Intestinal Perforation in Children - A Clinico-pathologic Evaluation of 67 Cases

Abstract

Purpose: Intestinal perforation is a rare entity in paediatric age group when compared to adults. This entity has attracted little attention and the causes have not been elaborated. A clinico pathologic analysis of intestinal perforation in this age group was conducted to determine the underlying etiopathogenesis. Methods: The retrospective study included 66 children with intestinal perforation admitted to in-patient department of our hospital, over a period of one year, from January 2010 to December 2010. The case files of all the patients were retrieved and demographic and clinical data was recorded. The histopathology sections of all cases were re-reviewed and analysed. Results: Mean age of the patients ranged from 1 day to 12 years. There were seven neonates and twelve infants. The male to female ratio was 2.3:1. Children presented with symptoms of acute abdominal pain (most common), diarrhoea, or absence of meconium passage. Clinical evidence of peritonitis was present at initial evaluation in 22 (33%) children. Radiological evidence of perforation (pneumoperitoneum) was present in 40 (60.6%) cases with a further 12 (18%) cases showed dilated bowel loops or air-fluid levels. Thus, the radiographs were diagnostic in only 78% cases. The mean time from admission to laparotomy was 17 hours. The most common site of perforation was distal ileum followed in descending order by appendix, jejunum and caecum. A single perforation was noted in 60 cases, while multiple intestinal perforations were present in seven patients. The most common cause of perforation in neonates was necrotising enterocolitis. After the neonatal period infective causes were more common including tuberculosis, amoebiasis and fungal infection (most common being mucormycosis). In eighteen (27%) cases no specific cause of perforation could be detected. Conclusion: Intestinal perforation in infants and children can have a very varied aetiology. Clinical and radiological evidence of bowel perforation can be misleading and reliance on such indicators may result in significant diagnostic delay. Further, early diagnosis of infective causes followed by prompt treatment could prevent perforation, thus significantly reducing morbidity and mortality in these children.