Gastric Perf

8/2/2019 Gastric Perf

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GASTRIC PERFORATION IN THE NEWBORN

Ai-Xuan Le Holterman, M.D.

[email protected]


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Objectives

The types of gastric perforation of the newborn

Clinical presentation

Management


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BACKGROUND

Two major causes of gastric perforation:

a) Iatrogenic (accidental)b) Idiopathic (no identifiable causes)

First described in 1825 by Siebold- spontaneous gastric rupture

Idiopathic gastric perforation was defined by Castleton in 1958 asGastric perforation with no obvious causes: no history of gastric ulcer,

of nasogastric tube, ventilation or any mechanical trauma, no intestinal

obstruction

Neonatal gastric perforation is rare

30 cases were reported in the literature between 1943 and 1969

All are babies born at term, all idiopathic

About 300 cases have been reported in the literature to date


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Gastric perforation occurs in about 1/2900 live births and in about

7% of neonates with gastrointestinal perforation

St-Vil et al. J Ped Surg 1992

20 years experience

81 infants with gastrointestinal perforation

68% with necrotizing enterocolitis (NEC)

7% with idiopathic gastric perforation. All survived

Reported cases of gastric perforation after 1980: more patients

were premature and very low birth weight babies (


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Mortality were reported to be from 0%-83% but the difference in the

mortality rate depends on the patient population and treatment

Age of the neonate Mortality

Term babies: 40%

Premature babies 56%

Very low birth weight babies 78%


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Gastric perforations were described in patients with

1) Mechanical ventilation2) Tracheoesophageal fistula

3) Corticosteroid treatment

4) Stressed babies (respiratory distress, patent ductus arteriosus,

sepsis,)

Possible physiological causes for gastric perforation

1) Asphyxia--- poor oxygenation to selected organs---localized

mucosal ischemia in the stomach wall

2) Prematurity---gastric dysmotility and uncoordinated vomiting

Possbile anatomical causes

1) ?lack of intestitial cells of Cajal?

2) ?congenital absence of musculature?

SPECULATIVE CAUSES


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ANATOMY

Extensive blood supply: Left and

Right gastric vessels, Left and Right

gastroepiploic vessels

Short gastric---end vessels

Most distensible part of the stomach: the

greater curvature

Acute gastric distention ---angulation at

the gastroduodenal junction --- Acute

obstruction---?perforation


8/23Houck et al., Ann Surg 1981

Most distensible part of the

stomach: the greater curvature

Acute gastric distention ---

angulation at the gastroduodenal

junction --- Acute obstruction


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1) linear perforation along the greater curvature (most common)

2) discrete punched out perforation in the anterior or posterior wall3) linear perforation along the lesser curvature

4) Gastric necrosis

The many presentations of spontaneous gastric rupture


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ACUTE GASTRIC

DISTENSION

Ventilation

Tracheoesophageal fistula

Prematurity with abnormal

gastric motility

LOCALIZED INJURY

a) Localized perforation or

b) linear tear along greater curvature (1-10 cm)

Lowersurgical

complications

if early

treatment?

MECHANICAL CAUSES

PNEUMATIC

RUPTURE


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Vascular thrombosis

Selective ischemia, necrosis

EXTENSIVE INJURY

Greater curvature necrosis

Stress, perinatal asphyxia

Low blood flow state

High operativecomplications

Poor outcome

because of

underlying medical

problems

VASCULAR CAUSES

Gastric dilatation


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1) Isolated perforation

a) Iatrogenic

Nasogastric tube trauma, hyperventilation,

b) Unidentified mechanical causes

Acute distention with acute obstruction and perforation

2) Necrotizing gastritis

? A vascular or asphyxiating event

Clinical types of gastric perforation

It is however less important to know the causes of gastric

perforation as it is very important to promptly recognize and treat

gastric perforation before extensive peritonitis and sepsis occur.


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Localized perforation Linear tear


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CLINICAL DIAGNOSIS

Sudden onset respiratory distress

Sudden onset abdominal distention

Lethargy

Rapid clinical deterioration: difficulty with ventilation, shock, sepsis

Coffee ground emesis

Gastric hemorrhage


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Pneumoperitoneum on cross-table lateral KUB

Massive pneumoperitoneum

No stomach bubble

Pneumoperitoneum transilluminates


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Necrotizing enterocolitis (NEC)

Pneumatosis intestinalis

DIFFERENTIAL DIAGNOSES


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Spontaneous intestinal perforation

Pneumoperitoneum (subtle)

No pneumatosis intestinalis

Gastric bubble

Very low birth weight babies

(


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Decompress free air with needle for acute respiratory distress

Aggressive fluid resuscitation

Broad spectrum antibiotics

Immediate surgery

Peritoneal lavage

Debridement of perforation site to healthy tissueTwo-Layer closure of perforation

Onlay omental or jejunal patch at the closure site as needed

Gastrostomy tube to decompress stomach during healing as needed

Peritoneal drain as needed

Do not miss posterior perforation

Massive injury:

Partial or total gastrectomy

TREATMENT


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POST OPERATIVE CARE

Pulmonary support

Volume resuscitation for peritonitis, third spacing and septic shock

Infection: Treat sepsis with broad spectrum antibiotics

Nutrition support until patient can resume orogastric feeding

Central parenteral nutrition

Enteral support by post pyloric feeding (with duodenal or

jejunal tube)


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Hunt-Lawrence pouch

at 8 weeks

Durham et al., JPS 1999

Extensive gastric necrosis-RARE


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SUMMARY

1) Idiopathic neonatal gastric perforation may actually have

underlying causes: accidental or multifactorial as many of theinfants have underlying illnesses

2) Occurs in term and premature infants

3) The majority of the perforation occurs as linear tear along the

greater curvature

4) Patients present with acute abdominal distention and clinical

deterioration

5) Gestational age and underlying medical problems, but most

importantly, prompt diagnosis and treatment affects survival

6) Treatment is not only surgical but also medical with volumeresuscitation, sepsis control and nutrition support

7) Needs better outcome data to understand the true nature of this

condition, treatment approaches and results, especially for cases of

gastric necrosis


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THANK YOU.

Questions or comments?


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Binge eating or refeeding in severely malnourished anorexia

Abnormal gastric peristalsis---Delayed gastric emptying or gastric atony

Acute gastric dilatation

Gastric necrosis and perforation

Documents

Gastric Perf