Annals of Pediatric Surgery, Vol 2, No 1, January 2006, PP 45-47

Case Report

Gastric Perforation in Neonates: Analysis of Five Cases

K.Desouki & M.Kamal Osman
Department of Pediatric Surgery, Maadi Armed Forces Hospital, Cairo, Egypt

ABSTRACT Neonatal gastric perforation has always been a mysterious entity regarding its cause. Although
some have definite causes e.g. TOF causing severe dilatation of the stomach, iatrogenic secondary to the
introduction of a hard nasogastric tube but the majority have no obvious reasons. Many theories have been
advocated such as gastric ischemia or aerophagia due to excessive crying. The common feature in the five cases
seen at Maadi Military hospital over a period of 5 years was marked abdominal distension causing dyspnea.
Fortunately, all of them survived. This good survival rate in our opinion was due to the good pre and post-
operative care as well as the lack of sepsis oftenly encountered with gastric juice leakage.

Index Words: Gastric Perforation, Neonates, Pneumopertoneum

INTRODUCTION

S pontaneous gastric perforation is a very

uncommon event that occurs more often in
children than adults,1,2 usually occurs in intensive
care units.
A series of five cases, 2 males and 3 females, has
been reported over a period of 5 years at our neonatal
intensive care unit.
Four of them presented at the 2nd day of life and one
at the seventh day. They were all full term with a
weight range of 2.25 to 3 kg. All were referred because
of severe abdominal distension. Over a period of 6
hours they became increasingly irritable, tachycardic
and tachypneic. The abdomen was tender and
distended. They developed emesis, which
subsequently turned bilious. A nasogastric tube was
inserted, feedings were discontinued and intravenous
fluids and antibiotic therapy were started. Abdominal
radiographs were obtained (Fig 1, 2) which
demonstrated free pneumoperitoneum, consistent
with the diagnosis of intestinal perforation. Over the
next hour, while preparations for laparotomy were
under way, acute worsening of the abdominal
distension occurred.
The standard approach has been nasogastric tube
and fluid resuscitation for few hours followed by
laparotomy and 1ry repair.
Tiny single fundic perforation has been recognized
in the four 2 day babies while a complete necrosis of
approximately ¾ of the anterior wall of the stomach
starting from gastro-oesophageal junction till the
pylorus was detected in the 5th baby aged 7 days,
probably, it was unrecognized neglected perforation.
In one of the four 2 day babies air was coming out
through the perforation with ventilation denoting
trachea-oesophageal fistula. Perforation closed,
gastrostomy done and fistula was closed later.
Neither of them has got sepsis or necessitated
drainage. Oral feeding started on the 5th day while the

Correspondence to: K.Desouki , Department of Pediatric Surgery, Maadi Armed Forces Hospital, Cairo, Egypt

baby with the severe gastric necrosis had oral feeding
on the 10th day. They all survived and been followed
Fig 1. Abdominal X-ray in supine position
DISCUSSION
Three mechanisms have been proposed for stomach
perforation: traumatic, ischemic and spontaneous.
Most gastric perforations are due to iatrogenic
trauma.2, 3
The most common perforation results from vigorous
nasogastric tube placement. It usually occurs at the
greater curvature and appears as a puncture wound.
Perforation may develop also as a result of gastric
over distension during the course of positive pressure
ventilation or bag-mask resuscitation.4, 5
Spontaneous gastric perforations have been
reported in otherwise healthy infants, usually within
the first week of life particularly in between the first 2
and 7 days of life.6, 7 The term spontaneous suggests a
cause separate from necrotizing enterocolitis or
ischemia, trauma from gastric intubation, distal
intestinal obstruction or accidental insufflation of the
stomach during assisted ventilation.
Although perinatal stress and prematurity are
common associations, no predisposing factors can be
identified in at least 20% of patients.8
One hypothesis is that spontaneous perforations are
46
Desouki & Osman
up for 6 months later.
Fig 2. Abdominal X-ray in left lateral decubitus
due to the congenital defects in the muscular wall of
the stomach.9,10 Gastro duodenal perforation has been
associated with postnatal steroid therapy.6-11 Most
infants are being fed normally up to the time of
perforation.
Signs and symptoms of gastric perforation are
usually those of an acute abdominal event associated
with sepsis and respiratory embarrassment. The
abdominal examination shows significant abdominal
distension compromising ventilatory support.
Vomiting is an inconsistent feature.
Radiologically, massive pneumoperitoneum is
suggestive and contrast studies to confirm the
diagnosis are not indicated. Signs of hypovolemic
shock and sepsis complete the clinical picture. Gastric
perforation in a newborn infant is actually an
immediate surgical emergency. The rapidly
progressive pneumoperitioneum with associated
cardiopulmonary compromise is probably due to the
large size and proximal nature of the perforation.8, 9
A nasogastric tube should be placed while prompt
resuscitation is undertaken. Surgical repair of most
Annals of Pediatric Surgery

perforations consist of debridement and two layer
closure of the stomach. A gastrostomy may be
warranted. Significant gastric resections should be
avoided. The tear often involves the posterior wall of
the stomach along the greater curvature making
division of the gastro colic omentum and exploration
of the posterior gastric wall necessary even if a
disruption is also found on the anterior wall.
Post operative vigorous supportive therapy coupled
with the use of broad spectrum antibiotics
administered intravenously is necessary.
The most important factors affecting survival
appear to be the interval between the onset of
symptoms and the start of definitive therapy, the
extent of peritoneal contamination, the degree of
prematurity and the severity of other associated
consequences of asphyxia. Due to the associated
problems of sepsis and respiratory failure often found
in premature infants, mortality rates of gastric
perforations are high, ranging from 45% to 58%.1, 2
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