Spontaneous neonatal gastric perforation

Spontaneous neonatal gastric perforation

Spontaneous Neonatal Gastric Perforation By Samuel B. Rosser, Charles H. Clark, and Edwin N. Elechi Washington, D.C. 9 Sixteen cases of spontaneous ne...

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Spontaneous Neonatal Gastric Perforation By Samuel B. Rosser, Charles H. Clark, and Edwin N. Elechi Washington, D.C. 9 Sixteen cases of spontaneous neonatal gastric perforation seen b e t w e e n January 1969 and March 1979 are reported, There w e r e 13 surgically treated patients and three autopsy cases. This study provides information relative to the incidence among black populations, an incidence 1 per 2 , 9 0 0 live births. The entity is at least four times more common in males than females. All perforations occured within the first w e e k of life (average 72 hr). All perforations w e r e on the greater curvature of the fundus. The operative mortality of this series is 7 . 5 % (1 of 13) with an overall mortality of 2 5 % (4 of 16). A gastrostomy was routinely done. No peritoneal cavity drainage or segmental gastric resection was necessary. I N D E X W O R D S : SPOntaneous neonatal gastric perforation.

HIS I S A R E P O R T of a retrospective study

T of 16 cases of spontaneous neonatal gastric perforation seen at Howard University Hospital

and on the Howard University Surgical Service at the District of Columbia General Hospital over a 10 yr period (January 1969-March 1979). The report includes an evaluation of the clinical presentation, surgical procedures and operative results of this entity. Thirteen cases were surgically treated and three were diagnosed at autopsy. Six of these cases were previously reported in January 1973.1 Associated perinatal findings and possible etiology are briefly discussed. INCIDENCE AND SEX RATIO D u r i n g t h e 1-0 y r p e r i o d c o v e r e d ~ b y ~ t h i s s t u d y t h e r e w e r e 4 5 , 6 4 4 live b i r t h s a t t h e t w o i n s t i t u tions. T h e i n c i d e n c e is t h e r e f o r e , 16 in 4 5 , 6 4 4 or o n e p e r 2 , 9 0 0 live b i r t h s . T h e r e w e r e 13 m a l e s a n d t h r e e f e m a l e s in t h e s e r i e s , a r a t i o o f 4:1.

CLINICAL PRESENTATION The onset of symptoms began from 36 to 144 hr after birth with an average of 75 hr. This has been noted by other

From the Department of Surgery, Howard University College of Medicine, Washington, D.C. Address reprint requests to Samuel B. Rosser, M.D., Howard University Hospital, 2041 Georgia Avenue, N. IV., Washington, D.C. 20060. 9 1982 by Grune & Stratton, Inc. 0022-3468/82/1704~9013501.00/0

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investigators.2'3'4'5Failure of the neonate to feed and abdominal distention with radiographic demonstration of pneumoperitoneum was seen in all patients. Respiratory difficulty and listlessness was seen in 12 patients. Jaundice was present in five cases but exchange transfusion was required in only two cases. Radiographic demonstration of pneumomediastinum was seen in one case.

Associated Perinatal and Maternal Conditions The most commonly associated perinatal condition was low birth weight seen in nine patients. Six of the patients were premature by weight (less than 5 lb) and gestational age (less than 38 wk). Another three patients were diagnosed as small for date (38 wk and less than 5 lb, 5 oz). Five patients had one minute APGAR scores of less than five; of these, three we!;e autopsy cases, one died in the early post operative period and the other one sustained a major wound infection and was hospitalized for 31 days after surgery. Maternal age, duration of labor and mode of delivery did not seem to predispose to the development of gastric perforation. It is interesting to note that multiparity was present in only two cases. Of the remaining 14 cases, eight were para 0 and six were para 1. Once the diagnosis was established the child was prepared and taken to the operating room (average time 5 hr). General endotracheal anesthesia, with the anesthetic gases pre-warmed, was used in all but one case, in which local anesthesia was given. A supraumbilical transverse incision was used. Upon entering the peritoneal cavity, obvious contamination was always noted, and the gastric perforation located without difficulty. The usual location was high on the anterior wall at or near the greater curvature of the fundus. Similar findings have been reported by others.2,3's'6'7'sThe size of the perforation varied from 2 to 5 cm in diameter. The edges were usually dark brown hemorrhagic, ragged, thin and friable. The edges were debrided and the defect closed in two layers. The earlier cases were closed with chromic gut and silk and the later cases were closed with Dexon (Davis and Geck, American Cyanamid Company, Pearl River, New York 10965). Local irrigation with warm saline was carried out and a gastrostomy done. In the 13 surgically treated cases, there were four with major complications. There was one death in the early post-op period (12 hr), one wound infection, one intraabdominal abscess which required reoperation and one case of pneumonia. This is a post-op mortality rate of one in thirteen or 7.5% in this series. The overall mortality, (including those autopsy cases in which gastric perforation may have been a factor) is four of sixteen or 25%.

DISCUSSION In

1825

S i e b o l d r e p o r t e d t h e first c a s e o f

neonatal spontaneous gastric perforation) It was n o t u n t i l 1929 t h a t t h e first a t t e m p t a t a r e p a i r

Journal of Pediatric Surgery, Vol. 17, No. 4 (August), 1982

SPONTANEOUS NEONATAL GASTRIC PERFORATION

was made by Stern, et al. ~~ The first successful surgical repair of this condition was accomplished by Leger, et al., ~ in 1950. Since 1950 several cases of successful surgical repair with increasing salvage rate have been variously reported in the medical literature by Ross, Hill and Hass, ~2 Linker and Benson, ~3 Field, et al., 14 Castelton, is Clark, et al., ~ and others. Despite successes, the mortality rate, which was initially 100%, has only been reduced to just under 50% in some series. ~6 In the present series there was no reason for segmental resection or near total gastrectomy as alluded to by Dehner. 6 The etiology of spontaneous neonatal gastric perforation is still unknown. Congenital muscular defect in the muscularis has been cited by Herbut ~7 as a causative factor in neonatal spontaneous gastric rupture. Several authors 2"18'~9 including Amadeo et al. 2~ have noted similar findings. None of the cases in the present series exhibited this finding. Asphyxia, hypoxia and stress at birth have all been incriminated as possible etiologic factors. 2"3'21'22'23'24'2526These factors may have played some part in causing the perforation in five patients in the present series. (Table 1, Cases 4,7,11,12,13) Trauma after birth due to vigorous respiratory resuscitative measures may have played some part in four cases in the present series, but nasogastric tubes 27'28 seemed to have played no part. In the one instance where a nasogastric tube was found through the rent, it was not the cause; the tube was inserted as a measure of treating the condition. At the two institutions tube feeding is utilized for neonates who do not have sucking ability or for those neonates who are under three pounds at birth. Cheek, 29 Rhea et al., 3~ and Rhea and Kirby 31 have described a useful technique for inserting such tubes. Increasing hydrostatic pressure due to various factors such as distal obstruction by atresia, bands, meconium, Hirschsprungs, have been cited by several authors. 2'7J9'32 In the present series there were no associated distal obstructions. Peptic ulceration in the presence of increased acidity 33 has been known to cause gastric 9 and duodenal ~6 perforations. Acute necrotizing enterocolitis 4'22'34 as a cause of neonatal gastrointestinal tract perforations has been reported after exchange blood transfusions by

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Lister and Noosa 35 as well as by Orme and Eades. 36 DIFFERENTIAL DIAGNOSIS

The differential diagnosis of neonatal spontaneous gastrointestinal perforations include: a) acute necrotizing enterocolitis, b) septicemia, c) intestinal obstruction and d) pneumoperitoneum without gastrointestinal perforation. The clinical presentations of acute necrotizing enterocolitis are quite similar but the two can be differentiated by roentgenographic studies. 4'22"34'37 Free peritoneal gas cannot be demonstrated in nonperforating acute necrotizing enterocolitis, though pneumatosis 4'22 may be seen. Septicemia can present with abdominal distention and inability of the neonate to feed. Roentgenography should demonstrate a gastric air bubble in the fundus which is lacking with gastric perforation. Free air in the peritoneal cavity is present with gastrointestinal perforations. Intestinal obstruction by any cause can produce abdominal distention, poor feeding, vomiting and respiratory difficulty simulating perforation of the GI tract. Roentgenographic studies aimed at demonstrating pneumoperitoneum, such as left lateral decubitus of the abdomen (patient must be placed on the left side for 10 to 20 min) 37'38'39 followed by erect chest posteroanterior view, 37 are very helpful. Occasionally a supine projection of the abdomen in the neonate can demonstrate the "air dome" or "football" sign described by Miller. 38"4~The prone view may occasionally demonstrate free air at the flanks and the inverted projection of the abdomen may demonstrate air in the scrotum. 37 For intestinal obstruction without perforation a fiat and erect of the abdomen should demonstrate air fluid levels and proximal dilations. 37'4~ Pneumoperitoneum without gastrointestinal perforation must be distinguished from pneumoperitoneum associated with GI tract perforation. Among the entities causing pneumoperitoneum without G1 tract perforation are tension pneumothorax and pneumomediastinum, 33'38"4~rupture pneumatosis intestinalis cystoides 37 and idiopathic pneumoperitoneum.'8 37 '42 Abnormal fat under the diaphragm can simulate free air under the diaphragm on erect posterioanterior chest projection. This finding has been reported by Martinez and Raskin. 43 It should be kept in mind

392

ROSSER, CLARK, A N D ELECHI

T a b l e 1.

Durationof Labor (Hrs)

One Min. Apgar

Mode of D e l .

MaternaJ Age-Yrs.

Time of Surgery After DX (Hrs)

Day PO Feeding Began (Oral)

Sex

1

M

4.8

36

7

7

NSVD

41

G2P1

48

5

5

2

M

7.6

40

14

8

C/S

23

G1Po

48

5

4

3

M

4.4

38

8

6

NSVD

38

G3P2

36

5

6

4

M

3.9

34

61

5

NSVD

21

G2Po

72

4

--

5

M

5.4

40

4.3

8

NSVD

27

G3P ~

72

5

4

6

M

5.6

36

6

8

NSVD

23

G=P~

120

4

4

7

F

4.6

33

7.2

4

NSVD

24

G2P ~

72

6

6

8

M

5.4

39

12.5

8

NSVD

20

G~Po

96

4.5

4

9

M

5.7

40

14.5

8

NSVD

24

G1Po

72

3.5

3

10

M

7.1

38

16.5

9

NSVD

17

G~Po

144

5

4

11

F

3.8

34

12

3

NSVD

26

G2P~

Autop.

--

--

12

M

4.8

36

16

3

LFD

21

G~Po

Autop.

--

--

Case

Gestational Age in Wk

Age at DX {Hrs)

B.W. Lbs.

Parity

13

M

7.0

40

38

2

C/S

24

G~Po

Autop.

--

--

14

M

6.0

38

10

9

NSVD

17

G2P ~

72

5

5

15

M

6.5

40

4

8

NSVD

36

GsP4Ab3

84

6

9

16

F

7.3

39

10

9

NSVD

G4PoAb3

36

5

6

t h a t the most c o m m o n cause of p n e u m o p e r i t o n e u m is still a b d o m i n a l surgery, which m a y last up to 4 wk, with a n o r m a l range of 4 to 5 days. 39

REFERENCES

1. Clark C, et ah Spontaneous perforations of the stomach in the newborn. JNMA 65:50, 1973 2. Hailer JA and Talbert JL: Gastrointestinal perforations in the neonate. In Surgical Emergencies in the Newborn. Hertzler JH and Mirza M (eds), p 282, Lea and Febiger, Philadelphia, 1972 3. Hertzler JH: Gastrointestinal perforations in the newborn (ischemic). Handbook of Pediatric Surgery, Yearbook Publishers, Chicago, 1974 4. Santulli TV, Schullinger J, Heird W, et al: Acute necrotizing enterocolitis in infancy. A review of 64 cases. Pediatrics 55:376, 1975 5. Dennison WM: Spontaneous perforations of the stomach in the newborn. Surgery of Infancy and Childhood. Churchill Livingstone, London, 1974

31

6. Dehner LP: Gastric perforations in the pediatric age group. Pediatric Surgical Pathology. C.V. Mosby Company, St. Louis, 1975 7. Lloyd JR, Bernstein J, Espiasse E: The etiology of gastrointestinal perforations in the newborn. Harper Hosp Bull 22:224, 1964 8. Shija JK: Pneumoperitoneum in a newborn baby: A case report. East African Medical Journal 52:162, 1975 9. Thelander HE: Perforation of the gastrointestinal tract of the newborn infant. Amer J Dis Child 58:371, 1939 10. Stern MA, Perkins EL and Nessa N J: Perforated gastric ulcer in a two-day old infant. Lancet 49:492, 1929 11. Leger JL, et al: Ulcere gastrique perfore chez un nouveau-n6 avec. Survie, Union Med Canada, 79-2, 1277, 1950 12. Ross M, Hill P, Haas C: Neonatal rupture of the stomach, second survival. JAMA 146:1313, 1951 13. Linker LM and Benson CD: Spontaneous perforation of the stomach in the newborn. Ann Surgery 149:525, 1959 14. Field EM, Northway RO, Manning JW: Perforation of the stomach in the newborn. Michigan M Soc 58:1262, 1959

SPONTANEOUS NEONATAL GASTRIC PERFORATION

393

T a b l e 1. C o n t i n u e d

Postop Hosp. Stay (Days) 17

Associated Perinatal Disease

Complications

None

None

Associated Maternal Disease None

Location of Perforation

Gastric Fundus

Size of Perforation

2.5 cm

Greater Curvature 15

None

None

Transverse

Gastric Fundus

3.0 cm

Greater Curvature 12

None

None

None

Gastric Fundus

5.0 cm

Curvature Died 12 hrs

--

Post OP 18

None

1 RDS

None

Prematurity Jaundice Req.

None

Pneurnomediastinum

3.0 cm

Greater Curvature None

Exch. Trans. 12

Gastric Fundus Gastric Fundus

2.0 cm

Greater Curvature None

Gastric Fundus

2.0 cm

Greater Curvature 31

Wound infection

25

None

1 RDS

None

Jaundice None

Gastric Fundus

2.0 cm

Greater Curvature None

Gastric Fundus

5.0 cm

Greater Curvature 13

None

None

None

Gastric Fundus

3.0 cm

Greater Curvature 44

None

1 RDS Jaundice

None

Req. Exch. Trans. --

Died 18 hrs Post. Del.

--

Died 30 hrs.

Prematurity: H.M.D.

5.5 cm

Greater Curvature None

Pneumothorax 1 RDS

Gastric Fundus Gastric Fundus

3.5 cm

Greater Curvature None

Prematurity

Transverse Colon

2.5 cm

Gastric Fundus

4.0 cm

--

Died 11 hrs

1 RDS

Eclampsia

Gastric Fundus

3.4 cm

15

None

None

None

Gastric Fundus

3.0 cm

28

Intraabd.

None

None

Greater Curvature Abscess

Gastric Fundus

4.0 cm

Greater Curvature

Repeated on 4th PO Day 15

(I & D) Pneumonia

None

None

Gastric Fundus

3.0 cm

Greater Curvature

15. Castleton KB and Hatch FF: Idiopathic perforation of the stomach in the newborn. AMA Arch Surgery 76:87, 1958 16. Swenson O: Pneumoperitoneum in the newborn, in Swenson O (ed): Pediatric Surgery, 3rd Edition, Appleton Century Croft, New York, 1969. 17. Herbut PA: Congenital defect in the musculature of the stomach with rupture in a newborn. Arb Path 36:91, 1943 18. Tow A, and Ross H: Rupture of stomach in a newborn. J A V A 111:1178, 1938 19. Brody H: Ruptured diverticulum of the stomach in a newborn infant associated with congenital membrane occluding the duodenum. Arch Path 29:125, 1940 20. Amadeo JH, Ashmore HW, Aponte GE: Neonatal gastric perforation caused by congenital defects of gastric musculature. Surgery, 47:1010, 1960 21. Benson CD, Mustard WT, Ravitch M, et al: Spontaneous perforation of the stomach in the newborn. In Pediatric Surgery p 661, Yearbook Publishers, Chicago, 1962 22. Master SP, Truscott DE, Templeton AC, et al: Neo-

natal necrotizing enterocolitis. Brit J Radiology, 46:1063, 1973 23. Scholander PF: The master switch of life. Scientific American, 209:92, 1963 24. Corday E, Irving OW, Gold H, et al: Mesenteric vascular insufficiency. Am J Med 33:365, 1962 25. Eisner R, Franklin D, Van Citters R, et al: Cardiovascular defense against Asphyxia. Science 153:941, 1966 26. Kieswetter WB: Spontaneous rupture of the stomach of the newborn. Am J Dis Childhood 91:162, 1956 27. Sun SC, Samuels S, Lee J, et al: Duodenal perforation: a rare complication of neonatal nasojejunal tube feeding. Pediatrics 55:371, 1975 28. Jones PF: Neonatal Peritonitis. Emergency Abdominal Surgery in Infancy, Childhood and Adult Life. Blackwell Scientific Publications, London, 1974 29. Cheek, JA and Stauh GF: Nasojejunal alimentation for premature and full-term newborn infants. J Pediatrics 82:955, 1973 30. Rhea JW, Ghazzawi O, Weidman W: Nasojejunal feeding: an improved device and intubation technique. J Pediatrics 82:951, 1973

394

31. Rhea JW and Kilby JO: A nasojejunal tribe for infant feeding. Pediatrics 46:36, 1970 32. Campbell RE, Boggs TR, Kirkpatrick JA: Early Neonatal pneumoperitoneum from progressive massive tension pneumomediastinum. Radiology 114:121, 1975 33. Miller RA: Gastric acidity during the first year of life. Arch Dis Childhood 17:198, 1942 34. DeLuca FG and Wesselhoept CW: Neonatal necrotizing enterocolitis. Am J Surgery 127:410, 1974 35. Lister J and Noosa A: Colonic perforations after exchange blood transfusions. BMJ 4:334, 1968 36. Orme RL and Eades SM: Colonic perforation with exchange transfusion. BMJ 4:349, 1968 37. Paster SB and Brogdon BG: Roentgenographic diagnosis of pneumoperitoneum. JAMA 235:1264, 1976

ROSSER, CLARK, AND ELECHI

38. Miller RE: The radiologic evaluation of intraperitoheal gas (pneumoperitoneum). Radiologic Science 4:61, 1973 39. Wiot JF, et al: Post operative pneumoperitoneum in children. Radiology 89:285, 1967 40. Miller JA: The "football" sign in neonatal perforate viscus. Am J Dis Child 104:311, 1962 41. Hodges GP: Intestinal Obstruction. Am J Roentgenol Rad Ther Nuc Med 74:1015, 1955 42. Leonidas J, Hall R, Rhodes P, et al: Pneumoperitoneum in ventilated newborns. Am J Dis Child 128:672, 1974 43. Martinez L and Raskin M: Fat under diaphragm simulating pneumoperitoneum. Br J Radial 49:492, 1929