Abstract
Background/Purpose: The etiology and management of spontaneous intestinal perforation (SIP) in neonates carry many controversial issues. The aim of this study is to review Aseer region experience with cases of SIP over a seven- year period and to document the usefulness of the clinical, radiological and histopathological pictures in differentiating SIP from necrotizing enterocolitis (NEC). This differentiation is important as it may affect the type of management as well as the prognosis.
Materials & Methods: From June 1999 to July 2006, all charts of confirmed NEC and SIP cases admitted to Aseer central hospital and Armed forces hospital southern region, Saudi Arabia were retrospectively reviewed. Charts of patients with SIP without radiological evidence of pneumatosis intestinalis or portal venous gas (PVG) who had surgery were extensively studied. Patient demographics, predisposing factors, methods of diagnosis, operative and histologic findings together with the final outcome were documented.
Results: Out of 147 cases of clinically diagnosed NEC or SIP, 91 required surgery. Only 18 neonates were diagnosed as SIP. There were 8 Males and 10 females. The gestational age (GA) ranged between 26-37 weeks (mean = 29.9 weeks). The birth weight (BIN) ranged from 650 to 3500 grams (mean = 1323 grams). Greenish discoloration of the groin and leukocytosis were seen in 12 neonates (66.7%). Pneumoperitoneum was present in 16 patients (88.9%). Intraoperatively, there were jejunal perforation in one, terminal ileal perforations in 15 and sigmoid perforations in two. One full term patient had concomitant ileal atresia with perforations distal to it. Histologic studies showed evidence of Coagulative necrosis in that ileal atresia patient and the two full term patients with sigmoid perforations. Both cases with colonic perforations developed post operative stricture that required surgical resection. Fourteen out of 18 patients survived (77.8%).
Conclusion: SIP mainly affects premature infants. The differentiation between SIP and NEC based on the clinical and radiological pictures is difficult. Histopathological studies are required to confirm the diagnosis. Coagulative necrosis and intramural air spaces if present confirm the diagnosis of NEC. Hence, peritoneal drainage cannot be considered a definitive treatment based on clinical and radiological findings alone. Early post operative feeding is not advised and the possibility of post operative stricture should be raised in mind. If the perforation is colonic, the diagnosis of SIP is doubtful and the option of proximal stoma formation is advisable. The final outcome is usually better in cases of SIP than that of NEC.