Focal gastrointestinal perforations not associated with necrotizing enterocolitis in very low birth weight neonates

Abstract

Nine very low birth weight (VLBW) neonates (<1,000 g) undergoing abdominal exploration for peritonitis were found to have focal perforations of the gastrointestinal (GI) tract and no clinical or histologic evidence of necrotizing enterocolitis (NEC) or other mechanical cause. Although most patients presented initially with clinical findings suggestive of NEC, none developed the traditional clinical or radiographic findings associated with this diagnosis. Most patients initially had normal bowel gas patterns or transient bowel distension on abdominal x-ray, followed within hours by a paucity of bowel gas or a totally gasless abdomen. Paracentesis was positive in 7 patients. A blue, purplish, or dusky discoloration of the abdomen was described in 7 patients prior to surgery. Surgery was performed at an average age of 16.7 days. In all, the bowel appeared grossly normal with the exception of a 0.3- to 1-cm focal perforation of the small intestine or colon. One patient had an additional similar perforation of the stomach. Treatment in most was simple exteriorization of the perforation. The one gastric perforation was oversewn. Biopsy specimens at the site of perforation from 4 patients were described as having focal necrosis without intrinsic bowel disease. Two were noted to have Candida invading the bowel wall. Unlike the typical bowel flora found on culture in infants with perforations due to NEC, these patients had cultures and histological specimens positive for Candida and/or Staphylococcus epidermidis. We conclude that focal GI perforations occurring in the VLBW infant represent a clinically distinct phenomenon and that the traditionally accepted diagnostic criteria for bowel perforation due to NEC are unreliable in this condition. The presence of a blue discoloration of the abdominal wall and disappearing bowel gas on abdominal x-rays should lead to a high suspicion of bowel perforation. Diagnostic paracentesis should be used to confirm GI perforation. These perforations appear to be associated with Candida and/or S epidermidis infections in these patients and may be precipitated by small septic emboli from umbilical catheters implanting pathogens in a locally compromised segment of bowel.