Gastrointestinal perforation following indomethacin therapy in very low birth weight infants

Reassessing acquired neonatal intestinal diseases using unsupervised machine learning

BACKGROUND

Acquired neonatal intestinal diseases have an array of overlapping presentations and are often labeled under the dichotomous classification of necrotizing enterocolitis (which is poorly defined) or spontaneous intestinal perforation, hindering more precise diagnosis and research. The objective of this study was to take a fresh look at neonatal intestinal disease classification using unsupervised machine learning.

METHODS

Patients admitted to the University of Florida Shands Neonatal Intensive Care Unit January 2013-September 2019 diagnosed with an intestinal injury, or had imaging findings of portal venous gas, pneumatosis, abdominal free air, or had an abdominal drain placed or exploratory laparotomy during admission were included. Congenital gastroschisis, omphalocele, intestinal atresia, malrotation were excluded. Data was collected via retrospective chart review with subsequent hierarchal, unsupervised clustering analysis.

RESULTS

Five clusters of intestinal injury were identified: Cluster 1 deemed the "Low Mortality" cluster, Cluster 2 deemed the "Mature with Inflammation" cluster, Cluster 3 deemed the "Immature with High Mortality" cluster, Cluster 4 deemed the "Late Injury at Full Feeds" cluster, and Cluster 5 deemed the "Late Injury with High Rate of Intestinal Necrosis" cluster.

CONCLUSION

Unsupervised machine learning can be used to cluster acquired neonatal intestinal injuries. Future study with larger multicenter datasets is needed to further refine and classify types of intestinal diseases.

IMPACT

Unsupervised machine learning can be used to cluster types of acquired neonatal intestinal injury. Five major clusters of acquired neonatal intestinal injury are described, each with unique features. The clusters herein described deserve future, multicenter study to determine more specific early biomarkers and tailored therapeutic interventions to improve outcomes of often devastating neonatal acquired intestinal injuries.

A randomized trial of intravenous acetaminophen versus indomethacin for treatment of hemodynamically significant PDAs in VLBW infants

Objective was to compare the rate of successful treatment of hsPDA based on echocardiogram criteria after use of IV acetaminophen or IV indomethacin in very low-birthweight infants. The study was a multi-center, randomized controlled trial. Infants born prior to 32 weeks with birthweight ≤ 1500 g were included if PDA treatment was indicated within the 21 days after birth. hsPDA was defined by strict echocardiogram criteria. Eligible infants were randomized to treatment with either IV acetaminophen or IV indomethacin. Of 86 eligible infants, 17 infants were randomized to acetaminophen and 20 to indomethacin. One (5.9%) hsPDA in the acetaminophen group had successful treatment compared to 11 (55%) in the indomethacin group (p = 0.002). Eight (47%) in the acetaminophen group and 3 (15%) in the indomethacin group received transcatheter PDA closure (p = 0.07). IV indomethacin was more effective than IV acetaminophen for treatment of hsPDAs. More infants in the acetaminophen group received transcatheter closure.

Oral diatrizoate acid for meconium-related ileus in extremely preterm infants

BACKGROUND

Intestinal disorders are common in very low-birthweight infants. The purpose of this study was to evaluate the impact of prophylactic oral Gastrografin^® (diatrizoate acid) on meconium-related ileus (MRI) in extremely preterm infants.

METHODS

This was a retrospective case-control study of infants born extremely preterm at <28 weeks of gestation and treated with diatrizoate acid (prophylactic group) or not (control group) in the periods 2007-2014 and 2000-2009, respectively. In the 2007-2014 period, 120 infants received prophylactic diatrizoate acid solution. From the 165 infants in the control group, we selected 120 infants matched for gestational age. Cases of death before 72 h of life or congenital abnormalities were excluded. Intestinal disorders, time until full enteral feeding, duration of hospital stay, mortality rate, and neurodevelopmental outcome were compared.

RESULTS

MRI occurred in six infants in the control group and in none of the infants in the prophylactic group (P = 0.039). Median time until full enteral feeding was 25 versus 22 days (P < 0.01), hospital stay was 142 versus 126 days (P < 0.01), and mortality rate for infants aged 24-27 weeks was 8.2% versus 0% (P = 0.021), respectively.

CONCLUSIONS

Prophylactic oral diatrizoate acid reduced MRI in extremely preterm infants without side-effects and decreased the mortality rate of infants born at 24-27 weeks, and is thus beneficial in extremely preterm infants.

Effect of prophylactic indomethacin administration and early feeding on spontaneous intestinal perforation in extremely low-birth-weight infants

OBJECTIVE

To determine the effect of concomitant administration of prophylactic indomethacin and early enteral feeds on the risk of spontaneous intestinal perforation (SIP) in extremely low-birth-weight (ELBW) infants, and to describe the variation in prophylactic indomethacin use in Canada.

STUDY DESIGN

A retrospective cohort study of 4268 ELBW infants born at <30 weeks' gestation admitted to Canadian neonatal units between 2010 and 2014 was conducted. Prophylactic indomethacin (I+ or I-, administered within 24 h) and early feeding (E+ or E-, initiated in the first 2 days) exposures were studied concurrently and independently. The primary outcomes were SIP and death before discharge. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated.

RESULTS

Compared with the I-/E+ reference group (n=1829), infants in I+/E+ (n=285; aOR 2.92, 95% CI 1.41 to 6.08) and I+/E- (n=213; aOR 2.84, 95% CI 1.35 to 5.98) groups had higher odds of SIP, whereas those in the I-/E- group had similar odds (n=1941; aOR 1.37, 95% CI 0.88 to 2.14). Odds of SIP were higher in the indomethacin exposed group (I+) compared with the unexposed (I-) group when controlled for early feeding (aOR 2.43, 95% CI 1.41 to 4.19), but not in the early feeding group when controlled for indomethacin. The use of prophylactic indomethacin ranged from 0% usage in 13 sites to 78% use in one site.

CONCLUSION

Prophylactic indomethacin was associated with increased odds of SIP independently from early feeding in this cohort; however, early enteral feeding was not associated with SIP. Marked variation in the use of prophylactic indomethacin was identified.

Non-steroidal Anti-inflammatory Drug Induced Injury to the Small Intestine

Non-steroidal anti-inflammatory drug (NSAIDs) induced enteropathy represents an important complication of one of the most commonly used drugs worldwide. Due to previous diagnostics difficulties the real prevalence of this disease was underestimated for a long time. The pathogenesis of NSAID-enteropathy is more multifactorial and complex than formerly assumed but has still not been fully uncovered. A combination of the local and systemic effect plays an important role in pathogenesis. Thanks to novel enteroscopy methods (wireless capsule endoscopy, double balloon enteroscopy), small bowel lesions are described in a substantial section of NSAID users although most are clinically asymptomatic. The other non-invasive tests (small bowel permeability, faecal calprotectin, scintigraphy using faecal excretion of 111-indium-labelled leukocytes etc.) proposed for diagnostics are not generally used in clinical practice, mainly because of their non-specificity. Despite intensive research into possible treatment, the main measure for patients with NSAID-enteropathy is still withdrawal of NSAIDs. Double balloon enteroscopy plays an important role in the treatment of complications (bleeding, strictures).

Definitive peritoneal drainage in the extremely low birth weight infant with spontaneous intestinal perforation: predictors and hospital outcomes

OBJECTIVE

To identify characteristics associated with definitive peritoneal drainage (PD) in the extremely low birth weight infant diagnosed with spontaneous intestinal perforation (SIP). We also sought to determine whether patients requiring a second operation (salvage laparotomy) following PD are at increased risk of adverse hospital outcomes, including increased times to full enteral feedings and decreased 30-day survival.

STUDY DESIGN

We performed a retrospective chart review of infants with a birth weight <1000 g who underwent PD for SIP at a single tertiary neonatal unit from 2003 to 2012. Infants with signs of necrotizing enterocolitis on abdominal plain films, including pneumatosis intestinalis, portal venous gas or fixed, dilated small loops of bowel were excluded from the study. Perinatal and perioperative data and short-term neonatal outcomes prior to hospital discharge were collected. Comparison was made between two groups: infants treated with definitive PD vs infants requiring salvage laparotomy. Data were analyzed using independent samples t-test and Cochrane-Mantel-Haenszel.

RESULT

Eighty-nine infants who fit all inclusion criteria were identified during the study period. PD was definitive in 67 (75.3%) patients. Patients who had definitive PD vs those who required salvage laparotomy were significantly more likely to present at a later day of life (9.6±5.3 vs 5.6±2.7, P<0.0001) and to have a lower birth weight (724.6 g±132.5 vs 809.2 g±143.1, P=0.02). The administration of indomethacin or ibuprofen prior to the diagnosis of SIP was also associated with definitive PD (74.6% vs 50%, P=0.03). Comparison of feeding outcomes revealed that the time to achieve full enteral feeds was significantly longer for those who underwent a salvage laparotomy (95.9±30.2 vs 60.4±30.4 days, P<0.005). Short-term survival (>30 days) was not significantly different between the two groups.

CONCLUSION

PD was definitive therapy for the majority of neonates included in this study who were referred for surgical evaluation of SIP. Our data point to trends in being able to identify infants with SIP who are at risk for salvage laparotomy following PD, and thus, adverse nutritional outcomes. Larger, prospective studies are needed to further evaluate this specific patient population and identify those patients who are likely to succeed with PD following the diagnosis of SIP.

Mortality associated with laparotomy-confirmed neonatal spontaneous intestinal perforation: a prospective 5-year multicenter analysis

BACKGROUND

Spontaneous intestinal perforation (SIP) has been recognized as a distinct disease entity. This study sought to quantify mortality associated with laparotomy-confirmed SIP and to compare it to mortality of laparotomy-confirmed necrotizing enterocolitis (NEC).

METHODS

Data were prospectively collected on 177,618 very-low-birth-weight (VLBW, 401-1500g) neonates born between January 2006 and December 2010 admitted to US hospitals participating in the Vermont Oxford Network (VON). SIP was defined at laparotomy as a focal perforation of the intestine without features suggestive of NEC or other intestinal abnormalities. The primary outcome was in-hospital mortality.

RESULTS

At laparotomy, 2036 (1.1%) neonates were diagnosed with SIP and 4076 (2.3%) with NEC. Neonates with laparotomy-confirmed SIP had higher mortality (19%) than infants without NEC or SIP (5%, P=0.003). However, laparotomy-confirmed SIP patients had significantly lower mortality than those with confirmed NEC (38%, P<0.0001). Mortality in both NEC and SIP groups decreased with increasing birth weight and mortality was significantly higher for NEC than SIP in each birth weight category. Indomethacin and steroid exposure were more frequent in the SIP cohort than the other two groups (P<0.001).

CONCLUSIONS

In VLBW infants, the presence of laparotomy-confirmed SIP increases mortality significantly. However, laparotomy-confirmed NEC mortality was double that of SIP. This relationship is evident regardless of birth weight. The variant mortality of laparotomy-confirmed SIP versus laparotomy-confirmed NEC highlights the importance of differentiating between these two diseases both for clinical and research purposes.

Spontaneous intestinal perforation in extremely low birth weight infants: association with indometacin therapy and effects on neurodevelopmental outcomes at 18-22 months corrected age

BACKGROUND

Spontaneous intestinal perforation (SIP) is associated with the use of postnatal glucocorticoids and indometacin in extremely low birth weight (ELBW) infants. The authors hypothesised: 1) an association of SIP with the use of antenatal steroids (ANS) and indometacin either as prophylaxis for intraventricular hemorrhage (IVH) (P Indo) or for treatment of PDA (Indo/PDA) and 2) an increased risk of death or abnormal neurodevelopmental outcomes in infants with SIP at 18-22 months corrected age.

DESIGN/METHODS

The authors retrospectively identified ELBW infants with SIP in the Neonatal Research Network's generic database. Unadjusted analysis identified the differences in maternal, neonatal and clinical variables between infants with and without SIP. Logistic regression analysis identified the adjusted OR for SIP with reference to ANS, P Indo and Indo/PDA. Neurodevelopmental outcomes were assessed among survivors at 18-22 months corrected age.

RESULTS

Indo/PDA was associated with an increased risk of SIP (adjusted OR 1.61; 95% CI 1.25 to 2.08), while P Indo and ANS were not. SIP was independently associated with an increased risk of death or neurodevelopmental impairment (NDI) (adjusted OR 1.85; 95% CI 1.32 to 2.60) and NDI among survivors (adjusted OR 1.75, 95% CI 1.20 to 2.55).

CONCLUSION

Indometacin used for IVH prophylaxis and ANS were not associated with the occurrence of SIP in ELBW infants. Indometacin used for treatment of symptomatic PDA was however associated with an increased risk of SIP. ELBW infants with SIP have an increased risk of poor neurodevelopmental outcomes.

Segmental absence of intestinal musculature: an increasingly reported pathology

BACKGROUND

Segmental absence of the intestinal musculature (SAIM) is a known but clinically rare entity involving partial or complete absence of the intestinal muscularis propria. Clinical presentation is consistent with peritonitis, and treatment involves an emergent laparotomy, bowel resection, and reanastamosis or possible ostomy creation. Diagnosis results from histopathologic evaluation of the resected intestinal specimen. Most of the publications are case reports.

METHODS

We retrospectively reviewed all surgical pathology files at a tertiary pediatric hospital from 2003 to 2010, identifying children who were noted to have absence of intestinal musculature on pathology. Patients meeting criteria were reviewed in detail, and data regarding clinical presentation, diagnostic testing, radiologic findings, treatment, and outcome were recorded.

RESULTS

Five patients were identified between 2003 and 2010 who received the diagnosis of SAIM. Patient age ranged from 1 to 99 days of life. All children were born preterm by cesarean section, had a mean birth weight of 828 ± 338 g, and were intubated after birth.

CONCLUSIONS

The 5 patients presented are reviewed and contrasted with previous cases presented in the literature. Theories of pathogenesis and classification are discussed, and the cases are labeled as primary versus secondary SAIM.

Evidence-based use of indomethacin and ibuprofen in the neonatal intensive care unit

Indomethacin and ibuprofen are potent inhibitors of prostaglandin synthesis. Neonates have been exposed to these compounds for more than 3 decades. Indomethacin is commonly used to prevent intraventricular hemorrhage (IVH), and both drugs are prescribed for the treatment or prevention of patent ductus arteriosus (PDA). This review examines the basis for indomethacin and ibuprofen use in the neonatal intensive care population. Despite the call for restrained use of each drug, the most immature infants are likely to need pharmacologic approaches to reduce high-grade IVH, avoid the need for PDA ligation, and preserve the opportunity for an optimal outcome.

Gastrointestinal complications associated with ibuprofen therapy for patent ductus arteriosus

OBJECTIVE

To review intestinal complications associated with ibuprofen treatment of patent ductus arteriosus (PDA).

STUDY DESIGN

Data from preterm infants treated with ibuprofen were retrospectively reviewed. χ(2) test and Fischer's exact test were used for univariate analyses. Multivariate analyses with logistic regression modeling were used to identify risk factors.

RESULT

One hundred and two infants were treated with ibuprofen for PDA. Nine (9/102, 8.8%) infants developed spontaneous intestinal perforation (SIP), whereas 93/102 (91.2%) did not. The mean (± s.d.) gestational age (GA) at birth in infants with and without SIP was 25.2 (± 1.3) vs 27.6 (± 2.4) weeks (P=0.02) and the median (interquartile) length of stay (LOS) was 109.5 (91.0 to 116.5) vs 75.0 (53.0 to 94.5) days (P=0.002), respectively. The mean (± s.d.) age at starting ibuprofen was 3.3 (± 1.3) vs 5.8 (± 3.5) days in infants with and without SIP, respectively (P=0.03). In logistic regression analyses, increasing GA and later initiation of ibuprofen treatment were protective against risk of SIP; odds ratio, 95% confidence interval (OR, 95% CI)=0.26 (0.09 to 0.75), P=0.01 and 0.63 (0.41 to 0.95), P=0.03, respectively.

CONCLUSION

Infants at lower GA are at risk of SIP when treated early with ibuprofen for symptomatic PDA.

Understanding intestinal vulnerability to perforation in the extremely low birth weight infant

Spontaneous intestinal perforation (SIP) occurs commonly in extremely low birth weight (ELBW) infants. Our understanding of its etiologies has improved dramatically over the last decade. Included in this comprehension is an ongoing reconciliation of the iatrogenic risk factors, the microbiology, and the histopathology. The latter shows focal perforations with necrosis of the muscularis externa and no sign of ischemic damage (typically characterized by mucosal necrosis in the preterm bowel). Associations include extreme prematurity, early postnatal steroids (EPS), early use of indomethacin (EUI), and two common pathogens (Candida and Staphylococcus epidermis). Animal models of SIP suggest that all risk factors converge on a common collection of signaling pathways: those of nitric oxide synthases (NOS), insulin-like growth factors (IGFs), and epidermal growth factors (EGFs). Many of these factors skew trophism of the ileum (defined as thinning of the submucosa concomitant with hyperplasia of the muscosa). Global depletion of NOS is associated with disturbed intestinal motility and diminished transforming growth factor-alpha (TGF-alpha) in the muscularis externa. This constellation of insults seems to make the distal intestine vulnerable to perforation during recovery of motility.

Focal intestinal perforation in extremely-low-birth-weight neonates: etiological consideration from histological findings

In Japan, mortality due to intestinal perforation has been increasing for the last 15 years, as the survival rate of extremely-low-birth-weight neonates (ELBWs) has been increasing. In our NICU, although the incidence of necrotizing enterocolitis has been decreasing, that of focal intestinal perforation (FIP) has been increasing. To elucidate the pathogenesis of FIP, a histological study was performed. For the last 20 years, in our NICU, 11 ELBWs with FIP, including one with multiple perforations and impending rupture, underwent laparotomy and enterostomy. The intestinal wall around the perforation was resected for histological study. Histological studies revealed well-developed ganglion cells in all the cases. Although some lymphocytic infiltration and hemorrhage were observed, no apparent neutrophilic infiltration, or necrotic change was identified in any case. No evidence of microcirculatory impairment was identified. The intestinal musculature discontinued abruptly with thinning in three cases, and without thinning in the others. The histology of impending rupture showed an absence of the muscularis with preservation of the remaining components of the bowel wall. The findings that the punched-out perforations had the appearance of Hirschsprung's disease, FIP exclusively occurred in ELBWs, and that neither mechanical obstruction nor necrotic change could be identified as the cause of the perforation suggest that immature bowel movement and congenital muscle defects may be involved in the pathogenesis of FIP.

Etiology of neonatal gastric perforations: review of 10 years' experience

BACKGROUND

Neonatal gastric perforation (NGP) is a rare event and its etiology is still controversial. Although it has previously been described as spontaneous, recently some risk factors have been reported to be associated with the development of NGP including prematurity and nasal ventilation. The purpose of the present paper was to report and discuss etiology, clinical features, and outcome of the authors' NGP cases over a 10 year period.

METHODS

Charts of five infants with NGP was reviewed in terms of gender, birthweight, gestational age, time of diagnosis, associated disease, site of perforation, type of surgery performed, and clinical outcome.

RESULTS

There were three boys and two girls with a mean birthweight and gestational age of 1650 g and 32 weeks, respectively. Three of them were premature. Mean perforation time was day 10 postnatally. Three infants had associated problems including prematurity, respiratory distress syndrome type 1, necrotizing enterocolitis, mechanical ventilator support, and one of them had tracheaesophageal fistula. Mothers of two out of these three infants had chorioamnionitis. One full-term infant received dexamethasone because of brain edema. Only one patient had no associated problem. Perforation occurred in the lesser curvature in three infants and in the greater curvature in two infants. Mortality rate was 60%.

CONCLUSIONS

Contrary to previous literature, and similar to recent publications, it was found that essentially low-birthweight infants with tracheaesophageal fistula or chorioamnionitis and full-term babies on steroid therapy may have a risk for NGP, suggesting that an infant with contributing factors should be monitored more carefully for the development of NGP.

Clinical considerations for the pharmacologic management of patent ductus arteriosus with cyclooxygenase inhibitors in premature infants

When medical management is warranted for closure of a persistent patent ductus arteriosus (PDA) in premature infants, treatment with a cyclooxygenase (COX) inhibitor is indicated. Indomethacin, available since 1976, has been the conventional pharmacologic treatment for PDA, but its use is associated with vasoconstrictive effects that impair renal, mesenteric and cerebral blood flow. Intravenous (IV) ibuprofen lysine, approved in the United States in 2006, has less severe vasoconstrictive effects on these vital organs than IV indomethacin. Clinical trials have shown both of these COX inhibitors to be equally effective in closing the PDA in approximately 70%-80% of treated infants, with less vasoconstrictive and adverse renal effects occurring with IV ibuprofen lysine.1,2 Several clinical considerations are important in the process of medical decision-making when faced with the need for PDA treatment with one of these pharmacologic agents in the premature infant. This paper focuses on these clinical considerations, including cerebral, renal and mesenteric blood flow, renal function, pulmonary effects, protein-binding capacity as it relates to hyperbilirubinemia, and platelet aggregation. No differences in chronic lung disease, pulmonary hypertension, hyperbilirubinemia and coagulopathy were observed in clinical trials when comparing these 2 COX inhibitors; however, significant differences have been observed in arterial blood flow to the cerebral, renal and mesenteric organs, suggesting that IV ibuprofen lysine may be the more favorable agent.

Rhabdomyolysis and necrotic bowel after acetaminophen and ibuprofen overdose

A 28-year-old man with schizophrenia intentionally ingested a lethal dose of acetaminophen and an unknown quantity of ibuprofen. He arrived at the hospital with acute renal and fulminant liver failure complicated by rhabdomyolysis. His creatine kinase level was 20,306 U/L on admission, which increased to 245,595 U/L by hospital day 2, and subsequently decreased to 339 U/L by day 16. The patient underwent liver transplantation on day 3; necrotic bowel was found during surgery. Rhabdomyolysis associated with acetaminophen overdose has been described only in a few case reports, but rarely in association with acetaminophen taken alone. The literature does not provide a clear association between acetaminophen and rhabdomyolysis because of other possible traumatic and nontraumatic causes. In this case, the Naranjo adverse drug reaction probability scale indicated a probable adverse reaction of rhabdomyolysis associated with acetaminophen overdose. In addition, nonsteroidal antiinflammatory agents (NSAIDs) are well known to be ulcerogenic in the upper gastrointestinal tract, but potential effects on the lower tract are less well known. Only a few NSAID-induced cases of ischemic colitis have been reported. Several mechanisms of action have been proposed, such as direct mucosal damage and inhibition of intestinal prostaglandin production. In this patient, the Naranjo scale indicated a probable adverse reaction of ischemic colitis associated with ibuprofen overdose. Patients who have taken an acetaminophen overdose should be assessed for rhabdomyolysis as a possible complication. In addition, an evaluation of ibuprofen-induced bowel necrosis in these patients may be warranted.

Intestinal mucosal damage caused by non-steroidal anti-inflammatory drugs: role of bile salts

The strong analgesic, anti-inflammatory effects of non-steroidal anti-inflammatory drugs (NSAIDs) are hampered by high occurrence of gastrointestinal side effects. Therapeutic actions of NSAIDs result from cyclooxygenase (COX) enzymes inhibition with reduced synthesis of prostaglandins, major modulators of inflammation. Since prostaglandins also regulate key events in gut homeostasis -mucosal secretion, blood flow, epithelial regeneration - COX inhibition has been accepted as the reason for NSAID gastrointestinal toxicity. Several findings challenge this theory: first, intestinal damage by NSAIDs occurs also in COX-1 knockout mice, demonstrating that topical (non-prostaglandin mediated) mechanisms are involved; second, no correlation is found in vivo between the extent of intestinal injury and the degree of inhibition of prostaglandin synthesis; third, bile flow interruption in animal models completely prevents intestinal damage by parenterally administered NSAIDs. What is in bile that could play a role in NSAID toxicity? This timely review will critically discuss the role of bile salts in NSAID-dependent gut damage.

Gastrointestinal perforation in very low-birthweight infants

BACKGROUND

Spontaneous isolated gastrointestinal perforation (SIP) in very low-birthweight infants has been reported as a different disease entity from necrotizing enterocolitis (NEC). The objective of this study was to investigate the incidence and risk factors of NEC and SIP.

METHODS

The authors reviewed the medical records of very low-birthweight infants who were admitted to Toho University Perinatal Center, Tokyo, Japan, between 1 January 1991 and 31 December 2002. The diagnosis of NEC was made with the finding of bloody gastric fluid or stool, abdominal distention, and abnormal abdominal X-ray findings such as pneumatosis intestinalis or fixed dilated intestinal loops. SIP was defined at laparotomy as the presence of an isolated gastrointestinal perforation surrounded by normal appearing bowel.

RESULTS

A total of 556 very low-birthweight infants were included in this study. Of those, 15 infants were excluded because of major anomalies. Out of 541 infants, 14 were diagnosed to have NEC or gastrointestinal perforation. In total, 13 infants had gastrointestinal perforation and 10 were confirmed as SIP. Two SIP suggestive cases were included in SIP cases. There was only one case of NEC (0.2%) during 12 years in the authors' institute. Eight SIP cases had antenatal nonsteroidal anti-inflammatory drugs (NSAID). The treatment with antenatal NSAID was significantly associated with the incidence of SIP (p<0.001).

CONCLUSION

The authors experienced only one proven case of NEC (0.2%), 12 cases of SIP (2.2%) among 556 very low-birthweight infants admitted during 12 years. Antenatal NSAID were strongly associated with SIP.

New insights into spontaneous intestinal perforation using a national data set: (1) SIP is associated with early indomethacin exposure

BACKGROUND

Spontaneous intestinal perforation (SIP) is increasingly common in the premature infant and is associated with significant morbidity. Indomethacin use has been implicated as a co-risk factor for SIP when combined with glucocorticoids, but previous evidence argued against indomethacin being an independent risk factor when used prophylactically.

OBJECTIVES

(1) To establish a homogeneous cohort of SIP patients in a national data set and to contrast them to patients with surgical necrotizing enterocolitis (NEC). (2) To test the hypothesis that early post-natal indomethacin is independently associated with SIP.

METHODS

A large de-identified data set was retrospectively queried by diagnosis, and then multiple antenatal and post-natal variables were tested by both univariate and multivariate analysis to identify associations with SIP. Sub-analyses were also performed to look at the timing of drug administration.

RESULTS

There were 2105 patients evaluated in the data set. Patients were divided into matched controls (n = 581), those with SIP without report of NEC (n = 633) and those with NEC requiring surgery (n = 891). Infants with SIP were more likely to have a patent ductus arteriosus and more likely to be treated with vasopressors than either control or NEC patients. Compared to infants with NEC, patients with SIP were smaller, less mature and required more support. SIP was also diagnosed earlier than NEC (median of 7 vs 15 days). Patients with SIP were more likely to be treated with indomethacin, hydrocortisone or both on days of life 0-3 than controls.

CONCLUSIONS

(1) Surgical NEC and SIP have significant differences in presentation, demographics and morbidity. (2) A detailed look at drug timing revealed that early post-natal indomethacin is independently associated with SIP.

Spontaneous gastric perforation in a neonate presenting with massive hydroperitoneum

We report the imaging findings in a case of neonatal spontaneous gastric perforation presenting as massive hydroperitoneum rather than pneumoperitoneum. Plain abdominal radiography showed a diffuse ground-glass opacity with paucity of bowel gas. Subsequent ultrasonography demonstrated numerous echogenic peritoneal fluid collections containing echogenic debris shown at surgery to be due to milk and bile.

Multiple ileal polyps associated with gastrointestinal perforation in a 2-day-old neonate

We experienced a very rare case of a gastrointestinal perforation due to multiple ileal polyps. The patient was a 2-day-old boy who weighed 1,430 g at birth. At neonatal day 2 subdiaphragmatic free air was noted and an emergency operation was performed. During surgery a distended ileum approximately 5 cm in size was found approximately 40 cm distal from the ileocecum, and a perforation was discovered in the distended portion of the intestine. Approximately 8 cm of the ileum was resected, including the distended portion of the intestine, and an ileostomy was performed. Examination of the resected specimen revealed three pedunculated polyps with a perforation proximal to the polyps.

Pretreatment cortisol values may predict responses to hydrocortisone administration for the prevention of bronchopulmonary dysplasia in high-risk infants

OBJECTIVES

To investigate the effect of hydrocortisone treatment on survival without bronchopulmonary dysplasia (BPD) and to study whether serum cortisol concentrations predict the response.

STUDY DESIGN

We performed a randomized, placebo-controlled trial on infants with gestation < or =30 weeks, body weight of 501 to 1250 g, and respiratory failure. Hydrocortisone was started before 36 hours of age and given for 10 days at doses from 2.0 to 0.75 mg/kg per day. Shortly before hydrocortisone treatment, basal and stimulated (ACTH, 0.1 microg/kg) serum cortisols were measured.

RESULTS

The study was discontinued early, because of gastrointestinal perforations in the hydrocortisone group (4/25 vs 0/26, P = .05); 3 of the 4 had received indomethacin/ibuprofen. The incidence of BPD (28% vs placebo 42%, P = 0.28) tended to be lower, and patent ductus arteriosus (36% vs 73%, P = .01) was lower in the hydrocortisone group. The hydrocortisone-treated infants with serum cortisol concentrations above the median had a high risk of gastrointestinal perforation. In infants with cortisol values below the median, hydrocortisone treatment increased survival without BPD.

CONCLUSIONS

Serum cortisol concentrations measured shortly after birth may identify those very high-risk infants who may benefit from hydrocortisone supplementation.

Visible small-intestinal mucosal injury in chronic NSAID users

BACKGROUND & AIMS

Patients who regularly take nonsteroidal anti-inflammatory drugs (NSAIDs) have an increased risk for small-intestinal mucosal ulceration and bleeding, which may present as anemia of undetermined gastrointestinal origin or protein loss. The prevalence and severity of small-intestinal lesions remains unclear. Our aim was to assess the frequency of NSAID-induced small-bowel injury among chronic NSAID users.

METHODS

Ambulatory patients with various types of arthritides who took NSAIDs daily (>3 mo duration) or took either acetaminophen alone or nothing were enrolled in the study. All patients fasted overnight and underwent wireless video capsule endoscopy. Two investigators, blind to therapy, reviewed each video beginning after the pylorus. Lesions were scored as normal, red spots, small erosions, large erosions, or ulcers. An ulcer was defined as a larger lesion with apparent depth and a definite rim.

RESULTS

Forty-one patients, 36 men and 5 women, ages ranging from 22 to 66 years (mean age, 49.8 y) were analyzed including 21 chronic NSAID users and 20 control patients. Small-bowel injury was seen in 71% of NSAID users compared with 10% of controls (P < .001). Injury was mild (few or no erosions, absence of large erosions/ulcers) in 10 NSAID users compared with 2 controls. Five NSAID users had major (>4 erosions or large ulcers/ulcers) damage compared with none in the control group. There were no complications or problems with the capsule endoscopy procedure.

CONCLUSIONS

Endoscopically evident small-intestinal mucosal injury is very common among chronic NSAID users. The role of endoscopically evident injury in unexplained iron-deficiency anemia and hypoalbuminemia among chronic NSAID users remains undetermined.

Toxic effects of nonsteroidal antiinflammatory drugs on the small bowel, colon, and rectum

The gastrointestinal toxicity of conventional nonsteroidal antiinflammatory drugs (NSAIDs) is not confined to the stomach and proximal duodenum but extends also to the rest of the small bowel, colon, and rectum. Long-term NSAID therapy usually induces clinically silent enteropathy characterized by increased intestinal permeability and inflammation. Chronic occult bleeding and protein loss may result in iron-deficiency anemia and hypoalbuminemia. NSAIDs can also induce small bowel ulcers that infrequently lead to acute bleeding, perforation, or chronic scarring responsible for diaphragm-like strictures. At the colon and rectum, NSAID use can result in de novo lesions such as nonspecific colitis and rectitis, ulcers, and diaphragm-like strictures. NSAIDs have been implicated in the development of segmental ischemic colitis. In patients with diverticular disease, NSAID use increases the risk of severe diverticular infection and perforation. NSAIDs can trigger exacerbations of ulcerative colitis or Crohn's disease. With selective COX-2 inhibitors, the risk of gastrointestinal toxicity is reduced as compared to conventional NSAIDs but is not completely eliminated. Experimental studies suggest that long-term COX-2 inhibitor therapy may cause damage to the previously healthy small bowel. Similar to conventional NSAIDs, COX-2 inhibitors may be capable of triggering exacerbations of inflammatory bowel disease.

Variations in incidence of necrotizing enterocolitis in Canadian neonatal intensive care units

OBJECTIVES

Necrotizing enterocolitis (NEC) is the most common acquired intestinal disease of neonates. Previous reports on incidence have generally examined small cohorts of extremely low-birth-weight infants and have not examined risk-adjusted variations among neonatal intensive care units (NICUs). The authors examined risk-adjusted variations in the incidence of NEC in a large group of Canadian NICUs and explored possible therapy-related risks.

METHODS

The authors obtained data on 18,234 infants admitted to 17 tertiary level Canadian NICUs from January 1996 to October 1997. They used multivariate logistic regression analysis to examine the inter-NICU variation in incidence of NEC, with adjustment for population risk factors and admission illness severity, and explored therapy-related variables.

RESULTS

The incidence of NEC was 6.6% (n = 238) among 3,628 infants with birth weight < or = 1,500 g (VLBW), and 0.7% (n = 98) among 14,606 infants with birth weight > 1,500 g (HBW). Multivariate logistic regression analysis showed that for VLBW infants, NEC was associated with lower gestational age and treatment for hypotension and patent ductus arteriosus. Among HBW infants, NEC was associated with lower gestational age, presence of congenital anomalies (cardiovascular, digestive, musculoskeletal, multiple systems) and need for assisted ventilation. There was no significant variation in the risk-adjusted incidence of NEC among NICUs, with the exception of one NICU reporting no cases of NEC.

CONCLUSIONS

Risk factors for NEC were different in VLBW and HBW infants. There was no significant variation in the risk-adjusted incidence of NEC among Canadian NICUs, with one possible exception.

Current issues in the management of necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is the most common surgical emergency in the neonatal intensive care unit and remains a major cause of death in neonates. Although the pathophysiology of NEC has not been completely elucidated, progress has been made in the characterization of the molecular events which may take place during an episode of ischemia. This possible initiating event is followed by a complex cascade of inflammatory mediators active in NEC: epidermal growth factor, platelet-activating factor, and, nitric oxide. Additionally, unique characteristics of the premature gut are thought to be crucial to the development of NEC. The diagnosis of NEC continues to be based on clinical and radiographic features. Several new laboratory tests are under investigation for the purposes of earlier diagnosis, but none have prevailed at this time. Both exploratory laparotomy, with intestinal resection and peritoneal drainage are widely practiced. Mortality rates remain high and have improved little over the last couple of decades. Therefore, prevention remains crucial in order to decrease the incidence of NEC. Cautious feeding regimens, the use of maternal breast milk, passive immunization, and the use of probiotics have all been suggested but not proven as possible preventive methods. Although many advances have been made, significant opportunity remains to improve our understanding of the disease process and to develop better strategies for prevention and treatment.

Peritoneal drainage as definitive management of intestinal perforation in extremely low-birth-weight infants

BACKGROUND/PURPOSE

The optimal management of extremely low-birth-weight (ELBW) infants with intestinal perforation remains unclear. The authors evaluated ELBW neonates with intestinal perforation in whom peritoneal drainage (PD) was intended as definitive therapy.

METHODS

The records of 29 consecutive ELBW infants with intestinal perforation were reviewed. All underwent PD. Survival, the need for other abdominal procedures, the transition to enteral feeding, and the incidence of cholestasis and infectious complications were noted. Variables associated with nonsurvival were assessed.

RESULTS

Overall survival rate was 66%. In 24% of cases, a second abdominal procedure was required. Full feedings were achieved at a mean of 69 days. Extraabdominal infectious complications occurred in 63% of survivors, and direct bilirubin was greater than 2.0 mg/dL in 57% at 2 months. Thrombocytopenia and vasopressor requirements at the time of perforation were associated with nonsurvival.

CONCLUSIONS

In this consecutive series of ELBW infants in whom PD was intended as definitive treatment for intestinal perforation survival was comparable with that found in series in which immediate laparotomy and resection were used. Few secondary abdominal procedures were required. The interval between PD and full enteral nutrition, however, was long, and the incidence of nonabdominal infectious complications and cholestasis was substantial.

Non-steroidal anti-inflammatory drugs, aspirin and newly diagnosed colitis: a case-control study

BACKGROUND

There have been a number of reports of colitis following exposure to non-steroidal anti-inflammatory drugs (NSAIDs) and salicylates.

AIM

To conduct a case-control analysis of new cases of colitis, with particular reference to the usage of NSAIDs and salicylates prior to the development of the disease.

METHODS

One hundred and five consecutive new cases of colitis presenting to a single gastroenterologist were questioned about their recent usage of NSAIDs and salicylates. For comparison, the frequency of usage of these compounds was studied in two groups of 105 age- and sex-matched controls taken from hospital in-patients and community cases attending the Accident and Emergency Department.

RESULTS

Of the 105 cases of colitis studied, 78 patients (74%) had been taking NSAIDs or salicylates prior to or during the development of their disease. By comparison, 20% of community controls were using NSAIDs or salicylates (P < 0.001) and 30% of hospital in-patients were taking these compounds (P < 0.001). Comparison of these frequencies with those of the colitis group gave odds ratios of 9.1 (4.5, 21.9) with the community controls and 6.2 (3.2, 13.5) with the hospital controls.

CONCLUSIONS

In new patients presenting with colitis, there is a significantly high frequency of antecedent exposure to NSAIDs or salicylates, supporting the concept that these agents may be important in the pathogenesis of colitis.

Patent ductus arteriosus in micropreemies and full-term infants: the relative merits of surgical ligation versus indomethacin treatment

BACKGROUND/PURPOSE

Treatment of ductus arteriosus is controversial. The merits and timing of ductus ligation versus indomethacin treatment were compared.

METHODS

Study parameters for infants with PDA (June 1988 through March 2001) included age, weight, physical findings, echocardiograph, success/complications of treatment, and length of stay (LOS). Statistical analysis was by descriptive univariate analysis.

RESULTS

Two hundred twelve infants were included. Median gestational age was 26 weeks (range, 22-38); weight, 836 g (447 to 2,863). Findings included murmur (94%), congestion (20%), cardiomegaly (15%), bounding pulses (6%), hyperdynamic precordium (4%), and CHF (2%). Echocardiographic measurements were left atrial diameter, 0.92 cm; posterior wall thickness, 0.26 cm; PDA diameter, 2.5 mm; septal thickness, 0.27 cm; aortic root diameter, 0.64 cm; ejection fraction, 39%; left ventricular internal diameter-diastole, 1.3 cm; left ventricular internal diameter-systole, 0.82 cm; right ventricular internal diameter-diastole, 0.51 cm. No measurement, except PDA diameter, was predictive of medical failure or need for reoperation. However, weight less than 1,000 g was highly predictive of medical failure. Additional cardiac anomalies included ASD (69%), VSD (3%), and aortic coarctation (1%). One hundred sixty-seven babies (79%) received indomethacin, closing the PDA in 88 cases (53%, recurrence = 47%). Indomethacin complications (73%) included thrombocytopenia (36%), BUN increase (31%), sepsis (30%), oliguria (25%), hyponatremia (25%), IVH (16%), pulmonary interstitial emphysema (11%), NEC (8%), intestinal perforation (4%), and bleeding (3%). Seventy-seven babies (36%) required operations (92% in the NICU) performed by pediatric surgeons. Ligation criteria included hypoxia, hypercapnia, decreasing compliance, CHF, and contraindications/failure of indomethacin. Complications included pneumothorax (4%), IVH (4%), bleeding (4%), NEC (1%), and wound infection (1%). LOS averaged 82 days.

CONCLUSIONS

Although indomethacin therapy is a reasonable treatment alternative, it is associated with significant complications. Ductus ligation may be preferable, especially in very low birth weight babies, because it is associated with low morbidity and almost certain degree of success.

Spontaneous localized intestinal perforation in very-low-birth-weight infants: a distinct clinical entity different from necrotizing enterocolitis

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.

Indomethacin, dexamethasone, and intestinal damage in infant rats

BACKGROUND

Indomethacin is commonly used in the Neonatal Intensive Care Unit to induce closure of the patent ductus arteriosus and to prevent intraventricular hemorrhage. It is known that indomethacin causes intestinal ulceration in adults, but its effect in infants is less clear. In a preliminary experiment, it was found that the administration of 10 mg/kg/d of indomethacin, a dose that damages the adult rat intestine, had no detrimental effects on newborn suckling rats whereas dexamethasone at 0.25 mg/kg/d caused significant growth failure and villous blunting. It was then hypothesized that the lack of intestinal damage with indomethacin in infants was related to protection given by mother's milk.

METHODS

Subsequent experiments were performed wherein 10 mg/kg/d of indomethacin was provided to infant mother-reared, infant artificially fed, and adult rats. The expression of intestinal cyclooxygenases in the prostaglandin synthetic pathway of control rats was examined to initiate an exploration into a mechanism for the developmental response to indomethacin.

RESULTS

Mother-reared and artificially fed infant rats demonstrated resistance to the ulcerogenic effects of indomethacin, in contrast to the adults. A differential presence of cyclooxygenase-1 and cyclooxygenase-2 was not distinctly seen between infancy and adulthood.

CONCLUSIONS

The results indicate that a varying response to the damaging effects of indomethacin on the intestine occurs during development with the infant being less susceptible than the adult. This differed from the effects of dexamethasone administration, which caused significant intestinal atrophy in the infant rats. The intestinal protection to the effects of indomethacin in infants is not dependent on mother's milk or a developmental difference in the prostaglandin biosynthetic pathway.

Advances in fetal and neonatal surgery for gastrointestinal anomalies and disease

The last decade has seen considerable improvement in the understanding and treatment of neonatal surgical disorders. Translation of basic molecular biology research to clinical practice has directly improved the understanding and treatment of a number of congenital, developmental disorders, such as Hirschsprung's disease and congenital hyperinsulinism. Miniaturized instruments and improved optics have permitted increased use of videoscopic and minimally invasive techniques to even the smallest infants. Continued improvements in prenatal imaging will permit enhanced understanding of the prenatal natural history of congenital structural disorders and the development of more specific therapies. Finally, rigorous clinical research tools have begun to be applied to rare pediatric surgical disorders with the use of organized multicenter trials. It is an exciting time for all involved in the care of neonates.

Clinical implications of prostaglandin inhibition in the small bowel

NSAID-induced intestinal toxicity is more common than previously recognized and may have clinically significant sequelae, especially in elderly arthritic patients. Increased awareness of the potential intestinal complications associated with prostaglandin inhibition is required for early recognition and appropriate management. An increase in the level of suspicion by physicians may lead to earlier diagnosis and subsequent discontinuation of the offending NSAID; this is important in that discontinuation of the offending agent may be preferable to multiple endoscopic radiologic and surgical procedures in the patient with obscure blood loss and anemia. Appropriate diagnosis in selected patients may prevent the increased morbidity and mortality associated with small intestinal surgery. The emergence of selective COX-2 inhibitors likely will bring this issue to the forefront because it will become increasingly important to determine the effects of these agents on the small intestine and colon, in addition to their effects on the gastroduodenal mucosa. The new generation of selective COX-2 inhibitors may offer a potential therapeutic advantage over the nonselective NSAIDs with respect to their intestinal toxicity. Well-designed safety trials that have intestinal injury as a predefined end point will provide important information as to the overall gastrointestinal safety of these compounds. These agents must be evaluated with respect to their overall safety profile and not just by their gastrointestinal safety. Nevertheless, these agents are continuing to provide new directions for exciting basic and clinical scientific investigation.

Peritoneal drainage as definitive treatment for neonates with isolated intestinal perforation

BACKGROUND/PURPOSE

To better define the indications for peritoneal drainage (PD) in premature babies with intestinal perforation, the authors reviewed their experience with this procedure in a tertiary neonatal intensive care setting.

METHODS

The charts of all neonates who underwent PD as initial treatment for intestinal perforation between 1996 and 1999 were reviewed. Those patients with pneumatosis intestinalis on abdominal radiograph had perforated necrotizing enterocolitis (NEC) diagnosed; whereas, those infants with no pneumatosis had isolated intestinal perforation diagnosed. The clinical characteristics and outcomes of these 2 groups were compared.

RESULTS

Twenty-one premature neonates had primary PD between 1996 and 1999, 10 for isolated intestinal perforation and 11 for perforated NEC. Patients with isolated intestinal perforation had lower birth weights (708 v 949 g; P < .05), were less likely to have started feedings (30% v 91%, P < .05), and the perforation developed at an earlier age (10.6 v 28.0 d, P < .05) compared with the patients who had perforated NEC. Only 2 of 10 infants with isolated perforation required subsequent laparotomy (at 10 weeks for stricture and 12 weeks for a persistent fistula). For these patients, the long-term survival rate was 90%. In contrast, 8 of 11 infants with perforated NEC required laparotomy, and although the 30-day survival rate was 64%, the long-term survival rate was only 27%.

CONCLUSIONS

Peritoneal drainage provides successful and definitive treatment for most premature babies with isolated intestinal perforation. For neonates with perforation caused by NEC, peritoneal drainage may provide temporary stabilization, but most of these infants require subsequent laparotomy, and few survive.

Indomethacin-associated bowel perforations: a study of possible risk factors

BACKGROUND

The association between indomethacin administration and bowel perforation in premature infants is well known. The goal of this study was to examine possible risk factors for this complication.

METHODS

Fifteen cases of indomethacin-associated bowel perforation occurred from 1993 to 1996. All had a birth weight < or = 1,100 g. These patients were compared with a control group of 51 infants who were cared for contemporaneously, had birth weights < or = 1,100 g and received indomethacin.

RESULTS

Survival rate in the control group was 96%. For the group with perforations, it was 53%. Two types of perforation were seen, one occurring in the setting of necrotizing enterocolitis, and the other, a simple perforation in an otherwise normal-appearing bowel. For the latter group, the survival rate was 86%, and, when possible, primary repair was the procedure of choice. Use of aminophylline was greater in the control group. Otherwise, there were no significant differences between the two groups in any of the variables observed. However, when the simple perforations were observed separately, these patients had, on average, received indomethacin at a younger age than the controls (P < .05). The clustering of perforation cases from May through August suggests an infectious agent might be involved.

CONCLUSIONS

Earlier administration of indomethacin correlates with an increased risk of focal perforation. It is unclear, however, whether the risk factor is the drug itself or the earlier need for it. Aminophylline use was somewhat more in the control group, but this is not likely to reflect a protective role for that drug. The possible involvement of an infectious agent should be considered.

Multiple intestinal ulcerations and perforations secondary to methicillin-resistant Staphylococcus aureus enteritis in infants

PURPOSE

The aim of this study was to define a distinctive clinical entity of multiple intestinal ulcerations and perforations in infants.

METHODS

Two infants underwent abdominal exploration for surgical abdomen and were noted to have multiple intestinal ulcerations and perforations. A peculiar and unique surgical finding, numerous transverse linear ulcerations scattered along the entire small intestine, prompted us to search for similar instances. Five similar cases were additionally identified by members of the Korean Association of Pediatric Surgeons. The clinical courses, the surgical findings, and the results of bacterial cultures were reviewed. As well, the tissues of resected intestines were examined histopathologically.

RESULTS

The characteristics of this entity are as follows. (1) It usually occurs in infants who have been treated with broad-spectrum antibiotics. (2) Despite broad-spectrum antibiotic treatment, diarrhea and abdominal distension developed progressively and deteriorated. (3) Histological evaluation showed mucosal ulcers with neutrophil infiltration, submucosal microabscesses, and colonies of Gram-positive cocci. (4) Methicillin-resistant Staphylococcus aureus (MRSA) was the predominant organism cultured from the body fluid. (5) Only two cases, the completely resected one and the one immediately treated postoperatively with vancomycin, survived.

CONCLUSIONS

This entity is caused by multiple intestinal ulcerations and perforations secondary to MRSA enteritis in infants. It has a high mortality rate because of its difficult diagnosis. However, early recognition of this entity can lead to successful treatment.

Upper gastrointestinal tract bleeding in critically ill pediatric patients

Similar to adults, children under physiologic stress can develop an imbalance in defensive (mucosal layer, motility) and aggressive (gastric acid, bile salts, enzymes) factors responsible for maintaining a healthy gastrointestinal tract. Hypoxia in the gastrointestinal tract likely disrupts the defensive factors, thereby permitting damage by aggressive factors to upper gastrointestinal epithelium that may progress to stress ulceration and acute upper gastrointestinal tract bleeding (UGIB). The basic pathophysiology may be similar in children and adults; however, differences in the time to developing ulceration, ulcer location, and number of ulcers have been reported. Functional development of the gastrointestinal tract is influenced by disease, gestational and postnatal age, and exposure to and type of enteral feedings, thereby confounding the development and prophylaxis of UGIB in neonates and infants. In addition, pharmacotherapy decisions are often complicated by drug administration issues and adverse effects.

Gastrointestinal side effects of nonsteroidal anti-inflammatory drugs

The gastrointestinal (GI) tract is the most common location for side effects of nonsteroidal anti-inflammatory drugs (NSAIDs). These drugs may cause problems in any part of the GI tract, from the esophagus to the rectum. The severity of these side effects ranges from nuisance symptoms such as dyspepsia to life-threatening ulcer complications. The diagnosis, treatment, and prevention of the various GI side effects of these commonly prescribed drugs are reviewed in this article.

Indomethacin-induced reduction in neonatal piglet mesenteric blood flow is blunted by dopexamine

BACKGROUND

Dopexamine is a specific dopaminergic and beta2-adrenergic agonist. Using newborn piglets, we have previously shown that (1) dopexamine increases cardiac output and mesenteric blood flow; (2) indomethacin reduces mesenteric blood flow.

METHODS

Ultrasonic blood flow probes were placed around the ascending aorta, cranial mesenteric artery, and a renal artery of 0 to 2-day-old and 2-week-old piglets. Animals of each age were grouped (5 to 8 animals per group) and subjected to one of three experimental protocols: (1) 0.4 mg/kg indomethacin infusion, (2) 10 microg/kg/min dopexamine infusion begun 10 minutes before indomethacin, or (3) no treatment.

RESULTS

Control animals demonstrated no significant alterations in mesenteric blood flow. Compared with baseline, indomethacin produced significant (P< .05, analysis of variance) declines in cranial mesenteric artery blood flow in 0 to 2-day old (37.2+/-5.7 mL/min v 17.9+/-3.7 mL/min at 90 min), and 2-week-old (80.2+/-12.5 mL/min v 29.7+/-5.7 mL/min at 90 minutes) piglets. In both animal groups treated with dopexamine before indomethacin, the decreases in cranial mesenteric artery blood flow were eliminated (38.4+/-7.6 mL/min at baseline v 36.5+/-6.8 mL/min at 90 minutes in 0 to 2 day olds; 79.9+/-10.0 mL/min at baseline v 77.5+/-14.7 mL/min in 2 week olds). Indomethacin-induced declines in renal blood flow were similarly abrogated by dopexamine.

CONCLUSION

Dopexamine may prove of clinical benefit when a neonate is considered a candidate for indomethacin therapy.