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CASE REPORT Table of Contents   
Year : 2011  |  Volume : 8  |  Issue : 2  |  Page : 249-251
Spontaneous intestinal perforation in neonates: Is surgery always indicated?


1 Division of Paediatric Surgery, Department of Surgery, JNMCH, Aligarh, India
2 Department of Paediatric Surgery, PGI, Chandigarh, India

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Date of Web Publication14-Oct-2011
 

   Abstract 

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.

Keywords: Newborn, spontaneous pneumoperitoneum

How to cite this article:
Khan RA, Mahajan JK, Rao KN. Spontaneous intestinal perforation in neonates: Is surgery always indicated?. Afr J Paediatr Surg 2011;8:249-51

How to cite this URL:
Khan RA, Mahajan JK, Rao KN. Spontaneous intestinal perforation in neonates: Is surgery always indicated?. Afr J Paediatr Surg [serial online] 2011 [cited 2014 Oct 20];8:249-51. Available from: http://www.afrjpaedsurg.org/text.asp?2011/8/2/249/86076

   Introduction Top


Pneumoperitoneum may not always be an absolute indication for surgery in infants. Pneumoperitoneum without peritonitis is a rare phenomenon which creates a management dilemma for the treating surgeon. A neonate with pneumoperitoneum, but with a normal abdominal examination, may deserve the trial of conservative management, thereby avoiding a laparotomy.


   Case Reports Top


From January 2006 to December 2007, 34 neonates were admitted to our neonatal surgical intensive care unit, with pneumoperitoneum. Out of 32 patients with features of peritonitis, 28 were managed with flank drains alone whereas four babies underwent laparotomy. The following two babies were managed without any surgical intervention.

Case 1

A 1.7-kg, full-term, male baby born to a first gravida mother by normal vaginal delivery presented to us on the 12 th day of life with the features of abdominal distension and non-passage of the stools. The mother received adequate antenatal and perinatal care and there was no history of birth asphyxia. There was no drug intake in the antenatal period. In the postnatal period, the baby was being breast fed until five days before presentation, when due to decreased lactation mother started to feed formula milk. At presentation, the general condition of the baby was stable. His activity was a little sluggish but the circulation was good and the baby was crying lustily. On abdominal examination, there was a minimal abdominal distension. However, there was no erythema, tenderness or a palpable lump. Laboratory investigation revealed a white cell count of 14.5×10 3 /mm 3 and haemoglobin 14 g%. The blood gas values, renal function parameters and the electrolytes were within normal range. Abdominal X-ray revealed the pneumoperitoneum [Figure 1]. The patient was resuscitated with intravenous fluids, antibiotics and a nasogastric tube was placed to decompress the stomach. In view of the stable general condition and no clinical evidence of peritonitis it was decided to continue with the conservative treatment. The patient was kept under close monitoring in the neonatal intensive care unit and a regular physical examination with frequent abdominal girth measurements was performed to detect any deterioration in the condition. The abdominal distension resolved and the baby passed stools spontaneously after three days of treatment. The repeat abdominal radiographs showed resolution of the pneumoperitoneum. A trial feed on Day 3 of admission was well tolerated and the baby was slowly graduated to full feeds by the ninth day of admission. The patient was discharged on the tenth day and is doing well in the follow-up.
Figure 1: Abdominal radiograph showing pneumoperitoneum

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Case 2

A 34-week, 1900-g male baby born to a primi-gravida mother presented to us on the 12 th day of life with abdominal distension. The antenatal and perinatal periods were uneventful. The baby was started on formula feeds on the seventh day of life as the mother thought the breast feeds to be inadequate for the baby. The patient was taken to a local practitioner on the ninth day of life for poor activity and refusal to feed. After three days of treatment, the patient developed abdominal distension and was brought to our centre. At presentation, the activity and cry of the baby were fairly good. There was moderate abdominal distension but without abdominal wall erythema, tenderness or muscle guarding on palpation. An X-ray of the abdomen showed pneumoperitoneum with dilated bowel loops and no evidence of pneumotosis intestinalis. The haematological and biochemical investigations including the blood gas analysis were normal. The baby was resuscitated in the usual manner and a nasogastric decompression effected for bowel rest. Since the baby was active with a good capillary refilling time, the nasogastric aspirates were clear and there were no signs of peritonitis, a trial of conservative treatment was given. A close watch was maintained on his peripheral circulation, activity, abdominal girth and the return of peristaltic activity. Serial abdominal X-ray showed resolution of the pneumoperitoneum. The nasogastric feeds were started after a period of four days as the patient started passing stools. The patient was discharged after 11 days and is on regular follow-up.


   Discussion Top


Radiological evidence of the free intraperitoneal air under the diaphragm is usually an indication of perforated intestine and requires an early surgical intervention. [1],[2] Pneumoperitoneum can develop without an intestinal perforation as well. [3],[4] Besides neonatal necrotizing enterocolitis (NNEC), there are numerous other causes of bowel perforation in a neonate and these include stress, hypoxia, or shock leading to the regional hypo-perfusion and transient intestinal ischemia initiating local hyperactivity of the defence mechanisms resulting in spontaneous intestinal perforation (SIP). Although the aetiology of SIP remains unknown, some authors argue that SIP and NEC represent different manifestations of the same pathogenic process. Premature rupture of membranes, lower Apgar scores, and the need for cardiovascular resuscitation in the perinatal period resulted in an increased susceptibility to SIP. The terminal ileum is more prone to local ischemia, but isolated perforations, like SIP, have also been observed in the transverse and descending colon. Other rare causes of neonatal intestinal perforation could be mechanical injury from the gavage tubes, rectal thermometers, resuscitation with oxygen under pressure in patients with distal pyloric or duodenal obstruction, congenital defects of the musculature, diverticula and meconium stasis. [5],[6],[7],[8]

The most common abdominal cause of the pneumoperitoneum without a perforation is pneumatosis intestinalis. [9] Pneumoperitoneum without a ruptured viscus may also be observed in premature infants who are on mechanical ventilation for pulmonary or cardiac diseases. [7],[2] Also, free air under tension in the mediastinum can extend along the vascular planes through the normal diaphragmatic openings into the abdomen. Another possible mechanism for the spread of the air from the lungs to the peritoneum is a retrograde path through the pulmonary lymphatics. [5],[8] Therefore, if pneumothorax or pneumomediastinum immediately precedes or appears simultaneously with pneumoperitoneum, conservative management should be considered. [1] Neither of our patients had associated pneumothorax or pneumomediastinum.

Spontaneous intestinal perforation (SIP) without clinical or histological evidence of NEC is a distinct entity in neonates, especially in the low birth weight neonates. Our patients did not have clinical features suggestive of NNEC, had low birth weight and had received formula enteral feeds, hence, were presumed to have SIP, a localised condition. The clinical experience and intra-operative findings in SIP suggest a self-limiting character of the disease, but there are a few reports of recurrent or multiple perforations as well. Whenever possible, primary closure of the perforation either with a few sutures or resection and primary anastomosis, is the procedure of choice. Recently, peritoneal drainage (PD) has been used in very sick neonates with perforation caused by NEC, for whom general anaesthesia and laparotomy are risky. PD may provide temporary stabilization and recovery, but most of these infants require subsequent laparotomy. [10],[11] It is debated whether SIP can seal spontaneously restoring the integrity and patency of the small bowel. PD has also been reported to provide successful and definitive treatment for many premature infants with isolated intestinal perforation. There is a small subset of patients with mild abdominal distension (e.g., less free air, less free fluid) and minimal or absent peritoneal signs similar to our patients, who are possible candidates for expectant line of treatment neither requiring laparotomy nor drainage [Table 1]. In the absence of peritoneal signs, we did not institute peritoneal drainage for our patients and observed them in the intensive care unit setting. Therefore, the neonates with pneumoperitoneum require a proper clinical and the radiographic correlation to establish the aetiology of perforation and the clinical picture should guide the therapy as happened in our patients. However, additional radiological evidence of air-fluid levels may also warrant a surgical intervention. [12]
Table 1: Indications for non-operative management

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Therefore, the absolute indications for surgery are established precisely when perforation is suspected, according to the abdominal signs, blood parameters including pH, and radiographic findings thereby avoiding some unnecessary explorations and peritoneal drainage.

 
   References Top

1.Williams NM, Watkin DF. Spontaneous pneumoperitoneum and other nonsurgical causes of intraperitoneal free gas. Postgrad Med J 1997;73:531-7.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Zerella JT, McCullough YJ. Pneumoperitoneum in infants without gastrointestinal perforation. Surgery 1981;89:163-7.  Back to cited text no. 2
    
3.Hill BJ, Saigal G, Patel S, Abdenour GE Jr. Transplacental passage of non-ionic contrast agents resulting in fetal bowel opacifi cation: A mimick of pneumoperitoneum in the newborn. Pediatr Radiol 2007;37:396-8.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Goodman RA, Riley TR 3rd. Lactulose-induced pneumatosis intestinalis and pneumoperitoneum. Dig Dis Sci 2001;46:2549-53.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Briassoulis GC, Venkatraman ST, Vasilopoulos AG, Stanidou LC, Papadatos JH. Air leaks from the respiratory tract in mechanically ventilated children with severe respiratory disease. Pediatr Pulmonol 2000;29:127-34.  Back to cited text no. 5
    
6.Simsek S, Ter Wee PM. Klebsiella pneumoniae and pneumoperitoneum. Lancet 2004;364:1172.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  
7.Steves M, Ricketts RR. Pneumoperitoneum in the newborn infant. Am Surg 1987;53:226-30.  Back to cited text no. 7
[PUBMED]    
8.Zahraa J, Abu-Ekteish F, Al Bassam AR, Nosir AA. Perforated Meckel's diverticulum in a neonate mimicking necrotizing enterocolitis. Pediatr Emerg Care 2003;19:418-9.  Back to cited text no. 8
[PUBMED]  [FULLTEXT]  
9.Heng Y, Schuffler MD, Haggitt RC, Rohrmann CA. Pneumatosi intestinalis: A review. Am J Gastroenterol 1995;90:1747-58.  Back to cited text no. 9
[PUBMED]    
10.Fasching G, Hollwarth ME, Schmidt B, Mayr J. Surgical strategies in very-low-birth weight neonates with necrotizing enterocolitis. Acta Paediatr Suppl 1994;396:62-4.  Back to cited text no. 10
    
11.Kosloske AM. Indications for operation in necrotizing enterocolitis revisited. J Pediatr Surg 1994;29:663-6.  Back to cited text no. 11
[PUBMED]    
12.Kosloske AM. The epidemiology and pathogenesis of necrotizing enterocolitis. Semin Neonatol 1997;2:231-8.  Back to cited text no. 12
    

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Correspondence Address:
Rizwan Ahmad Khan
4/817-F, Sir Syed Nagar, Mallah Nagla Road, Aligarh - 202 002
India
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DOI: 10.4103/0189-6725.86076

PMID: 22005379

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