J Ped Surg Case Reports 1 (2013) 14e16

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Journal of Pediatric Surgery CASE REPORTS

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Neonatal gastric perforation with tension pneumo-peritoneum

Suzanne Lawther, Ramnik Patel*, Anupam Lall*
Department of Pediatric Surgery, Great North Children’s Hospital, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Queen Victoria Road,
Newcastle Upon Tyne NE1 4LP, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: A case of neonatal gastric perforation presenting as acute abdominal compartment syndrome mani-
Received 22 January 2013 festing as refractory metabolic acidosis and difficulty in ventilation during transfer is described. Plain
Received in revised form abdominal X-ray and decubitus view were helpful in defining a perforation of a hollow viscous. On
7 February 2013
arrival, she needed immediate needle decompression followed by an exploratory laparotomy and repair
Accepted 9 February 2013
of the gastric perforation and a temporary tube gastrostomy. The baby did well postoperatively and was
discharged home in 6 days. Neonatal gastric perforation is a serious and potentially life threatening
condition. Long distance to tertiary center and a prolonged transfer time mandates that the tension
Key words:
Neonatal gastric perforation
pneumo-peritoneum is relieved by needle compression by the transfer team at the base hospital.
Tension pneumoperitoneum Ó 2013 Elsevier Inc. Open access under CC BY-NC-ND license.
Abdominal compartment syndrome
Needle decompression
Gastrostomy
Peritonitis

Neonatal gastric perforation, although rare, has serious conse-
quences and is potentially life threatening [1e11]. A high index of
suspicion is essential for an early diagnosis. Management depends
on the extent and the timing of detection of persistent progressive
tension pneumo-peritoneum. During transfer the leak around
endo-tracheal tube worsens the abdominal compartment
syndrome leading to splinting of the diaphragm and reduction of
the venous return. This can cause profound combined metabolic
and respiratory acidosis unresponsive to fluid boluses.
1. Case report
A baby girl was born at 34 þ 2/40 gestation with a birth weight
of 2840 g by an induced vaginal delivery at a small district general
hospital (DGH). At birth she was in a very good condition needed no
resuscitation. Antenatal scans and period was uneventful apart
from spontaneous rupture of membranes at 30 weeks. The mother
was given two doses of dexamethasone and started on nifedipine
and erythromycin. Induction of labor was considered because of
raising maternal C-reactive protein despite antibiotic treatment.
The baby was started on 60 ml/kg of expressed breast milk and
20 ml/kg of Aptamil 3 hourly as nasogastric tube feeds on day 1 of
* Corresponding author. Tel.: þ44 191 2824711; fax: þ44 191 2820077.
E-mail addresses: patelramnik@rediffmail.com (R. Patel), Anupam.Lall@nuth.
nhs.uk (A. Lall).
life. She however, developed abdominal distention; large bile
stained gastric aspirates and remained unsettled on 2nd day of life.
Physical examination showed that the baby was pale and febrile
with a temperature of 37.8  C. She was grunting and had a shallow
respiration with a rate of 70 breaths/min and tachycardiac (190/
min) with a systolic BP of 80 mm of Hg. Her abdomen was tense,
tender and distended.
Full blood count revealed hemoglobin of 13.7 g/dl, high WBC
23.5  109/l, and neutrophils 15.6  109/l, platelets 262  109/l.
Other bloods showed bilirubin 162 mmol/l and CRP of 39 mg/l.
Capillary blood gas showed pH 7.07, PCo2 7.85 kPa, O2 8.65 kPa, Base
excess 15 mEq/l. She was given 20 ml/kg bolus of normal saline
and started on IV benzyl penicillin, gentamicin and metronidazole.
Initial abdominal X-ray suggested central non-dilated loops;
however, on repeat study it was quite evident that there was
extensive free air in the abdomen (Figs. 1 and 2). Following
consultation with us arrangements were made for transfer by the
regional neonatal transfer team.
Because of logistical problems there was significant delay in the
transfer team to get to the DGH and the baby’s condition deterio-
rated. Her abdominal distention worsened leading to combined
respiratory and metabolic acidosis which was not responsive to
fluid boluses. The tension pneumo-peritoneum was causing poor
venous return and splinting of the diaphragm.
On arrival, she needed decompression of her abdomen with
a wide bore cannula. Her respiration immediately improved and the
pressures on the ventilator got reduced before going to theater. On

2213-5766 Ó 2013 Elsevier Inc. Open access under CC BY-NC-ND license.

http://dx.doi.org/10.1016/j.epsc.2013.02.004
 S. Lawther et al. / J Ped Surg Case Reports 1 (2013) 14e16
Fig. 1. Abdominal X rays showing pneumo-peritoneum with American football and
saddle bag signs.
exploration, the peritoneal cavity was grossly contaminated by thick
yellow undigested foul smelling milk. The tip of the nasogastric tube
was protruding through a large 3 cm linear tear found on the
anterior wall of the stomach near the lesser curvature just distal to
the gastroeesophageal junction. The perforation was closed in two
layers and a temporary tube gastrostomy was fashioned. A trans-
pyloric nasojejunal tube was passed to start early feeds. The
abdominal cavity was thoroughly lavaged with warm saline.
Her post-operative period was uneventful and she was extu-
bated the following morning. Enteral feeds were started on 3rd
post-operative day, which she tolerated well and they were grad-
ually increased to full feeds. Her bilirubin remained high and she
needed phototherapy. She was discharged home after 6 days. Her
gastrostomy was removed in clinic after 4 weeks and it closed
spontaneously. At 2 year follow up she is thriving well and is
completely asymptomatic.
2. Discussion
Gastric perforation with resultant tension pneumo-peritoneum
is a rare but serious and life-threatening condition in neonates [1].
A variety of causative factors including prematurity, vigorous
resuscitation, nasal CPAP, perinatal stress, distal obstruction,
Fig. 2. Decubitus view showing massive tension pneumoperitoneum.
15
nasogastric tube trauma have been suggested rather than sponta-
neous perforation [3]. Our patient did not need any support in form
of ventilation or nasal CPAP at birth but had nasogastric tube
inserted for feeding. Baby was slow to accept breast or bottle feeds
initially so a decision was taken at the initial special care baby unit
to insert nasogastric tube for feeding. It is, therefore, more likely to
be a tube associated gastric perforation. If she would have been
nipple fed, this problem of acute neonatal gastric perforation would
have been avoided altogether.
The clinical presentation is very characteristic with rapid dete-
rioration of general condition after the feeds are started. Abdominal
distension, increasing aspirates and pneumo-peritoneum on
transillumination or abdominal X-ray are hallmarks as described in
literature [1e5]. Transillumination is a quick and easy technique for
diagnosing pneumo-peritoneum and obviates the need for frequent
radiographs [2].
Tension pneumo-peritoneum following neonatal gastric perfo-
ration complicates the matter as despite intubation, the ventilation
remains difficult and the acidosis becomes refractory with
combined metabolic and respiratory component [1,11]. Because of
regionalization of the neonatal transfer team it sometimes takes
much longer to transfer them to tertiary units. Many staff members
at smaller neonatal units lack the skill set to safely transfer sick
infants. A wide bore cannula decompression is an easy and life
saving technique and the medical team responsible for neonatal
transfers should familiarize themselves with the technique. It’s
useful in many other similar situations, which they may confront
during transfers such as premature babies with perforated necro-
tizing enterocolitis. Early diagnosis and prompt management
should improve the prognosis of this potentially life threatening
problem.
The conventional treatment of gastric perforation is imme-
diate laparotomy and suturing of the rent. Laparoscopy has been
described for the repair, but under the circumstances of acute
compartment syndrome due to tension pneumo-peritoneum it
may not be feasible due to deranged physiology [7]. The prog-
nosis is poor if it is detected late and prompt management has
not been done. Mortality rates as high as 70% been reported in
literature.
3. Conclusion
Neonatal gastric perforation with tension pneumo-peritoneum
is a rare but life threatening condition. Due to regionalization of the
neonatal transport teams there are delays in transfer and loss of
skills of staff at smaller neonatal units. In the case of tension
pneumoperitoneum the transferring staff may need to perform
needle decompression to stabilize the infant, and help decrease the
chances of life-threatening events during transfer. This will avoid
any life threatening events during transfer. The outcome of this
intervention is excellent and technique is easy to learn. Subsequent
definitive surgical treatment can be done at the regional neonatal
surgical unit. Our case is the powerful reminder of the fact that
gastric perforations may be more likely to cause tension pneumo-
peritoneum because of the large volume of air, as opposed to small
or large intestinal perforations, in which the diagnosis of pneu-
moperitoneum may be more difficult to recognize.
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