Perforated viscus in infants: a new roentgen sign.

Abstract

Spontaneous nontraumatic rupture of the intestinal tract during the first few hours or days of life is an unusual, rather perplexing condition with a grave prognosis. The perforation most frequently involves the stomach wall, but occasionally occurs in the duodenum or colon. The usual entity, perforation of the stomach, is more common in boys and is often associated with prematurity or other congenital anomalies. The perforation is generally due to a congenital defect in the musculature of the stomach. Peptic ulcer, distal obstruction, trauma (especially that from the passage of tubes or the administration of oxygen), and other known causes of gastric perforation also occur in the newborn. Of 38 cases in which the site of perforation was reported, 25 were on the greater curvature, 5 on the lesser curvature, 4 on the anterior wall, 2 in the cardia, and 1 each in the fundus and posterior gastric wall. Clinically, the general picture in practically every instance is one of a baby perfectly well until four or five days after birth, when emesis occurs, followed by distention, then usually dyspnea, and sometimes cyanosis. Upon x-ray examination there is positive evidence of free air in the peritoneal cavity. In most instances the distention is thought to be due to bowel obstruction and, while supine films are usually made, frequently no upright films are taken and the diagnosis is missed. In 1950, both Leger and his group (5) and Ross, Hill and Haas (9) reported successful repair of gastric perforations in the newborn, their patients being the first to survive. In 1959, Linkner and Benson (6) reported 17 survivals after perforation of the stomach, a survival rate slightly over 46 per cent. Perforation of the duodenum occurs in children of all ages but predominantly in infants. It has been attributed almost uniformly to peptic ulcer. It is believed that circulatory difficulty, especially in prolonged labor, tends to devitalize the duodenal mucosa and any damaged area is more liable to digestion by the acid gastric juices. Miller (7) has shown that a remarkably high acidity is present in the first forty-eight hours of life. More rarely, perforation of the duodenum occurs from an unrecognized surgical nick at a Ramstedt operation and from swallowed objects, such as safety pins. The usual onset of duodenal perforation in infants is quite sudden, with acute fulminating symptoms and marked abdominal distention. A large pneumoperitoneum is present, and often only supine films are made due to the mistaken diagnosis of bowel obstruction. Again, the correct diagnosis is often missed. Over 350 cases of peptic ulcer in infants have been recorded. In most reported cases, the discovery has been made only at autopsy, which, to quote Gross (3), “would suggest that there is room for improvement in recognizing the condition during life.” Bird, Limper, and Mayer's patient is the youngest on record successfully operated upon (1).