Focal intestinal perforation in extremely-low-birth-weight neonates: etiological consideration from histological findings

Abstract

In Japan, mortality due to intestinal perforation has been increasing for the last 15 years, as the survival rate of extremely-low-birth-weight neonates (ELBWs) has been increasing. In our NICU, although the incidence of necrotizing enterocolitis has been decreasing, that of focal intestinal perforation (FIP) has been increasing. To elucidate the pathogenesis of FIP, a histological study was performed. For the last 20 years, in our NICU, 11 ELBWs with FIP, including one with multiple perforations and impending rupture, underwent laparotomy and enterostomy. The intestinal wall around the perforation was resected for histological study. Histological studies revealed well-developed ganglion cells in all the cases. Although some lymphocytic infiltration and hemorrhage were observed, no apparent neutrophilic infiltration, or necrotic change was identified in any case. No evidence of microcirculatory impairment was identified. The intestinal musculature discontinued abruptly with thinning in three cases, and without thinning in the others. The histology of impending rupture showed an absence of the muscularis with preservation of the remaining components of the bowel wall. The findings that the punched-out perforations had the appearance of Hirschsprung's disease, FIP exclusively occurred in ELBWs, and that neither mechanical obstruction nor necrotic change could be identified as the cause of the perforation suggest that immature bowel movement and congenital muscle defects may be involved in the pathogenesis of FIP.

Morbidity after surgical treatment of isolated intestinal perforation and necrotizing enterocolitis is similar in preterm infants weighing less than 1500 g

“…Kubota et al [5] defined IIP as intestinal perforation without mechanical obstruction or massive necrotic change, a definition similar to ours. In the present study, differentiation between IIP and NEC was based on the extent of intestinal necrosis described in the operative report and 52% of patients had IIP and 48% NEC.…”

Laparoscopic localization and microlaparotomy for focal isolated perforation in necrotizing enterocolitis: an alternative approach to a challenging problem

“…We selected patients with sudden clinical deterioration, pneumoperitoneum, and little abdominal wall edema or erythema on the likelihood that these patients have focal intestinal perforation according to the criteria described by Kubota et al [1]. Patients with clinical signs of severe NEC including gross abdominal distension, abdominal wall edema, and redness were excluded from this study on the presumption that the disease was severe or widespread.…”

“…It is recognized that although many patients present with generalized severe widespread disease, a significant number of patients present with an isolated or focal intestinal perforation, as described by Kubota et al [1].…”

Evacuación del meconiointestinal para mejorar tolerancia alimentaria en prematuro de muy bajo peso (protocolo Emita)

“…esta situación es más prevalente en los niños de extremo bajo peso (peso al nacer < 1.000 g, RneBpn), en los pequeños para edad gestacional (peg) y en los hijos de madre hipertensa, especialmente si ha sido tratada con sulfato de magnesio [1][2][3][4] . como consecuencia de la demora en establecer la alimentación enteral, los prematuros requieren más tiempo de nutrición parenteral incrementando el riesgo de infecciones 5,6 , enterocolitis necrotizante (ecn 7,8 ), perforación intestinal 2 , y colestasia, comprometiendo además el aporte de nutrientes con consecuencias desfavorables en el crecimiento y neurodesarrollo de esta población 9 . ha sido postulado que la falta de eliminación y movilización del meconio en estos recién nacidos puede conducir a sobredistensión de asas intestinales como consecuencia de una obstrucción meconial no relacionada a fibrosis quística 2 .…”

“…(Palabras clave: enema, tolerancia, aporte enteral, meconio, muy bajo peso de nacimiento). Rev chil pediatr 2014; 85 (3): 304-311 jar un segmento con menor motilidad y mayor riesgo de sobreproliferación bacteriana 7,8 . Las conductas clínicas frente a esta situación son muy variables e incluyen desde una conducta expectante, hasta la necesidad de movilizar el meconio en situaciones de distensión marcada, ya sea mediante el uso de enema con gastrograffin o laparotomía exploratoria en los casos más severos 1,2,10 .…”