822 THE INDIAN JOURNA L OF PEDIATRICS 1993; Vol. 60. No. 6

lake due to the change of the original site' of springs may lead to increase in sandflies in the area.

REFERENCES

1. Khod AS, Thompson MH. Visceral leish- maniasis contracted in the Mediterranean area. Arch Dis Child 1983; 58 : 930-931.

2. Manson Bahr PEC, A,pted FLC. Manson's Tropical Diseases. 18th edition. London : Balliare Tindall. 1982 : 93-104.

3. Cachia EA, Fenech FF. A review of kala- azar in Malta from 1947 to 1962. Trans R Soc Trop Med Hyg 1964; 58 : 234-241.

4. Ozsoylu S, Hicsonmez G. Mediterranean leishmaniasis. Lancet 1980; i : 736.

5. Badoro R, Jones TC, Lorenco R et al. A

prospective study of visceral leishmania- sis in an endemic area of Brasil. J Infect Dis 1986; 154 : 639-649.

6. Sidding M, Ghalib H, Shillington DC et al. Visceral leishmaniasis in Sudan : Clinical features. Trop Geogr Med 1990; 42 : 107- 112.

7. Berentsen S, Langholm R, Reitan O. Vis- ceral leishrnaniasis (kala-azar). Tidsskr Nor Leasgeforen 1990; 110 : 3491-3493.

8. Hicsonmez G, Ozsoylu S. Kala-azar in childhood. A survey of clinical and labo- ratory findings and prognosis in 44 child- hood cases. Clin Pediatr 1972; 11 : 465-467.

9. Hicsonmez G, Ozsoylu S. Studies of the anemia of kala-azar in 68 childhood cases. Specific antiparasitic chemotherapy is the most effective treatment. Clin Pediatr 1977; 16 : 733-736.

, |

Spontaneous Gastric Perforation in Neonates

Anita Sharma, K.N. Rattan, Sanjiv Nanda and K.S. Ahlawat

Departments of Pediatric Medicine and *Pediatric Surgery, Medical College, Rohtak

S p o n t a n e o u s gastric perforat ion is an im- por tan t cause of gastrointestinal perfora- tion in neonates. I~ Inspite of recent surgi- cal advances in its management , i~ is asso- ciated with 50% mortality. 2,3 Because of physiological differences, immature im- mune mechanisms, variations in gastroin- testinal flora and poor localization of per- foration, a neonate with perforat ion is at higher risk. 2 Our experience of four neo- nates with spontaneous gastric perforation is reported.

CASE REPORT

All the four cases p resen ted with increas ing abdomina l dis tension, tach- ypne a and radiological pneumo-

per i t ioneum described as "air d o m e" or " 'foot-ball sign ''5'6 (Figure 1). Clinical details of the four neonates are given in Table 1. In three cases the perforat ion was closed in two layers. In case No. 4 partial gas t rectomy was done due to extensive ischemia s u r r o u n d i n g the perforation. Being home deliveries no obstetric details were available. There was no history of birth asphyxia, d rug intake or insertion of nasogastric tube.

DISCUSSION

Spontaneous gastric perforat ion was first repor ted by Siebolid in 1825. Its exact etiol- ogy is still unknown. Some of the reported

1993; Vol. 60. No. 6

. . ; ' ,:F,r, , i 1

I I

�9 ;;'~ .~;,i" :'.'

Fi 8. 1. Erect radiograph of abdomen showing pneumoperitoneum without intra- abdominal air-fluid level.

THE INDIAN JOURNAL OF PEDIATRICS 823

etiological factors are maternal obstetric complications, perinatal stress, birth as- phyx i ay ,8 trauma with nasogastric tubesfl vigorous resuscitative measures, 3 congeni- tal muscular defects) ~ increased hydro- static pressure due to distal obstruction, 11 acute ulcers exacerbated by physiological hyperac t iv i ty du r ing first week of life, 12 and oral indomethacin administra- tion. 13

In concordance with previous studies, the present s tudy also found a higher inci- dence in m a l e y 4 premature and low birth weight babies, z14 All the cases presented within 7 days of bir th) e'14 and had perfora- tion on the anterior wail at or near the greater curvature of the fundus. 3,14 All cases had respiratory distress, which has been reported to be an important clue in the diagnosis of intrabdominal eventsJ e

Impor tan t different ial diagnosis of spontaneous gastric perforation include, necrot iz ing enterocolit is , septicemia, intestinal obstruct ion, non-surgical

TABLE 1. Clinical Details

Case Sex Birth No. weight

(kg)

Gestation (weeks)

Age at diagnosis

(hrs)

Perfora tion

Site Size (cm) Outcome

1. Male 1.8

2. Male 1.6

3. Male 2.8

4. Male 2.2

36

30

37

37

72 Anterior wall near lesser curvature

84 Anterior wall near pylorus.

48 Anterior wall near greater curvature

144 Posterior wall near the greater curvature.

l x l

0.5•

1•

l x l

Died of septicemia on 11th post-operative day.

Discharged. Feeding started 4th post-operative day.

Discharged. Feeding started 4th post-operative day.

Died on 4th post-operative day of septicemic shock.

824 THE INDIAN JOURNAL OF PEDIATRICS !993; Vol. 60. No. 6

p n e u m o p e r i t o n e u m and abnorma l fat under the diaphragm. 3

REFERENCES

1. Bell MJ. Perforation of the gastrointestinal tract and peritonitis in the neonate. Surg Gynecol Obstet 1985; 160 : 20-26.

2. Tan CEL, Kiely EM, Agrawal M et al. Neonatal gastrointestinal perforation. J Pediatr Surg 1989; 24 : 888-892.

3. Rosser SB, Clark CH, Elechi EN. Sponta- neous neonatal gastric perforatior., f Pedf- atr Surg 1982; 17 : 390-394.

4. Prabhakar G, Agarwal LD, Shukia A et al. Spontaneous gastrointestinal perforation in the neonate. Indian Pediatr 1991; 28 : 1277-1280.

5. Miller RE. The radiologic evaluation of intraperitoneal gas (pneumoperitoneum). Radfologic Science I973; 4 : 61.

6 Miller JA. The "football" sign in neonatal perforate viscus. Am J Dis Child 1962; 104 : 311-312.

7. Corday E, Irving OW, Gold H et al. Mes- enteric vascular insufficiency. Am J Med 1962; 33 : 365-376.

8. Kieswetter WB. Spontaneous rupture of the stomach of the newborn. Am J Dis Child 1956; 91 : 161-167.

9. Sun SC, Samuels S, Lee J e t al. Duodenal perforation : A rare complication of neo- natal nasojejunal tube feeding. Pediatrics 1975; 55 ; 371-375.

10. Amadeo JH, Ashmore HW, Aponte GE. Neonatal gastric perforation caused by congenital defects of gastric musculature. Surgery 1960; 47 : 1010-1017.

11. Dubos JP, Hanesse M, Bricout M e t al. Les perforations gastriques neonatales. A propos de 25-observations. Ann Pediatr 1984; 31 : 641-646.

12. Watt J. The pathology of multiple gastric ulceration in the newborn infant. J Pathol Bacteriol I966; 91 : I05-116.

I3. Nagaraj HS, Sandhu AS, Cook LN et al. Gastrointestinal perforation following in- domethacin therapy in very low birth weight infants. J Pediatr Surg 1981; 16 : 1003-1007.

14. Hailer JA, Talber JL. Gastrointestinal per- foration in the neonate. In : Hertzler JY, Mirza M, eds. Surgical Emergencies in the Newborn. Philadelphia : Lea and Febiger, 1972; 107-109.