Research progress on risk factors of spontaneous intestinal perforation in premature infants / 中国小儿急救医学

Spontaneous intestinal perforation(SIP) is one of the causes of digestive tract perforation in premature infants and requires surgical intervention.Except for preterm delivery, the etiology and pathogenesis of SIP remain unclear.The studies have shown that it may be related to the application of magnesium sulfate, nonsteroidal anti-inflammatory drugs, hormones, vasoactive drugs and low perfusion status, infection, congenital intestinal dysplasia, non-invasive respiratory support, delayed nutrition initiation and other factors.In the management of premature infants, it is particularly important to improve the understanding of SIP, early diagnosis and treatment.

Prematuro con perforación intestinal espontánea de presentación muy precoz / Preterm neonate with spontaneous intestinal perforation of very early presentation

Resumen Introducción: La perforación intestinal espontánea es una condición que afecta principalmente a neonatos pretérmino. Caso clínico: Se presenta el caso de un neonato pretérmino de 26 semanas de gestación con neumoperitoneo en las primeras 24 horas de vida. Por lo precoz del cuadro y los hallazgos radiológicos, la primera hipótesis diagnóstica fue una perforación gástrica. Sin embargo, en la laparotomía se encontró una perforación ileal única, sin hallazgos de enterocolitis. Conclusiones: La perforación intestinal espontánea se ha asociado con intervenciones médicas, como el uso concomitante de esteroides e indometacina. Otras intervenciones, como el uso de magnesio prenatal y la colocación de surfactante pulmonar de forma mínimamente invasiva, se han propuesto como factores de riesgo para su desarrollo. En la actualidad, deben evaluarse la perforación intestinal espontánea y sus asociaciones. Las presentes y futuras investigaciones podrían contribuir a aclarar el papel de las intervenciones mencionadas en la revisión preliminar de la literatura.

Abstract Background: Spontaneous intestinal perforation is a condition that mainly affects preterm infants. Case report: The case of a preterm infant of 26 weeks of gestation with pneumoperitoneum in the first 24 hours of life is described. Due to the early symptoms and radiological findings, the first diagnostic hypothesis was gastric perforation. However, at laparotomy, a unique ileal perforation was found, without findings of enterocolitis. Conclusions: Spontaneous intestinal perforation is a complication associated with medical interventions such as the concomitant use of steroids and indomethacin. Recently, other interventions, such as the use of prenatal magnesium and treatment with exogenous pulmonary surfactants in a minimally invasive way have been proposed as risk factors for its development. At present, clinicians should evaluate spontaneous intestinal perforation and its associations, and ongoing and future research may clarify the role of the interventions mentioned in the review of preliminary literature.

Clinical or Radiological Findings Suggestive of Spontaneous Intestinal Perforation in Extremely Low Birth Weight Infants with Gasless Abdomen

PURPOSE: This study aimed to evaluate the clinical and radiologic findings suggestive of spontaneous intestinal perforation (SIP) in extremely-low-birth-weight infants (ELBWIs) with persistent gasless abdomen, and to investigate the usefulness of abdominal ultrasonography for the diagnosis of SIP. METHODS: In total, 22 infants with birth weights less than 1,000 g who showed persistent gasless abdomen on simple abdominal radiography were included. Perinatal, neonatal, and perioperative clinical findings were retrospectively reviewed, and the risk factors for intestinal perforation were evaluated. Abdominal sonographic findings suggestive of intestinal perforation were also identified, and postoperative short-term outcomes were evaluated. RESULTS: In total, eight of the 22 infants (36.4%) with gasless abdomen had SIP. The number of infants with patent ductus arteriosus who were treated with intravenous ibuprofen or indomethacin was significantly higher in the SIP group than in the non-SIP group (P<0.05). Greenish or red gastric residue, abdominal distension, or decreased bowel sound were more frequent in infants with SIP (P<0.05), in addition to gray or bluish discoloration of abdomen, suggestive of meconium peritonitis (P<0.05). Pneumoperitoneum on simple abdominal radiography was found in only one of the eight infants (12.5%) with SIP. Intramural echogenicity and echogenic extramural material on abdominal ultrasonography were exclusively observed in infants with SIP. Four infants (50%) with SIP died after surgical intervention. CONCLUSION: Intestinal perforation may occur in ELBWIs with gasless abdomen. As intramural echogenicity and extraluminal echogenic materials on abdominal ultrasonography are indicative of SIP, this technique could be useful for diagnosing SIP.

Comparison of Acute Abdominal Surgical Outcomes of Extremely-Low-Birth-Weight Neonates according to Differential Diagnosis

BACKGROUND: Improvements in perinatal intensive care have improved survival of extremely-low-birth-weight (ELBW) neonates, although the risk of acute abdomen has increased. The differential diagnosis resulting in abdominal surgery can be categorized into necrotizing enterocolitis (NEC), spontaneous intestinal perforation (SIP), meconium-related ileus (MRI), and meconium non-related ileus (MNRI). The purpose of this study was to review our experience with abdominal surgery for ELBW neonates, and to evaluate characteristics and prognosis according to the differential diagnosis. METHODS: Medical records of ELBW neonates treated between 2003 and 2015 were retrospectively reviewed. RESULTS: Of 805 ELBW neonates, 65 (8.1%) received abdominal surgery. The numbers of cases by disease category were 29 for NEC, 18 for SIP, 13 for MRI, and 5 for MNRI. Ostoma formation was performed in 61 (93.8%) patients; primary anastomosis without ostoma was performed in 4 (6.2%). All patients without ostoma formation experienced re-perforation of the anastomosis site. Seven patients had 30-day postoperative mortality (6 had NEC). Long-term survival of the surgical and non-surgical groups was not statistically different. NEC was a poor prognostic factor for survival outcome (P = 0.033). CONCLUSION: Abdominal surgery for ELBW neonates is feasible. Ostoma formation can lead to reduced complications compared to primary anastomosis.

Ausencia segmentaria del músculo intestinal con membrana ileal en un recién nacido de extremadamente bajo peso al nacer: A propósito de un caso / Segmental absence of intestinal muscle with ileal web in an extremely low birth weight infant: Case report

Las perforaciones intestinales espontáneas son perforaciones localizadas sin las características clínicas, radiológicas e histopatológicas típicas de la enterocolitis necrosante. La perforación intestinal espontánea es una entidad clínica de reciente definición. El factor de riesgo más conocido es la prematurez. Se presenta en el 2-3% de los recién nacidos de muy bajo peso al nacer y en el 5% de los neonatos de extremadamente bajo peso. En este artículo presentamos el caso de un recién nacido de extremadamente bajo peso al nacer con perforación intestinal espontánea, ausencia segmentaria del músculo intestinal y membrana ileal como causas subyacentes. Nuestro objetivo es llamar la atención a la ausencia segmentaria del músculo intestinal, una afección rara pero que se informa cada vez más como causa de perforación intestinal espontánea, y a la importancia del examen histopatológico de las muestras obtenidas durante una cirugía.

Spontaneous intestinal perforations are localized perforations without the typical clinical, radiological, and histopathological features of necrotizing enterocolitis. Spontaneous intestinal perforation is a recently defined clinical entity. The best-known risk factor is prematurity. It is seen 2-3% in very low birthweight infants and 5 % of extremely low birthweight infants. Herein we report an extremely low birthweight infant with spontaneous intestinal perforation, segmental absence of intestinal muscle and an ileal web as an underlying cause. We aimed to draw attention to the segmental absence of intestinal muscle which is rare but increasingly reported cause of spontaneous intestinal perforation and the importance of histopathologic examination of surgical specimens.

Can Neonatal Pneumoperitoneum be Managed by Conservative Management Alone.

Common causes of pneumoperitoneum in neonates includes necrotising enterocolitis (NEC), specific infections, gastro intestinal obstruction, iatrogenic causes, idiopathic focal intestinal perforation, perforation secondary to intra thoracic pathology, mechanical ventilation etc. Primary peritoneal drainage and exploratory laparotomy remain the definitive management of pneumoperitoneum in neonates. Here we report a case of suspected spontaneous idiopathic intestinal perforation managed conservatively with monitoring of vital signs. The neonate had an uneventful recovery. This case highlights the need to identify infants with benign or non surgical causes of pneumoperitoneum thus avoiding unnecessary laparotomies and referrals in these vulnerable neonates.

A Comparison of Necrotizing Enterocolitis and Spontaneous Intestinal Perforation in Preterm infant

PURPOSE: Besides necrotizing enterocolitis (NEC), the most common cause of intestinal perforation in preterm infants, there is another condition called spontaneous intestinal perforation (SIP) which, though it does not have the clinical or histological nature of NEC has been reported with increasing tendency. Aims of this study are to analyze gastrointestinal perforation in preterm infants and to speculate any difference in clinical manifestations, perinatal histories, and laboratory results between NEC and SIP. METHODS: A retrospective review of medical records of preterm infants with gastrointestinal perforations in the neonatal intensive care unit of Seoul National University Children's Hospital between January 2000 and August 2007 was performed. Preterm infants who underwent surgical intervention, and who had available histologic specimens, were enrolled. RESULTS: A total of 29 preterm infants were enrolled. They were classified into three groups: Group NEC (n=18), Group SIP (n=6), and Group Others (n=5). Group Others consisted of two patients with ileal atresia, one with meconeum ileus, one with omphalocele and one with anal atresia. Onset of perforation was delayed in Group NEC compared with that of Group SIP (18.1+/-13.0 versus 6.7+/-4.2; P<0.05) and enteral feeding before perforation was more frequent in Group NEC (94.4% versus 50%; P<0.05). CONCLUSION: During seven years and eight months, there were six cases of SIP and 18 cases of NEC in preterm infants. As well as NEC, SIP should be considered when gastrointestinal perforation is suspected, especially when patients with early onset time and no enteral feeding.