Intestinal perforation, defined as a loss of continuity of the bowel wall, is a potentially devastating complication that may result from a variety of disease processes. Common causes of perforation include trauma, instrumentation, inflammation, infection, malignancy, ischemia, and obstruction. YOUTUBE CHANNEL LINK:- https://www.youtube.com/results?search_query=medic+o+mania

1. Case
presentation
on Intestinal
Perforation
By:-Neha Malik

2. DEMOGRAPHIC PROFILE
B/o Sahana, male child
4days of life
Born on 21st feb 2020 and got admitted in the hospital
on 24th feb 2020
Diagnosed as having intestinal perforation
Both the parents were illiterate
Family lives in Bhagiriti Vihar

3. HISTORY OF THE CHILD
CHIEF COMPLAINT
 Abdominal distention since last 2 days
 Not passing urine and stool since morning
 No h/o of any fever or vomiting /loose stools
PRESENT MEDICAL HISTORY:-
Baby got delivered in the government hospital and cried immediately after birth but after 2-3
hours later the child developed some breathing difficulty. Child was kept under observation
with oxygen therapy for next 6 to 7 hours. After that the child was given to the mother for
breastfeeding .next day on 22nd feb baby’s abdomen started to get distended. For this problem
the parents took the child to their nearby private hospital, but due to some financial problem
the child got referred to kalawati hospital

4. Cont…
Child has no past medical or surgical history
Child had exp.laparotomy after getting
admitted in the kalawati

5. BIRTH HISTORY
ANTENATAL HISTORY;-
– Mother had not had any major ailment during her antenatal
period
– She had visited hospital 4 to 5 times for her routine checkups
– Had received 2 doses of Tt and took iron calcium tablets
throughout her pregnancy
INTRA NATAL HISTOY:-
– Delivered child normally in a govt hospital at 37 weeks of
gestation .didn’t had any postnatal complication.

6. Cont.….
NEONATAL HISTORY:-
– Child cried immediately after birth and birth
weight of the child was 2.7 kg . child passed
meconium within 1st hour of life

7. FAMILY HISTORY
Child is having a nuclear family .
There is no significant history of any chronic
or congenital illness in the family
B/O Sahana is the 2nd child ,he had one
elder sister in the family

8. PERSONAL HISTORY
Child is on NPO
Sleeps 20-22 hours a day
Child has not passed urine and stool
since last 24 hours

9. PHYSICAL ASSESSMENT
1. Biological assessment: PATIENT VALUE NORMAL RANGE
Length 49cms 49-50cms
Weight 3kg 2.5-3 kgs
Head circumference 33cms 30-33cms
Chest circumference 36cms 35cms
Abdominal circumference 37cms -

10. VITALS SIGNS
vitals Child’s value Normal value
temperature 36.7 c 36.5-37.5 c
pulse 120b/min 120-160b/min
respiration 34breaths/min 30-60
breaths/min

11. HEAD TO FOOT
EXAMINATION:
Skin colour of the child was pallor ,no sings of jaundice and cyanosis is
present
Skin rashes was not present ,milia and Mongolian spot was also not
present on the child's back
Head of the child was normal no caput ,cephalohematoma, birth injury
was there. Fontanelle and sutures of the child was normal
 Eyes of the child was Symmetrical , no discharge, congenital cataract or
squint was present in the child’s eyes
 Ears of the child was normal ,there was no any low set/ injury/ discharge
was present in the child

12. Cont.….
Nose of the child was normal no nasal flaring was present
 Mouth: Cleft lip/ cleft palate/oral thrush/ Tongue tie was not present
in the child. lip colour was normal
 Chest: Chest movements was normal ,Chest retractions was not
present ,Lungs -air entry in right, left lungs was normal , Heart position
was normal
 Abdomen was firm ,Distension was present, Bowel sounds was absent
Visible peristalsis was absent

13. Cont…
Umbilicus: Cord bleeding was absent, Cord was present,
Condition of umbilicus was healthy
Genitals.-child had not passes urine and stool since last 24
hours, bowel movement was not present, meconium was
passed, Scrotal swelling was absent, Undescended testes
was absent ,Patency of rectum was patent
Extremities: Polydactyly /Syndactyly/Hip dislocation was
not present in the child
–

14. Cont….
 Back: dimpling/tuft of hair/kyphosis/sqoliosis/lordosis
was not present in the child

15. REFLEXES
Sucking: was present in the child
Swallowing: was present in the child
Rooting: was present in the child
Gag: was present in the child
Blinking: was present in the child
Babinski’s; was present in the child
Dolls eye: was present in the child

16. DIAGNOSTIC AND LABORATORY
EXAMINATION
 Hb---17.5g/dl (increased)
 Urea-152.9mg/dl ---normal range is 18-55mg/dl (increased)
 Creatinine -3.6mg/dl--- normal range is 0.72-1.18mg/dl (increased)
 SGOT-61u/l--- normal range is 1-34u/l (increased) SGOTand SGPT are reasonably sensitive indicators of
liver damage or injury from different types of diseases
 SGOT—64U/L---- normal range is 1-31U/L (increased)
 ALBUMIN---2.09g/dl ---- normal range is 3.5 – 5.2g/dl (decreased)-Low albumin levels can also be seen in
inflammation, shock, and malnutrition. They may be seen with conditions in which the body does not
properly absorb and digest protein, such as Crohn disease or celiac disease, or in which large volumes of
protein are lost from the intestines
 X-ray shows intestinal perforation

17. MEDICATION
Drug name Dose route frequency action
Inj, cefataxim 150MG I/V TDS ANTIBIOTIC
Inj.amikacin 45MG I/V OD ANTIBIOTIC
inj,.
metramidazole
30MG I/V TDS ANTIMICROBIAL
IVF-ISOP 90ML I/V 8HOURLY Source of electrolytes,
calories and water for
hydration, and as an
alkalinizing agent.

18. INTESTINAL
PERFORATION

19. INTRODUCTION
The term Intestinal Perforation suggests a perforation in the gastrointestinal
tract of a new born.
Neonatal bowel perforation may have varied ethology - spontaneous,
secondary to NEC (Necrotizing Enterocolitis), and mechanical obstruction etc.
DEFINITION
Gastrointestinal perforation is a hole that develops through the wall of the
esophagus, stomach, small intestine, large bowel, rectum, or gallbladder. This
condition is a medical emergency.
Alternative Names
 Intestinal perforation
 Perforation of the intestines

21. EPIDEMIOLOGY
Commonly found in VLBW, ELBW
Risk -2to 3%in VLBW and 5%in ELBW
(670 to 973gm)
Babies with gestational age 25 to 27 weeks
More frequent in male infants
Incidence - 1%-8% of all NICU ’ s
admissions
Mortality rate 10%-50%

22. ON THE BASIS DIFFERENT ETIOLOGY ITS MAINLY
DIVIDED INTO :-
The term Spontaneous Intestinal Perforation suggests a perforation in
the gastrointestinal tract of a new born with no demonstrable cause that is
typically found in the terminal ileum. Though seen frequently in pre-term
new-borns with very low birth weight (VLBW) and extremely low birth
weight (ELBW), only a few cases have been described in full-term new-
borns. Shows symptoms within the first week of life
Necrotizing Enterocolitis: - it is a serious illness in which tissues in the
intestine (gut) become inflamed and start to die. This can lead to a
perforation developing, which allows the contents of the intestine to leak
into the abdomen .shows symptoms after 7 days of life.

23. PATHOGENESIS AND PATHOPHYSIOLOGY
Pathogenesis of the disease is unknown and multiple theories
have been proposed, but none has been proven.
NAC mostly results from an interaction between loss of mucosal
integrity due to factors like ischemia, infection and inflammation
The host’s response to that injury like circulation immunologic,
inflammatory responses resulting in narcosis of the affected area

24. Cont.…..
ENTERAL FEEDING
IMMATURE GI TRACT
 Disruption of tight
junction
 Decreased peristalsis
GI
MICROBIOLOGICAL
ALTERATIONS
NAC
HYPOXIC ISCHAEMIC INJURY

26. RISK FACTORS: -
intrauterine drug exposure, in particular cocaine,
If mothers drug addicts
intestinal anomalies (atresia)
congenital heart disease
sepsis
 asphyxia
respiratory distress syndrome
presence of umbilical catheter
low gestational age

27. low birth weight
feeding with adapted formulas instead of breastfeeding
early and fast increase in meal volume
bacterial colonization
intestinal ischemia
dehydration
use of indomethacin and steroids
In premature-necrotizing enterocolitis mostly develops in the
second week of life, whereas in term new-borns it usually
occurs earlier, i.e., in the first week of life

28. CAUSES
There is no single consistent cause of necrotizing
enterocolitis. In most cases, a specific cause isn't found.
But experts believe these things might play a role:
 an underdeveloped (premature) intestine
 too little oxygen or blood flow to the intestine at birth
or later
 injury to the intestinal lining
 heavy growth of bacteria in the intestine that erodes the
intestinal wall

29.  viral or bacterial infection of the intestine
 formula feeding (breastfed babies have a lower risk of
NEC)
NEC sometimes seems to happen in "clusters," affecting
several infants in the same nursery. This might be
coincidental, but some viruses and bacteria occasionally
have been found in babies with NEC. NEC does not
spread from one baby to another, but a virus or bacteria
that cause it can. This is one reason all nurseries and
NICUs have very strict precautions to help prevent the
spread of infection.

30. SIGNS & SYMPTOMS
A baby with necrotizing enterocolitis might have these
symptoms:
 a swollen, red, or tender belly
 trouble feeding
 food staying in the stomach longer than expected
 constipation
 diarrhoea and/or dark or bloody stools (poop)
 being less active or lethargic

31. CONT…..
 a low or unstable body temperature
 green vomit (containing bile)
 apnea (pauses in breathing)
 bradycardia (slowed heart rate)
 hypotension (low blood pressure)

33. DIAGNOSIS
In babies with symptoms of NEC, a diagnosis can be
confirmed if an abnormal gas pattern shows up on an X-
ray. This looks like a bubbly or streaky appearance of
gas in the walls of the intestine.
In severe cases, air escapes from the intestine and shows
up in the large veins of the liver or the abdominal cavity.
A doctor may insert a needle into the belly to withdraw
fluid to see whether there is a hole in the intestine.

36. Transillumination is commonly used by doctors as an emergency bedside procedure,
where X-ray facilities are unavailable or take time to organize and will also avoid the
need for repeated radiographs in the diagnosis of perforation in the setting of
neonatal necrotizing enterocolitis.

37. TREATMENT
After diagnosis, treatment begins immediately. It includes:
 temporarily stopping all feedings
 nasogastric or orogastric drainage (inserting a tube
through the nose or mouth into the stomach to remove
air and fluid from the stomach and intestine)
 IV (given into a vein) fluids for fluid replacement and
nutrition
 antibiotics to treat or prevent infection
 frequent exams and abdominal X-rays

38. SURGICAL INTERVENTION
 a consultation with a pediatric surgeon to discuss surgery, if needed
 in severe cases, surgery may be needed right away
 The surgeon will look for a hole in the intestine and remove any
dead or dying intestinal tissue. In some cases after this removal, the
healthy intestine can be sewn back together. Other times, especially
if the baby is very ill or a large section of the intestine was
removed, an ostomy is done. During an ostomy, surgeons bring an
area of the intestine to an opening on the abdomen (stoma) so that
stool can safely exit the body. A second surgery may be done to re-
examine the intestines. If an ostomy is made, it will be closed 6–8
weeks later, after the intestine is fully healed and healthy again.

40.  The baby's poop is watched for blood and the baby's belly size is checked
regularly. A hole in the intestine or an infection in the abdominal cavity
will make the belly swell. If a baby's belly is so swollen that it affects
breathing, extra oxygen or a breathing machine (ventilator) will help the
baby breathe. Also, blood tests will look for bacteria and check
for anemia (a decrease in red blood cells).
 After responding to treatment, a baby can be back on regular feedings
after a week or two. When feedings start again, breast milk is
recommended. Breast milk is beneficial for babies with NEC because it is
easily digested, supports the growth of healthy bacteria in the intestinal
tract, and boosts a baby's immunity — which is especially important for a
preterm baby with an immature immune system.

41. COMPLICATION
 In some cases, the intestine is scarred, narrowed, or
blocked. If so, more surgery might be needed.
 Malabsorption (when the intestine can't absorb nutrients
normally) can be a lasting problem from NEC. It's more
common in babies who had part of their intestine
removed. A baby with malabsorption may need nutrition
delivered directly into a vein until the intestine heals well
enough to tolerate normal feeding.

42. PROGNOSIS
Gastrointestinal perforation in neonates
presents important challenges and a high
mortality of 15-70% has been reported. Despite
improvements in anaesthesia and neonatal
intensive care, mortality has remained high,
especially in the preterm.

43. NURSING DIAGNOSIS
Inadequate nutritiona,less than body requirement
related to NPO status secondary to intestinal perforation.
Acute pain related to abdominal distention
Ineffective family coping related to the disease condition
of the child
Risk of infection related to invasive lines, foley's catheter
procedure

44. PROGRESS NOTES:-
DAY 1-24TH FEB 2020
Baby of Sahana got admitted in NICU on 24th feb 2020,as child abdomen is distended
and the child is not passing urine and stool since morning. Iv line inserted and IVF
started 80ml/hourly. Foley's catheter is inserted but no urine output was there.
All the required and needed nursing care are given.
 Vital signs are checked and were in normal range.
 Spo2-96% maintaining on room air.
 Medication are provided as per physician’s order.
 General assessment of the child is carried out.
 Pre operative care is provided to the child.

45. CONT…
DAY 2-25TH FEB 2020
Its 1ST Post ope day of the child ,child’s condition was stable and not deteriorating further ,child has
ileostomy present .child has no fever after surgery, child abdomen was distended. IVF was on 20ml/hourly.
Foley's catheter was present but no urine output in last 24 hr was there.
All the required and needed nursing care are given.
 Vital signs are checked and were in normal range.
 Spo2-96% maintaining on room air.
 Medication are provided as per physician’s order.
 General assessment of the child is carried out.
 Post operative care is provided to the child.

46. Cont…
DAY 3-26TH FEB 2020
Its 2nd Post ope day of the child ,child’s condition was deteriorating as child has fever since night ,child has
ileostomy present, child abdomen was still distended. IVF was on 20ml/hourly. Foley's catheter was present
but no urine output in last 24 hr was there.
All the required and needed nursing care are given.
 Vital signs are checked and recorded, child has 38’c temperature since last night and bp of the child was
dropping to 50/30mm of hg.
 Spo2-96% maintaining on room air.
 Medication are provided as per physician’s order.
 General assessment of the child is carried out.
 Post operative care is provided to the child.

47. Cont….
DAY 4-27TH FEB 2020
Its 3rd Post ope day of the child ,child’s condition was further deteriorating as child has fever since night
and had one cardiac arrest in the morning child was intubated and was on ventilatory support. Foley's
catheter was present but no urine output in last 24 hr was there.
All the required and needed nursing care are given.
 Vital signs are checked and recorded, child has 38’c temperature since last night and bp of the child
was droping to 60/30mm of hg.
 Spo2-93% maintaining on ventilator.
 Medication are provided as per physician’s order.
 General assessment of the child is carried out.
 Post operative care is provided to the child.

48. SUMMARY AND CONCLUSION
Baby of Sahana , 4days old, male child was admitted with the
complaint of distended abdomen and not passing urine and
stool since morning . The child was conscious but irritable at
the time of admission. Child had exploratory laparotomy for
intestinal perforation on the 3rd post ope day the child had
cardiac arrest and was put on ventilatory support, child's
condition was detoriating day by day.

49. Thankyou!!!