Neonatal Perforation Research Articles

Idiopathic Neonatal Colonic Perforation

Though the perforation of the colon in neonates is rare, it is associated with more than 50% mortality in high-risk patients. We report a case of idiopathic neonatal perforation of the sigmoid colon in an 8-day-old, healthy, male neonate without any demonstrable cause.

An Unusual Presentation of Corneal Perforation in a Neonate Following Instrument-Assisted Delivery

A 25-week-old neonate was noted to have unilateral corneal edema and buphthalmos at birth following a forceps assisted delivery. Ten days later, examination of the neonate under anesthesia showed a central corneal perforation with a possible retinal detachment. By this time the neonate’s affected eye was deemed unsalvageable, and therefore an enucleation was performed with insertion of an ocular implant. Subsequent histopathology of the enucleated eye revealed a grossly malformed anterior segment and findings usually associated with congenital glaucoma. This is the first reported case in the literature of a neonatal corneal perforation in the context of instrument-assisted delivery. This case highlights the need to actively investigate the aetiology of cloudy corneas in neonates. Early exploration and surgical intervention may be necessary especially if congenital glaucoma is suspected to be the underlying aeitlogy.

Neonatal Sigmoid Colon Perforation: A Rare Occurrence in Low Anorectal Malformation and Review of the Literature

Gastrointestinal perforation in neonates with anorectal malformation (ARM) is extremely uncommon. Delayed patient presentation is an important causative factor. A 2.5-kg neonate presented 72 hours after birth with abdominal distention and absent anal opening with meconium pearls. An abdominal X-ray revealed the presence of free gas. After adequate resuscitation patient underwent surgery. Closure of the sigmoid colon perforation with a proximal diverting loop colostomy with anoplasty was done. The literature reveals only two cases of sigmoid colon perforation with low ARM. Ours is the third case, in whom repair of the perforation and correction of the ARM was managed successfully at the same time.

Meckel’s diverticulum

Meckel’s diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract. It is usually encountered as an incidental finding at operation or autopsy. Symptomatic cases usually present during infancy with intestinal obstruction, intestinal hemorrhage, diverticulitis, or perforation. We report on a preterm newborn who developed abdominal distension at 17 h of age and pneumoperitoneum at 30 h. At laparotomy, a narrow-based MD with a small perforation at the tip was encountered. Segmental resection of the ileum, including the MD, and end-to-end anastomosis was performed. A review on perforated MD from the English medical literature is also presented. Perforated MD, although rare, should be included in the differential diagnosis of neonatal gastrointestinal perforations and acute abdomen. Keywords : acute abdomen, gastrointestinal perforation, perforated Meckel’s diverticulum, preterm newborn

Spontaneous Gastric Perforation in a Neonate Presenting as Gastric Outlet Obstruction

Gastric perforation in neonates is a rare but frequently fatal condition which is associated with massive pneumoperitoneum in radiography. Here, we report a case of neonatal spontaneous gastric perforation presenting as gastric outlet obstruction rather than pneumoperitoneum. Physical examination and imaging modalities were indicative of abdominal distension and gastric outlet obstruction. With diagnosis of gastric perforation at laparotomy, subtotal gastric resection was performed and a feeding jejunostomy was placed. The present report highlights that gastric perforation should be of clinical suspicion in neonates with abdominal distension and unusual imaging findings rather than pneumoperitoneum. Keywords: Spontaneous gastric perforation; gastric outlet obstruction; pneumoperitoneum

Gastrointestinal Perforation in Neonates: Aetiology and Risk Factors

Background: Gastrointestinal perforation (GIP) in neonates presents important challenges and mortality can be high. This is a report of recent experience with GIP in neonates in a developing country.Patients and methods: A retrospective review of 16 neonates treated for GIP in a 3 year period.Results: There were 9 males and 7 females, aged 0-28 days (median age =7days). Their weights at presentation ranged from 0.9 - 4.7kg (median =2.6). Five infants were premature. Twelve infants presented more than 72 hours after onset of symptoms. Plain abdominal radiographs showed peumoperitoneum in 9 infants. The cause of perforation was necrotising enterocolitis 6, intestinal obstruction 6, iatrogenic 3 and spontaneous 1. The site of perforation was ileum in 12 infants, stomach in 4 and colon in 4; 4 patients had involvement of more than one site. All the neonates underwent exploratory laparotomy with primary closure ( n=5) , resection and anastomosis( n=6), colostomy (n=3), Ileostomy ( n=2), partial gastrectomy (n=2) ,or gastrojejunostomy ( n=1). Two neonates had multiple procedures. Two very sick preterm babies had an initial peritoneal lavage. Surgical site infection is the commonest postoperative complication occurring in 9 infants. Anaesthesia sepsis and malnutrition is responsible for the seven deaths recorded.Conclusions: Neonatal GIP has multiple aetiologies; NEC is the most common cause. Major mortality risk factors include NEC, multiple perforations, delayed presentation and prematurity.

Gastrointestinal perforation in neonates: aetiology and risk factors.

Gastrointestinal perforation (GIP) in neonates presents important challenges and mortality can be high. This is a report of recent experience with GIP in neonates in a developing country. A retrospective review of 16 neonates treated for GIP in a 3 year period. There were 9 males and 7 females, aged 0-28 days (median age =7days). Their weights at presentation ranged from 0.9 - 4.7kg (median =2.6). Five infants were premature. Twelve infants presented more than 72 hours after onset of symptoms. Plain abdominal radiographs showed peumoperitoneum in 9 infants. The cause of perforation was necrotising enterocolitis 6, intestinal obstruction 6, iatrogenic 3 and spontaneous 1. The site of perforation was ileum in 12 infants, stomach in 4 and colon in 4; 4 patients had involvement of more than one site. All the neonates underwent exploratory laparotomy with primary closure ( n=5) , resection and anastomosis( n=6), colostomy (n=3), Ileostomy ( n=2), partial gastrectomy (n=2) ,or gastrojejunostomy ( n=1). Two neonates had multiple procedures. Two very sick preterm babies had an initial peritoneal lavage. Surgical site infection is the commonest postoperative complication occurring in 9 infants. Anaesthesia sepsis and malnutrition is responsible for the seven deaths recorded. Neonatal GIP has multiple aetiologies; NEC is the most common cause. Major mortality risk factors include NEC, multiple perforations, delayed presentation and prematurity.

Ileal duplication cyst associated with segmental ileal stenosis and neonatal perforation

A prenatally diagnosed terminal ileal duplication cyst associated with prenatal segmental mesenteric vascular thrombosis, ileal stenosis and proximal ileal perforation presenting in the neonatal period with bilious vomiting secondary to obstruction and perforation proximal to the segmental ileal stenosis in the proximal ileum has been reported. Plain X-ray, ultrasound scans and contrast studies were helpful in diagnosis. She underwent exploratory laparotomy, resection of terminal ileal duplication cyst with end-to-end anastomosis, resection of perforated stenotic proximal ileal segment with double barrel ileostomy formation uneventfully. She had staged closure of ileostomy and recovered well.

Neonatal Perforation Peritonitis Masquerading as Acute Scrotum

Neonatal Perforation Peritonitis Masquerading as Acute Scrotum

Six-year retrospective analysis of colonic perforation in neonates and infants: Single centre experience

Developing countries at tertiary referral centre. This study analysed the aetiology of colonic perforation (CP) in neonates and infants. Retrospective analyses of 60 CP cases (presented from May 2005 to May 2011) were done. The mean age at presentation was 8.33 ± 0.11 days (range, 2-110 days). The aetiology were Hirschsprung's disease (HD), necrotising enterocolitis (NEC) and idiopathic perforation in 78.33% (47/60), 6.67% (4/60) and 15% (9/60), respectively. There were 210 patients with histopathologically proven HD; 22.38% (47/210) cases of HD had CP. Most common site of perforation was mid-transverse colon (74%, 35/47) in HD patients. All HD-associated mid-transverse colonic, caecal, appendicular and ascending colon perforations (except one caecal perforation) had aganglionic recto-sigmoid region and ganglionic perforation site. Features of enterocolitis were not found in any HD patients. Two patients (3.33%) died due to sepsis. There was a high rate of primary HD-associated colonic perforation in this study. Colonic perforation may the initial presenting condition in HD disease. We advocate colonic biopsy to rule out HD in any neonate presenting with primary colonic perforation.

Idiopathic gastric perforation in an asplenic infant

The cause of idiopathic gastric perforations in neonates remains unknown. Perforations of the abdominal oesophagus, stomach and duodenum in infants and children are the rarest type of intestinal perforations. There are 21 reported cases of an idiopathic gastric rupture in non-neonates. A 6-week-old boy presented with nausea, vomiting and decreased oral intake. Physical examination revealed a firm, distended abdomen tender. Abdominal lateral decubitus radiograph revealed massive free air. Patient was found to have an idiopathic gastric perforation of the greater curvature with incidental findings of asplenia. Paediatric abdominal foregut perforations have diverse aetiologies. The foregut is the least likely portion of the gastrointestinal tract to perforate in children. The aetiology is unknown but there are many postulated theories. We present a case of an idiopathic gastric rupture involving the greater curvature of 6-week-old boy with incidental findings of being asplenic.

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

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.

Idiopathic Neonatal Colonic Perforation- A Case Report

Perforation of the transverse colon in neonate is a rare finding in clinical practice. We report a case of Idiopathic neonatal colonic perforation in a twenty-one days old, healthy, female neonate without any demonstrable cause. She presented with abdominal distention and constipation. Abdominal radiograph showed massive pneumoperitoneum. On exploration, transverse colonic perforation was found near splenic flexure area. The perforation was closed primarily. Other than inflammatory fibrin flakes the rest of the large intestine and small bowel appeared normal. Hirschsprung's diseases, necrotizing enterocolitis, small left colon syndrome, atresia, imperforate anus, cystic fibrosis are some causes of colonic perforation in neonates. However none of the clinical features or intra-operative finding of the above conditions could be found in our case. At follow-up, the baby showed normal weight gain without any symptoms.

Spontaneous bowel perforation in a neonate with anorectal malformation

Gastrointestinal perforation in neonates with anorectal malformations is extremely uncommon. Delayed patient presentation is an important factor that demands special attention. We present a neonate with anorectal malformation and meconium peritonitis following spontaneous bowel perforation. A day 1 neonate was referred with features suggested of peritonitis. After adequate resuscitation and drainage under local anesthesia, patient was successfully operated for a sigmoid perforation and is now awaiting definitive surgery for the anorectal malformation.

Acute spontaneous gastric perforation in neonates: A report of three cases

Gastric perforation in neonates is a rare, serious and life-threatening problem. The precise aetiology is obscure in most cases. By virtue of its high mortality rate, it requires prompt recognition and surgical intervention. We report three cases of neonatal gastric perforation managed by early resuscitation and primary repair.

Spontaneous intestinal perforation in neonates: Is surgery always indicated?

The usual accepted mode of treatment of neonates with necrotizing enterocolitis (NEC) and pneumoperitoneum is surgical. However, in a select group of patients conservative treatment is feasible. Pneumoperitoneum without peritonitis is a rare phenomenon which creates a management problem for the treating surgeon. We present two cases of pneumoperitoneum to discuss the non-surgical management of pneumoperitoneum and describe their outcomes.

Iatrogenic neonatal bladder perforation

Neonatal bladder rupture is rare as a complication of bladder obstruction due to abnormal anatomy or iatrogenic causes. The present study describes the case of a 3-day-old infant with ascites due to bladder perforation secondary probably to manual decompression of the bladder. The infant underwent successful surgical repair of the perforation.

Transthoracic echocardiographic assistance for interatrial stenting in low birth‐Weight neonates with hypoplastic left heart syndrome and intact atrial septum

Infants with hypoplastic left heart syndrome and intact or highly restrictive atrial septum require emergent therapy to relieve pulmonary congestion. Transcatheter stenting has become, in most large centers, the mainstay of therapy for relief of left atrial hypertension. Normally, this procedure is performed with the assistance of transesophageal echocardiographic guidance. However, the transesophageal approach is untenable in neonates of low birth weight, as the transducers can be traumatic and can cause ventilatory difficulty. We present two cases in which transthoracic echocardiographic guidance was used to guide atrial perforation and stenting in low birth-weight neonates with hypoplastic left heart syndrome with intact or highly restrictive atrial septum. Both procedures were straightforward and there were no complications. Real-time biplane imaging greatly assisted in the intervention in one case. The advantages of this approach are discussed.

Neonatal gastrointestinal perforation and perinatal distress factors

Background: Gastrointestinal perforation in the newborn is common, and often associated with poor outcome in developing countries. We determined the etiology and outcome of neonatal gastrointestinal perforation in an underserved region. Methods: A prospective study of neonates who presented with gastrointestinal perforation at the University of Benin Teaching Hospital, Benin City, and Leadeks Medical Center, both in Edo state, Nigeria, between July 2001 and June 2008. Results: A total of 68 neonates aged between 1 and 28 days (mean 12 ± 2.1 days), weighing from 1.5 to 4.1 kg (mean 2.8 ± 1.3kg), and comprising 41 males and 27 females (ratio 1.5:1) presented with gastrointestinal perforation. Fifty-one (75%) neonates had perinatal distress, following complicated delivery in 47 (69.1%) and drugs/infections in 4 (5.9%). These factors were the only cause of perforation (primary perforation) in 21 (37.5%) neonates, increased the risk of perforation of gut pathologies (secondary perforation) in 30 (62.5%), while only 17 (25%) neonates with perforation had no perinatal distress. Emergency caesarean delivery, prolonged rupture of membrane, prematurity, pre-partum hemorrhage, drugs, infections and maternal diabetes mellitus were the causes of perinatal distress. Volvulus. 20 (29.4%) anorectal anomaly, 14 (20.6%) necrotizing entero colitis, 11 (16.2%) and Hirschsprung’s disease, 2 (2.9%) were causes of secondary perforations. Late presentation of clinically compromised neonates was frequent with attendant 27 (39.7%) deaths. Conclusions: Factors associated with perinatal distress were the leading causes of gastrointestinal perforation in neonates. The mortality was high and antenatal care in hospitals with adequately supervised delivery and early referrals are advocated to improve outcome.Keywords: Neonates, gastrointestinal perforation, perinatal distress.

Correlation of complex ascites with intestinal gangrene and perforation in neonates with necrotizing enterocolitis

Background/Purpose The purpose of this study was to determine whether a correlation exists between the finding of complex ascites on ultrasound (US) and the presence of intestinal perforation or gangrene in neonates with complicated necrotizing enterocolitis (NEC). Methods Charts of neonates with NEC (n = 76) whose care involved consultations with the pediatric surgery service between 2005 and 2008 were reviewed. Twenty-three babies with NEC without free air had a bedside abdominal US. Neonates with pneumoperitoneum were excluded from the study because this was an absolute indication for surgical intervention. Results Twelve of the 23 neonates who had a bedside abdominal US were found to have ascites with debris or complex ascites. One of these 12 patients improved with medical management, and the ascites resolved. One infant with complex ascites had an initial laparotomy that revealed extensive bowel necrosis and gangrene that required intestinal resection and ostomy creation. This infant survived and is currently doing well. Ten patients were critically ill and were managed with bedside peritoneal drainage. Of those, 7 had drainage of intestinal contents after placement of the drain. Two of the babies who had a drain placed for complex ascites subsequently died of progressive disease. Five neonates with ascites with debris improved after peritoneal drainage and were subsequently subjected to laparotomy. All had gangrene with intestinal perforation. Three infants with complex ascites and intestinal contents were not observed during the initial peritoneal drainage. They improved after peritoneal drainage and had laparotomy. Free intestinal perforation was not demonstrated. The 3 infants in this group survived. Conclusions The presence of complex ascites with debris correlated well with intestinal gangrene or perforation. This correlation may also be a predictor of mortality. Neonates with complicated NEC without clear indication for surgical intervention would benefit from bedside abdominal US evaluation.