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April 2001

Radiological Case of the Month

Arch Pediatr Adolesc Med. 2001;155(4):522. doi:10.1001/archpedi.155.4.521

Denouement and Discussion: Spontaneous Neonatal Gastric Perforation

Figure 1. Abdominal radiograph, abdominoperineal view, shows pneumoperitoneum with "football sign."

Figure 2. Abdominal radiograph horizontal beam decubitus shows massive pneumoperitoneum.

An emergency laparotomy was performed. A massive release of air occurred with peritoneal incision, and formula was present in the peritoneal cavity. A 1-cm linear perforation on the greater curvature of the stomach in the cardiac region was observed. No necrosis was present around the site. All layers of the stomach wall were separated by air. The perforation was sutured in a double layer. Peritoneal fluid cultures grew coagulase-negative staphylococci and enterococci species. The postoperative course was uncomplicated. The patient started feeding on postoperative day 7 and was discharged home on day 10.

Gastric perforation is a rare abdominal catastrophe in the full-term newborn. It accounts for 10% to 16% of all gastrointestinal perforations. The usual age at presentation is 2 to 7 days1-5 in term infants. Incidence in African American infants is higher than in white infants1,2 and is higher in males than females.2,4 Usually the infants have been fed before they become symptomatic.1

Certain risk factors are associated with gastric perforation:

1. Prenatal. Premature rupture of membranes; toxemia; breech; diabetic mother; group B Streptococcus–positive mother; amnionitis; placenta previa; placental abruption; emergency cesarean delivery.1

2. Postnatal. Prematurity1,2,6; low birth weight1,2,6; small for gestational age infants2; low Apgar scores at birth; respiratory distress with resuscitation or ventilation.1

3. Exchange transfusion.

4. Surfactant deficiency; mechanical ventilation.6

5. Patent ductus arteriosus; indomethacin treatment.

Gastric perforation is associated with significant mortality and morbidity if it is not recognized early. There are several proposed causes for spontaneous gastric perforation: congenital deficiency of musculature in the gastric wall1; thinner stomach wall near the cardiac than the pylorus1; gaps in the circular musculature of the newborn stomach at the fundus near the greater curvature1; and acute gastric dilatation secondary to pylorospasm and atonic stomach in a stressed neonate. Some of these factors may have contributed to gastric perforation in this neonate despite the absence of notable risk factors.

Signs and symptoms include sudden onset abdominal distention,1,2,4-6 poor feeding,1-4 lethargy, and listlessness. Vomiting is an uncommon manifestation of gastric perforation. An idiopathic gastric perforation occurs on the anterior surface of the cardiac region along the greater curvature.1-4 No necrosis is visualized around the site when diagnosis is early.

Early diagnosis is essential to avoid catastrophic consequences. The abnormality is characterized radiologically by the presence of free air in the peritoneum-pueumoperitonem2-4,6; absent gastric gas bubble2; absence of bowel air-fluid levels and fixed dilated loops of intestine-positive "football sign"2; and an air-fluid level in the peritoneum. Differential diagnosis includes acute necrotizing enterocolitis, septicemia, intestinal obstruction, and spontaneous pneumoperitoneum without gastrointestinal perforation.

The surgical treatment is primary gastric wall closure in 2 layers.1-3,6 Occasionally, gastrostomy is needed for postoperative decompression. The prognosis is excellent with almost 100% survival if early diagnosis is made. Delay in diagnosis, prematurity, metabolic acidosis, and hyponatremia are associated with poor prognosis and increased mortality.1,4,5

Accepted for publication May 4, 1999.

Reprints: Pratibha Ankola, MD, Department of Pediatrics, Room 523, Metropolitan Hospital Center, 1901 1st Ave, New York, NY 10029.

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