Voi. 103, No.

NEONATAL GASTRIC PERFORATION*

By FI)WIN S. WIlSON, JR., \IAjOR, MC
SAN FRANCISCO, CALIFORNIA

N
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Fk)NAFAL gastric perforation is an

Suiitisual surgical energeicv which has
receive(I little attelltioll in tile radiologic
literature. Although Siebold reported the
first case of neonatal gastric perforation in
l#{188})2c,
by 1964 only 143 cases Witil 39 sur-
vivors ildd 1)een accun1ulate(l ill the world
literature. Flie high nlortalitv rate re-
tlects to a certaill extellt tile precariousness **

of the neonatal period, 1)ut tile process - ,S* * * -

evolves witii such rapidity tilat )r0Ipt

diagnosis
rates are
is a re(luisite
to be achieved.
if ifllprOved survival
--*5 5-
REPORI ()I- cAsEs
-i
CsI 1. liliS lb. OZ. Negro fenlale WaS

l)orn to an I ear olil prinligravida On No-

Verlli)er 9, I 965, following a ..O week gestation
afl(SI unconlplicated vaginal delivery. *I*he 1)100(1
type of the fllotiler \VtS (;rii 0, Rh negative,
FIG. 1. Case I. Supine roentgcnogram of the abdo-
tIl(1 the infant at birth as vigorous with a
men demonstrating gas outlining the falciform
lust\ cry and excellellt nluScular tone. OIl the
ligament (arrows).
fourth dt- the infant aI)ruptlV refused feedings
and 1)ecdflle lethargic, and abdominal distell-
proximal to this area of perforation, consistent
tiOfl \%tS noted. Fhis latter finding prompted
with focal aplasia of the musculature of the
the passage of a soft rubber lavage tube; a
gastric wall.
small amount of formula was recovered, and the
ll)d0fllifltl (listention diminished. The improve- C:sE Ii. This lb. 6 oz. Negro female was
Illeflt in tile clinical appearance was transient, born to a 28 year old gravida 2 Para 2 mother on
and \vitilifl several hours subnormal tempera- July I, I9$, following a gestation of approxi-
ture, tachvpnea, and mild cyanosis had de- matel 3 weeks and an uncomplicated vaginal
eloped. A supine roentgenogram, obtained at delivery. The infant was ervthroblastotic, and
the l)e(lside, demonstrated an abnormal gas an exchange transfusion was performed on the
pattern within the abdomen, with gas outlining third day of life, because of anemia and hyper-
the faiciform ligament (Fig. No pulmonary
). bilirubinemia. The infant experienced no dif-
abnormalities were seen. The infant expired be- ficulty during the procedure, but approximately
fore definitive measures could be instituted, 4 hours later, tachypnea and abdominal (listen-
approximately 10 hours following the onset of ti()n were noted. Supine and upright roentgeno-
s v mp torn s. grams of the abdomen were oi)tailled, which
The autopsy demonstrated generalized peri- disclosed the presence of a pneumoperitoneum
tonitis, seCoIldarV to a perforation high on the (Fig. 2 and 3). Celiotom was performed
greater curvature of the stomach. Microscopic promptly, and generalized peritonitis secondary
sections of tilis region revealed an abrupt cessa- to a perforation of the lesser curvature of the
tion of the musculature of the gastric wall stomach was discovered. The defect was suc-

* From the Radiology Department, Letterman (;eneral Hospital, San Francisco, california.
This material has been reviewed by the Oflice of lhe Surgeon General, Department of the Army, and there is no objection to its pre-
sentation and/or publication. This review does not imply any indorsement of the opinions advanced or any recommendation of such
products as ma be named,

307
 308 Edwin S. Wilson, Jr. JUNE, 1968

ture was the most frequent predisposing

cause for neonatal gastric perforation. Tile
most common site of perforation is the
greater curvature of tile stoniach, and tilis
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was especially true of those perforations

associated with a focal aplasia of the gas-
tric nlusculature. In tile consideration of
increased acidity and peptic ulceration as
a pre(lisposing cause, Miller4 has shown
that tile gastric acidity of tile Ilewborll
reaches a maximum at (lays of life, at
S which
Thereafter,
time
the
adult
level
levels
of
2
are
acidity
approached.
decreases
abruptly, to return to adult levels again at
the end of tile first year.
The entity most conlnlonlv manifests
u
itself (luring tile first week of life. Inouye
and Evans have emphasized tile high rate
of prematurity among these patients,
which approaches 40 per cent. Ihis is in
FIG. 2. Case ii. Supine roentgenogram of the abdo- marked contrast to the rate of 11.7 per

men demonstrating gas outlining the falciform cent among the normal population. The
ligament (arrows). infants characteristically become ill ratiler
suddenly, with lethargy, abdonlinal dis-
cessfully repaired, but the infant expired sud-
ten tion, decreased tern perature, and tac-
denly before the entire procedure could be
hpnea. Tile diagnosis of perforated viscus
completed.
Autopsy confirmed the generalized peritoni-
tis. Microscopic sections of the repaired defect
failed to demonstrate a muscular defect within
the gastric wall, and the predisposing cause for
the perforation was not determined.

DISCUSSION

Neonatal gastric perforation is an un-

common entity which, b virtue of its
high mortality rate, requires prompt rec-
ognition and surgical intervention. The
precise etiology is obscure in most cases.
A number of interesting theories have been
proposed to explain individual cases, in-
cluding congenital defects in the gastric
musculature,1 increased gastric acidity and
peptic ulceration,4 mechanical injury sec-
ondary to polyethylene and rubber tubes,3
sepsis and congestion of the bowel wall,
pvloric and small intestinal obstruction,5
and vigorous attempts at resuscitation.6
Excluding the apparently idiopathic cases, FIG. . Case u. Erect examination of the abdomen
Inouye and Evans2 established that a demonstrating large collections of gas beneath
congenital defect in the gastric muscula- the diaphragm.
 VOL. 103, No. 2 Neonatal Gastric Perforation 309

may be suggested by the clinical exami- nea, decreased temperature or fever, and
nation, and roen tgenograms usu ally estab- rapid demise within 12 to 24 hours follow-
lish the diagnosis. ing the onset of symptoms.
The supine examination of the abdomen The perforation manifests itself roent-
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may demonstrate a bizarre gas pattern, genographi cally as pneumopeni toneum,

due to the presence of gas within the pen- with gas collections about the falciform
toneal cavity, and an especially significant ligament on the supine examination, and
observation is gas outlining both sides of beneath the diaphragm on the erect
the falciform ligament or bowel wall, as roentgenogram.
originally described by Rigler.7 The pnes- The high mortality rate associated with
ence of a pneumopenitoneum is usually neonatal gastric perforation requires
more easily discernible on the erect roent- prompt remedial measures.
genognam, when gas collects beneath the Two cases are reported.
diaphragm. Obviously, the finding of a
pneumopenitoneum merely raises the sus- 1)epartment of Radiology
picion of neonatal gastric perforation, as Martin Army Hospital
Fort Benning, Georgia 31905
a similar appearance may be produced by
such entities as necrotizing enterocolitis,
perforated Meckels di verticulum, per-
REFERENCES
forated duodenal ulcer, and traumatic
perforation of the colon, as by a rectal I. HERIIUT, P. A. Congenital defect in musculature
thermometer. There is usually no indication of stomach with rupture in newborn infant.
Arch. Path., 1943,36, 91-94.
for positive contrast studies, since the pre-
2. INOUYE, W. Y., and EVANS, G. Neonatal gastric
cise diagnosis is established at laparotomy. perforation: report of 6 cases and review of 143
The proper therapeu tic regimen includes cases. A.M.A. Arch. Surg., 1964, 88, 7 1-485.
fluid and electrolyte replacement, anti- 3. KELLOGG, H. G., ABELSON, S. M., and CORN-
WELL, I. A. Perforation of stomach in new-
biotics, and prompt surgical intervention.
born infant: report of survivals. 7. Pediat.,
At the time of laparotomy it is important
1951,39, 357-362.
that careful examination of the entire stom- 4. MILLER, F. A. Neonatal gastrointestinal tract
ach be performed, as multiple perforations perforations. 7. Lancet, 1957, 77, 439-442.
have been reported.4 g. PARRISH, R. A., SHERMAN, R. T., and WILSON,
H. Spontaneous rupture of gastro-enteric tract
SUMMARY in newborn: report of 13 cases and description
of characteristic x-ray finding. Ann. Surg.,
Neonatal gastric perforation is an un- 1964, 159, 244-251.
usual entity requiring prompt diagnosis 6. PENDERGRASS, E. P., and BOOTH, R. E. Report
and surgical correction. of case of ruptured stomach in an infant three

The symptomatology usually begins days old. AM. J. ROENTGENOL. & RAD. THER-
APV, 1946, 56, 590*593
within the first week of life, and consists of
7. RIGLER, L. G. Spontaneous pneumoperitoneum:
poor feeding, regurgitation, abdominal roentgenologic sign found in supine position.
distention, listlessness, lethargy, tachyp- Radiology, 1941,37, 604-607.