Peritonitis Following Duodenal Ulcer Perforation in a Newborn: A Case Report

Abstract

A three-day-old male neonate with 38 weeks gestational age, normal vaginal delivery, weighing about 3150 grams at birth, was admitted to the hospital because of abdominal distension which had begun from the second day of birth. The neonate had a history of jaundice on the first day of life, in which serum bilirubin concentration was 10mg/dl. He had been treated with phototherapy and had been discharged with serum bilirubin concentration 8.5mg/dl on the second day of life. Afterwards, the neonate's mother had requested further investigations from a paediatrician. Abdominal ultrasonography was planned by paediatrician. As the neonate was lethargic with fever (T= 38 0 C) and there was lack of good sucking, a paediatric surgery consultation had been requested. Neonate's mother had a history of ulcerative colitis which had been treated using prednisolone and asacol. She had used high doses of both drugs in early pregnancy and lower doses in late pregnancy. Laboratory tests were as follows: WBC=14200, HCT=46.4%, Hb=16.1, Bilirubin=9.2, Blood group=B+. ABG analysis was as follows: pH=7.42, pO 2 =76, pCO 2 =35 and O 2 Saturation=95%. There was no family history of peptic ulcer. He was started on intravenous fluids and antibiotics. No steroids were ever administered to the baby.On examination, vital signs were as follows: Blood pressure 60/40, heart rate 170 beats/min, respiratory rate 76 breaths/min and axillary temperature 37.5 0 C. The patient was pale in general appearance. Respiratory distress, tachypnea and severe abdominal distension existed. Bowel sounds were absent on auscultation. There was generalized abdominal tenderness. Neonatal reflexes were weak. Abdominal and chest X-ray were performed. Chest X-ray showed air below the diaphragm [Table/ Fig-1] perforation of an organ was suspected. After administration of fluids and antibiotics, neonate underwent laparotomy. Laparotomy was performed with classic transverse incisions above the umbilicus. Large amounts of bile and gas were in the abdominal cavity and pelvic inflammation was present in intestines with a little fibrin. On exploration, there was a perforated ulcer, 5×5mm in size, on the anterior aspect of the first part of the duodenum [Table/ Fig-2] which was quite sharp without necrosis. The perforated ulcer was closed with a single layer of absorbable suture (vicryl 1). The abdominal wall was repaired. No drains were used. The patient was transferred to the Neonatal Intensive Care Unit (NICU). The feeding was started after 5 days and the patient was discharged after 9 days with a good general condition. Six-month follow-up revealed no abnormality. After discharge, serum gastrin was checked which was normal: 4.5pmol/L (children<60) and Anti-Helicobacter pylori Ab, was also normal: IgA = 17.7 and IgM = 0.35. Duodenal ulcer is an uncommon condition in children, that is why it is not usually considered as the differential diagnosis unless it presents with complications including perforation and haemorrhage. Moreover, duodenal ulcer perforation is an uncommon e...

Experience of management of pediatric upper gastrointestinal perforations: a series of 30 cases

“…Surgical approaches include open or laparoscopic repair, which is based on the age of the patient (≤3 years), general condition, duration from symptom onset to diagnosis, hemodynamic status, comorbidities, perforation site and size, and experience and preference of the surgeon ( 21 , 23 , 36 ). In the LR group, the duration from symptom onset to operation in half of the patients was within 24 h, while in the OSR group, only 27.3% of the patients underwent operation within 24 h. Four patients with shock on admission underwent laparoscopic repair, and one patient had complications of postoperative gastric fistula and MODS.…”

“…Regarding the management of UGI perforation, surgical intervention is relevant for the pediatric population, especially for those with intra-abdominal infections, sepsis, and unstable hemodynamics (1,16,(22)(23)(24). In patients with unstable vital signs, emergent surgical intervention is performed after initial fluid resuscitation, oxygen therapy, and intravenous antibiotics.…”

Spontaneous duodenal perforation in a neonate

“…The prevalence of duodenal perforation in newborns is unknown, with the majority of perforations located on the anterior duodenum. [1,3,6,7,8] Although duodenal perforation etiology is unknown, there are two hypotheses. One is a congenital absence of intestinal smooth muscle with intact mucosa and submucosa and the other is ischemic necrosis of the intestinal wall secondary to hypoxia.…”