gastric perf
TRANSCRIPT
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GASTRIC PERFORATION IN THE NEWBORN
Ai-Xuan Le Holterman, M.D.
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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
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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