were seen after feeding. No abnormal abdominal mass was felt. Roentgenograms of the abdomen were interpreted as showing signs of obstruction and revealed very little gas in the intestines. The stomach, visualized by barium given by nasogastric tube, did not empty completely in three hours, at which time only a small amount of the barium was seen in the jejunum. The complete blood count and bleeding and clotting times were normal. Reticuloeyte count was 1.4 per cent, total serum b i l i ~ b i n 9.45 mg. per cent, direct 0.31 mg., indirect 9.1 mg. Alkaline phosphatase was 6 Bodansky units. Gastric fluid obtained by lavage contained a small amount of blood. At 30 days of age an exploratory laparotomy was performed through an upper abdominal midline incision. The gall bladder was found to be adherent to the anterior portion of the duodenum, and cicatricial scarring was present about the first part of the duodenum. On opening the stomach in the antral area, a bleeding ulcer was seen on the anterior wall of the duodenum. Edema and scar tissue in the wall of the duodenum had produced almost complete obstruction. The liver and extra hepatic biliary system appeared normal. An anterior gastrojejunostomy was performed. The infant received whole blood and intravenous fluids during the operation and withstood the procedure well. The postoperative course was uneventful except for occasional episodes of vomiting. L yt r e n was given orally 24 hours after surgery. Within 48 hours feedings of skimmed milk were started. Two weeks after surgery roentgenographic study of the upper gastrointestinal tract showed that barium entered the jejunum
OF P E D I A T R I C S
through the gastrojejunostomy. Barium was also seen to enter a normalappearing duodenal bulb. Three weeks later, at the time of discharge, the jaundice had completely cleared, the baby was symptom free and weighed 8 pounds, 1 ounce (3,650 grams). He was taking a diet of evaporated milk formula, strained meats, and cereal. At the age of 80 days the patient weighed ]2 pounds, 1 ounce (5,500 grams). No vomiting had been noted since leaving the hospital. At this time roentgenograms of the upper gastrointestinal tract showed the gastrojejunostomy to be closed with all of the barium passing in a normal fashion through the duodenum, which was radiographically normal. At 12 months of age the infant weighed 24 pounds, 11 ounces (11.25 kilograms). He had not had any f u r t h e r gastrointestinal symptoms and was developing normally. DISCUSSION
This patient was noted to have bleeding from the gastrointestinal tract and jaundice 95 minutes after delivery. The hemorrhage continued until 3 days of age and was severe enough to necessitate two transfusions. He was discharged from the hospital at the age of 6 days, and remained asymptomatic until the eighteenth day of life when he again began to vomit. At 30 days of age laparotomy was performed and a duodenal ulcer was found to be producing duodenal obstruction. A gastrojejunostoniy was performed. The subsequent course was uneventful. The jaundice, which persisted until the age of 35 days, may have resulted from the absorption of Mood from the bleeding duodenal ulcer. Hematemesis and melena in the newborn period in most instances is due to blood that has been ingested
FLOYD:
DUODENAL ULCER WITH INTESTINAL OBSTRUCTION
either at the time of delivery or subsequently from a bleeding nipple while nursing at the breast. However, in those instances where the hemoglobin, e x t r a c t e d from the blood being passed orally or rectally, is found to be alkaline resistant, the blood can be assumed to be from h e m o r r h a g e and not ingested blood. 2 About 0.2 per cent of infants studied at autopsy have peptic ulcers2 They have been f o u n d in stillborns2 In one case p e r f o r a t i o n occurred during the intrauterine period. ~ However, intestinal obstruction resulting from a duodenal ulcer is e x t r e m e l y rare in the neonate. Disorders of the r e s p i r a t o r y or central nervous systems, burns, septicemia, and external t r a v m a have all been implicated as causes of peptic ulcers in the neonate. These conditions are more commoniy associated with gastric ulcers t h a n duodenal ulcers.a, 5, ~ The increased o u t p u t of hydrochloric acid shortly after birth ~, 8 m a y play some role in producing a greater incidence of ulcers at this age as compared with l a t e r infancy. ]n young children the t h e r a p y of peptic ulcers and their complications should be as conservative as possible. This is particularly t r u e in the newborn period since newborn infants recovering from peptic ulcers rarely
~71
have a recurrence. If s u r g e r y becomes necessary because of bleeding, gastrectomy should be avoided and the bleeding site should, when practical, be attacked directly. Gastrojejunostomy is the t r e a t m e n t of choice if s u r g e r y is r e q u i r e d for obstructionP SUMMARY
A case of duodenal ulcer producing intestinal obstruction during the neonatal period has been presented. I wish to t h a n k Dr. Itenry K. Silver for his assistance in preparation of the manuscript. REFERENCES 1. Bird, C. E., Limper, M. A., a n d Mayer, 5. 1~I.: Surgery in P e p t i c U l c e r a t i o n s of Stomach and Duodenum in I n f a n t s and Children, Ann. Surg. 114: 526, 1941. 2. Apt, L., and Downey, W . S . : C ' M e l e n a " N e o n a t o r u m : The Swallowed Blood Syndrome, J. PEDIAT. 47: 6, 1955. 3. Lusztig, G., Traub, A., and Korpassy, B.: On t h e P a t h o l o g y of Duodenal and Gastric Ulcers in I n f a n c y , A e t a Morph. hung. 4: 187, 1957. 4. Lee, W. E., and Wells, J. J.: Perforation in U t e r o of a Gastric Ulcer, Ann. Surg. 78: 36, 1923. 5. 1VicAleese, J. J.: The Surgical Problem P r e s e n t e d b y Peptic Ulcer of t h e Stomach and Duodenum in I n f a n c y a n d ChUdhood, Ann. Surg. 137: 334, 1953. 6. Hollander, M. 1:[., and Stark, IV[. W.: Duodenal Ulcers in I n f a n c y W i t h Present a t i o n of a Case, P e d i a t r i c s 6: 676, 1950. 7. l~[iller, R. A.: Gastric A c i d i t y in the F i r s t M o n t h of Life, Arch. Dis. C h i l d hood 16: 22, 1941. 8. Friedman, M. It. F.: Gastric Secretion in Newborn, Am. J. Digest. Dis. 9: 275, 1942.