Spontaneous intestinal perforation vs nec

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  • J Am Coll Surg. 2002 Dec;195(6):796-803. Spontaneous localized intestinal perforation in very-low-birth-weight infants: a distinct clinical entity different from necrotizing enterocolitis. Pumberger W , Mayr M , Kohlhauser C , Weninger M . Division of Pediatric Surgery, Department of Surgery, University of Vienna, Vienna, Austria. Abstract BACKGROUND: Idiopathic spontaneous intestinal perforation (SIP), a distinct clinical entity different from necrotizing enterocolitis (NEC), has an increasing prevalence in very-low-birth-weight infants. The aims of our study were to define patient characteristics and potential risk factors for premature infants with SIP compared with infants subjected to surgical treatment for NEC. STUDY DESIGN: The medical records of 29 premature infants with either SIP (n = 13) or NEC (n = 16) were reviewed retrospectively. RESULTS: Infants who experienced SIP were smaller at birth, had lower Apgar scores, and required more intensive neonatal resuscitation. An increased rate of premature rupture of membranes in infants with SIP (8/13 versus 6/16) was not associated with a higher rate of infection in mothers or infants. The onset of illness in SIP was significantly earlier than in NEC (p = 0.022). In contrast to patients with NEC (7/16), 11 of 13 patients in the SIP group had received indomethacin (p = 0.02). Bluish discoloration of the abdomen (8/13), a gasless abdomen (8/13), and the absence of pneumatosis intestinalis (0/13) were further significant markers in infants with SIP. At operation, SIP was always located in the terminal ileum in an antimesenteric position (13/13), and the remaining bowel appeared grossly normal. In most cases of SIP (10/13), the histologic investigation revealed an area of hemorrhagic necrosis without the typical coagulation necrosis seen predominantly in NEC. CONCLUSIONS: Based on clinical presentation and radiologic and intraoperative findings, SIP is a distinct pathologic entity in very-low-birth-weight infants and can be differentiated from classic NEC. Detected early, SIP can be treated by simple procedures (sutures, or resection and primary anastomosis) with a low rate of morbidity and mortality.
  • Focal small bowel perforation: an adverse effect of early postnatal dexamethasone therapy in extremely low birth weight infants. Gordon PV; Young ML; Marshall DD J Perinatol. 2001 Apr-May;21(3): OBJECTIVE: We tested the hypothesis that early postnatal dexamethasone (EPD) increases the risk of focal small bowel perforation (FSBP) in extremely low birth weight (ELBW) infants. STUDY DESIGN: The techniques of meta-analysis were applied to studies evaluating EPD, which we identified through a systematic literature search. Studies were included if they were randomized, placebo-controlled trials of EPD, enrolled infants with birth weights<or =1000 g, and reported FSBP as an outcome variable. The Breslow-Day test was used to assess for homogeneity and a summary odds ratio was calculated using the Mantel-Haenszel exact method. RESULTS: Four studies, with a pooled sample of 1383 infants, were included in the primary analysis. The Breslow-Day test showed a p-value of 0.61, indicating homogeneity among the studies. FSBP was significantly higher in EPD treated infants [odds ratio 1.91, 95% confidence interval (CI) 1.21, 3.07; p=0.004]. CONCLUSION: EPD increases the risk of FSBP in ELBW infants. New insights into spontaneous intestinal perforation using a national data set Attridge JT; Clark R; Gordon PV J Perinatol. 2006 Nov;26(11):667-70. Epub 2006 Oct 5. OBJECTIVE: To examine whether antenatal steroids (ANS), alone or with early indomethacin, are associated with spontaneous intestinal perforation (SIP). SIP is a known complication of concurrent post-natal administration of glucocorticoid and indomethacin in extremely low birth weight (ELBW) infants. STUDY DESIGN: A large de-identified national data set was retrospectively examined for infants with SIP without any report of other malformation or necrotizing entrocolitis. A control group was then derived matching for gender and birth weight (+/- 20 g). Pre- and post-natal variables were tested by both univariate and multivariate analysis to identify associations with SIP. RESULTS: From January 1996 to June 2004, there were 2 27 711 discharges from Pediatrix neonatal intensive care unit sites. From this population 388 infants with SIP associated with ELBW were compared to matched controls. Infants with SIP were more likely to have received early indomethacin and to have received a combination of early indomethacin with post-natal glucocorticoids (P<0.05 for both). When used alone (without subsequent indomethacin), ANS showed no association with SIP. When used in conjunction with indomethacin, ANS did not increase the rate of SIP beyond indomethacin alone. CONCLUSION: ELBW Infants that acquire SIP were more likely to have been exposed to early indomethacin and post-natal glucocorticoids. However, no association was found between SIP and ANS within a well-powered cohort. Spontaneous intestinal perforation (SIP) has emerged as a disease of extremely low-birth-weight (ELBW) infants over the last two decades. Several risk factors have been associated with this disease including early postnatal steroids (EPS; use within the first week of life), early use of indomethacin (EUI; use within the first 3 postnatal days), and the synergistic combination of the two. These two risk factors are thought to play a causal role in the etiology of SIP through their effects on ileal trophism and motility. Two infectious agents ( Candida and Staphylococcus epidermidis) are commonly grown from peritoneal cultures of patients with SIP. It is less clear whether these infections play a causal role or if they represent comorbidities of perforation. Chorioamnionitis is thought to be a risk factor for SIP, as is the stress and elevated cortisol that accompanies it. Recent analyses suggest that antenatal indomethacin may also be a risk factor for SIP, particularly when given close to birth. These latter variables are more challenging to rank in importance compared with EPS and EUI, which have been repeatedly associated with SIP in both retrospective cohorts and randomized controlled trials. Because neonatal care of the ELBW infant is commonly standardized, the habitual combination of any of these risk factors potentially amplifies the risk of SIP. Many of these factors are medicines, thus SIP risk is exacerbated by select forms of polypharmacy. Our challenge lies in understanding how these drug interactions lead to harm.
  • Infants who experienced SIP were smaller at birth, had lower Apgar scores, and required more intensive neonatal resuscitation. An increased rate of premature rupture of membranes in infants with SIP (8/13 versus 6/16) was not associated with a higher rate of infection in mothers or infants. The onset of illness in SIP was significantly earlier than in NEC (p = 0.022). In contrast to patients with NEC (7/16), 11 of 13 patients in the SIP group had received indomethacin (p = 0.02). Bluish discoloration of the abdomen (8/13), a gasless abdomen (8/13), and the absence of pneumatosis intestinalis (0/13) were further significant markers in infants with SIP. At operation, SIP was always located in the terminal ileum in an antimesenteric position (13/13), and the remaining bowel appeared grossly normal. In most cases of SIP (10/13), the histologic investigation revealed an area of hemorrhagic necrosis without the typical coagulation necrosis seen predominantly in NEC. CONCLUSIONS: Based on clinical presentation and radiologic and intraoperative findings, SIP is a distinct pathologic entity in very-low-birth-weight infants and can be differentiated from classic NEC. Detected early, SIP can be treated by simple procedures (sutures, or resection and primary anastomosis) with a low rate of morbidity and mortality.
  • Two infectious agents ( Candida and Staphylococcus epidermidis) are commonly grown from peritoneal cultures of patients with SIP. It is less clear whether these infections play a causal role or if they represent comorbidities of perforation.
  • The role of laparotomy for intestinal perforation in very low birth weight infants. AU Baird R; Puligandla PS; St Vil D; Dube S; Laberge JM SO J Pediatr Surg. 2006 Sep;41(9):1522-5.   BACKGROUND/PURPOSE: The management of intestinal perforation in very low birth weight (VLBW) infants (less than 1500 g) is controversial. Current practice favors peritoneal drainage (PD) with or without a delayed laparotomy over primary laparotomy (PL). We compared the outcomes of PD +/- delayed laparotomy vs PL in VLBW infants using the Score for Neonatal Acute Physiology with Perinatal Extension (SNAPPE-II) as a validated predictor of mortality. METHODS: A retrospective analysis (1998-2003) of VLBW infants with intestinal perforation at 2 pediatric centers was undertaken. Data retrieval included neonatal demographics and parameters for SNAPPE-II calculation. The primary end point was 30-day mortality. Other outcome measures included in-hospital mortality, days fasting, days to extubation, and length of stay. Statistical analysis was performed with either Student's t test or chi2 analysis. Subgroup and multivariate analyses were also performed. P values<.05 were considered significant. RESULTS: Fifty-two neonates (25 PD, 27 PL) were reviewed. Overall, 10 (19.2%) infants died. Observed 30-day mortality rates in PD and PL groups were 32% and 7.4% (P = .028), respectively. Average SNAPPE-II scores for PD (42.5 +/- 20.8) and PL (25.1 +/- 14.6) groups yielded predicted mortality rates of 15.7% and 4.9% (P = .001), respectively. PD group 30-day mortality far exceeded the rate predicted by the SNAPPE-II score. Days fasting (13.7 vs 20.4; P = .0001), days to extubation (26.7 vs 51.5; P = .014), and length of stay (56.1 vs 83.6; P = .031) all favored the PL group despite incorporating SNAPPE-II score as a covariate into the multivariate analysis. Of the 25 patients receiving drainage, 9 underwent PD alone (SNAPPE-II = 46.6 +/- 27.9), whereas 16 patients underwent delayed laparotomy (SNAPPE-II = 37.8 +/- 17.6). The PD-only group had a greatly elevated mortality rate (77.8% vs 15.7% predicted), whereas the delayed laparotomy group had a reduced mortality rate (6.3% vs 9.3% predicted). CONCLUSION: Our data suggest that laparotomy, either alone or after PD, provides an improved outcome in VLBW infants with intestinal perforation. PD should be used as a temporizing measure until laparotomy can be performed. No RCT comparing two interventions in infants with SIP
  • Intestinal perforation in very low birth weight infants: growth and neurodevelopment at 1 year of age. Adesanya OA; O'Shea TM; Turner CS; Amoroso RM; Morgan TM; Aschner JL J Perinatol. 2005 Sep;25(9):583-9. OBJECTIVE: To compare growth and neurodevelopment in surviving very low birth weight (VLBW) infants with an intestinal perforation (IP) caused by necrotizing enterocolitis (NEC) versus spontaneous intestinal perforation (SIP). STUDY DESIGN: Retrospective, observational cohort study. Infants born between January 1996 and December 1999 with birth weight<1500 g and a diagnosis of intestinal perforation were identified and data extracted from NICU, surgical and hospital databases. RESULTS: IP was identified in 62 of 1357 VLBW infants (5%); 39 infants (63%) had surgical NEC and 23 (37%) had SIP. Among survivors, 21/28 with surgical NEC (75%) and 13/18 with SIP (72%) returned for follow-up. At 1-year adjusted age, there were no differences in growth parameters but the Mental Developmental Index (MDI) and Psychomotor Developmental Index (PDI) were lower in survivors with NEC versus SIP (mean difference in MDI=15; 95% confidence limits=3, 28; p=0.02; mean difference in PDI=14; 95% confidence limits=0.4, 28; p=0.04 ). CONCLUSIONS: Intestinal perforation caused by NEC, as compared to SIP, is associated with worse neurodevelopmental outcome at 1 year. Discharge outcomes of extremely low birth weight infants with spontaneous intestinal perforations. Attridge JT; Herman AC; Gurka MJ; Griffin MP; McGahren ED; Gordon PV J Perinatol. 2006 Jan 1;26(1):49-54.   OBJECTIVE: To examine discharge outcomes of extremely low birth weight infants (ELBW) with spontaneous intestinal perforation (SIP). STUDY DESIGN: A single-center retrospective cohort study of all ELBW infants admitted to the University of Virginia neonatal intensive care unit between July 1996 and June 2004. RESULTS: We found 35 patients with SIP (incidence 8.4%). The median gestational age was 25 weeks, median birth weight was 722 g, and 71% of the infants were male. Most infants (n=28) with SIP were diagnosed secondary to pneumoperitoneum; however, one-third (7) of infants<25 weeks had occult presentations without pneumoperitoneum. When controlled for gestational age, gender, multiple gestation, indomethacin, and glucocorticoid exposure, infants with SIP have a higher risk of PVL and death than infants without perforation . SUMMARY: Periventricular leukomalacia and death are significantly associated with SIP in ELBW after adjusting for gestational age, multiple gestation, indomethacin, and glucocorticoid exposure.
  • Journal of Surgical Research Volume 161, Issue 1 , 1 June 2010, Pages 95-100 Peritoneal Drainage versus Laparotomy for Necrotizing Enterocolitis and Intestinal Perforation: A Meta-Analysis Background To determine whether peritoneal drain (PD) or laparotomy (LAP) is the most effective intervention in premature neonates with necrotizing enterocolitis (NEC) or intestinal perforation (IP). Methods A systematic review of the published literature between January 2000 and December 2008 was undertaken. Prospective studies with at least 25 patients in each of the PD and LAP arms were selected. Gestational age, birth weight, operation, and mortality data were extracted. Results Five prospective studies (two level I, three level II) with 523 (273 PD, 250 LAP) participants followed for mortality met selection criteria. Using a fixed effect model, the combined estimate indicates an increased mortality of 55% with PD (OR 1.55, 95% CI: 1.08–2.22, P  = 0.02) without statistical heterogeneity (χ2 = 5.88, P  = 0.21). PD patients were 0.78 wk younger ( P = 0.0002) and 67g smaller ( P = 0.0006). Analysis of the three level II trials yielded a combined estimate indicating an excess mortality of 89% with PD patients (95% CI: 1.20–2.98, P = 0.006) without statistical heterogeneity (χ2 = 3.74, P  = 0.15). Conclusions PD is associated with 55% excess mortality compared with LAP. Pediatric surgeons must individually assess and select patients with NEC and IP for optimal surgical therapy.
  • Spontaneous intestinal perforation vs nec

    1. 1. Spontaneous intestinal perforation vs NEC: What is the difference??Dr Varsha Atul Shah
    2. 2. Spontaneous intestinal perforation Isolated perforation of newborn Typically at terminal ileum Separate clinical entity from NEC* Differentiation is important as there are management considerations*J Am Coll Surg. 2002 Dec;195(6):796-803.Spontaneous localized intestinal perforation in very-low-birth weight infants: a distinct clinical entity different from necrotizing enterocolitis
    3. 3. epidemiology Commonly found in VLBW, ELBW Risk~2-3 % in VLBW, 5% in ELBW Median gestational age 25-27 weeks Median BW 670-973g More frequent in male infants
    4. 4. Risk factors Prematurity Antenatal3. Severe placental chorioamnionitis*4. ? Glucocorticoids/NSAIDS Postnatal6. Early postnatal glucocorticoids@7. ? Indocid* Maternal factors in extremely low birth weight infants who develop spontaneous intestinal perforation. Ragouilliaux CJ; Keeney SE; Hawkins HK; Rowen JL Pediatrics 2007.@Focal small bowel perforation: an adverse effect of early postnatal dexamethasone therapy in extremely low birthweight infants. Gordon PV; Young ML; Marshall DD J Perinatol. 2001 Apr-May;21(3)New insights into spontaneous intestinal perforation using a national data setAttridge JT; Clark R; Gordon PV J Perinatol. 2006 Nov;26(11):667-70. Epub 2006 Oct 5.
    5. 5. Pathology and pathogenesis Single isolated perforation Typically in terminal iluem, but also reported in jejunum, colon Focal hemorrhagic necrosis with well defined margins seen(in contrast to ischemic, coagulative necrosis in NEC) Bowel proximal and distal to perforation normal
    6. 6. Clinical presentationSIP NECFirst week of life, median age After first week,7(0-15) Median age 15Abdominal distension, bluish Abdominal distensiondiscoloration(groin, scrotum) Abdominal erythemaHypotension Crepitus, indurationPneumoperitoneum, gasless Pneumatosis intestinalis, portalabdomen venous gas, transient thickening of intestinal wall, fixed dilated SB loops, pneumoperitoneumAssociated sepsis due to CONS,fungemiaLeukocytosis, raised ALP,bilirubin, decreased platelet, hct
    7. 7. Clinical diagnosis based upon: Clinical presentation Physical examination Abdominal radiographs support diagnosisDefinitive diagnosis :Direct visualization of intestinal perforation in setting of otherwise healthy appearing small bowel
    8. 8. Management NBM, drip and suck Fluid resuscitation Intravenous antibiotics Surgical treatment5. Definitive treatment6. Exploratory laparotomy with bowel resection7. Primary peritoneal drainage
    9. 9. Primary peritoneal drainage Avoids laparotomy, need for GA and transport Many do recover without any further surgical intervention Laparotomy indicated if:4. Reaccumulation of free air after drain removed, indicating perforated bowel did not seal5. Fistula with intestinal drainage that fails to close6. Bowel obstruction secondary to adhesions or stricture at site of perforation
    10. 10. Long term outcome Survival rates of 64-90% Neurodevelopmental outcome better than those with NEC* Increased risk to develop ROP and PVL compared to controls*Intestinal perforation in very low birth weight infants: growth and neurodevelopment at 1 year of age. Adesanya OA; OShea TM; Turner CS; Amoroso RM; Morgan TM; Aschner JL J Perinatol. 2005 Sep;25(9):583-9.
    11. 11. NEC Ischaemic necrosis of intestinal mucosa, associated with inflammation, invasion of enteric gas forming organisms and dissection of gas into muscularis and portal venous system.
    12. 12. NEC 1-3 per 1000 live births Predominently in prems, up to 6-7% in VLBW Incidence decreases with increasing GA, BW Males and females equally affected Sometimes occurs in clusters, associated with epidermics Reported mortality of 15-30% 13% occur in term infants
    13. 13. Pathogenesis Terminal ileum and colon Entire GIT in severe cases Pathogenesis remains unknown Heterogeneous disease results from multiple factors that result in mucosal injury in susceptible host6. Prematurity7. Microbial bowel overgrowth8. Milk feeding9. Impaired mucosal defense10. Circulatory instability of intestinal tract11. Medications12. CHD, perinatal asphyxia, polycythemia, sepsis, respiratory disease13. Inflammation
    14. 14. Clinical presentation Timing of onset of symptoms varies, inversely related to GA Systemic signs3. Nonspecific (apnea, resp failure, lethargy, poor feeding, temp instability)4. Hypotension Abdominal signs- distension, gastric retention, tenderness, vomiting, diarrhoea, rectal bleeding, bilious aspirates
    15. 15. Bells staging Classifies severity of NEC based on severity of systemic, intestinal, radiographic findings Treatment directed at clinical signs rather than particular stage of NEC
    16. 16. Bells staging
    17. 17. Diagnosis Clinical Radiologic findings
    18. 18. Clinical Abdominal distension Rectal bleeding
    19. 19. Radiological AXR/lateral decubitus (left side down) Confirm diagnosis/follow progression of disease Abnormal gas patterns, dilated loops of bowel(ileus) Pneumatosis intestinalis(hallmark of NEC) Pneumoperitoneum (football sign) Sentinel loops(necrotic/perforation) Portal venous gas
    20. 20. Abdominal Ultrasound Bowel wall with central echogenic focus, hypoechoic rim(pseudo-kidney)-necrotic bowel and imminent perforation Intermittent gas bubbles in liver parenchyma, portal venous system Free gas, focal fluid collection
    21. 21. Supportive investigations FBC(neutropenia, thrombocytopenia) Coagulation studies(evidence of DIC) Electrolytes (hyponatraemia, hyperglycaemia, metabolic acidosis) CRP Septic workup Stool c/s, CD toxin Stool occult blood
    22. 22. Differential diagnosis Pneumatosis coli Infectious enterocolitis Intestinal obstruction secondary to hirschsprung, ileal atresia, volvulus, meconium ileus, intussusception SIP Anal fissures Neonatal appendicitis Cow’s milk protein allergy
    23. 23. Management Depends on severity of illness Medical management Surgical management
    24. 24. Medical management Supportive care-NBM, drip and suck, TPN, fluid replacement, correction of hematological and metabolic abnormalities, cardiorespiratory support Antibiotic therapy Close monitering and radiologic monitering(6-8 hrly)
    25. 25. Surgical intervention Perforation/severe peritonitis unremitting clinical deterioration despite medical management suggesting extensive necrosis presence of abdo mass, ascites or intestinal obstruction Primary peritoneal drainage Laparotomy with bowel excision
    26. 26. Complications Acute: cardioresp, metabolic complications, DIC Late: GIT complications (short bowel syndrome, intestinal strictures, increased frequency of bowel movements) Rare: enterocele, enterocolic fistula, intra-abd abscess Mortality Impaired Growth and neurodevelopmental outcome
    27. 27. Clinical presentationSIP NECFirst week of life, median age 7(0-15) After first week, Median age 15Abdominal distension, bluish Abdominal distensiondiscoloration (groin, scrotum) Abdominal erythemaHypotension Crepitus, indurationPneumoperitoneum, gasless abdomen Pneumatosis intestinalis, portal venous gas, transient thickening of intestinal wall, fixed dilated SB loops, pneumoperitoneumAssociated sepsis due to CONS, Concomitant bacteremiafungemiaLeukocytosis, raised ALP, bilirubin, Thrombocytopenia,neutropenia, hypoNa,decreased platelet, hct hyperglycaemia, metabolic acidosis

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