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Sakaria RP, Zaveri PG. Neonatal Gastric Perforation: 14-Year Experience from a Tertiary Neonatal Intensive Care Unit. Am J Perinatol 2021. [PMID: 34327684 DOI: 10.1055/s-0041-1733780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Neonatal gastric perforations (NGPs) are rare and account for 7 to 12% of all gastrointestinal perforations in the neonatal period. The etiology and prognostic factors associated with NGP remain unclear. The aim of this study is to review the cases of NGP in our neonatal intensive care unit (NICU) in the past 14 years and describe the risk factors, clinical presentation, and outcomes associated with it. STUDY DESIGN A retrospective chart review of neonates with gastric perforation admitted to the NICU between June 2006 and December 2020 was performed. Data regarding their antenatal and neonatal characteristics, laboratory and radiological results, intra-operative findings, hospital course, and outcomes were recorded. RESULTS We identified 350 patients with gastrointestinal perforation at our center during the study period of which 14 (4%; nine males and five females) patients were diagnosed with NGP during surgery. A total of 71% neonates were born preterm (range: 24-39 weeks, median: 34 weeks). Two neonates (14%) were SGA. Only one neonate received cardiopulmonary resuscitation at birth. In all neonates, except two, perforation occurred within the first 10 days of life (median: 4 days, range: 1-22 days). In total, 79% infants received feeds prior to perforation. Ten neonates had a feeding tube, and one neonate had a gastrostomy tube placed prior to perforation. Abdominal distension and pneumoperitoneum were present in all neonates. Majority of the babies had metabolic acidosis (64%) and elevated C-reactive protein (79%). Most (86%) neonates received surgical intervention within 12 hours. Overall survival in our study was 93%. CONCLUSION NGP is a rare entity seen mostly in preterm infants within the first 10 days of life. Clinical presentation is similar to perforation anywhere along the gastrointestinal tract and definite diagnosis requires exploratory laparotomy. With prompt recognition and surgical intervention, the overall mortality related to neonatal gastric perforation is low. KEY POINTS · Neonatal gastric perforation is a rare but life threatening entity with unclear etiology.. · Prematurity is associated with an increased incidence of gastric perforations in the neonate.. · Laparotomy is required for definitive diagnosis and treatment..
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Affiliation(s)
- Rishika P Sakaria
- Division of Neonatology, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Parul G Zaveri
- Division of Neonatology, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
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Chuang YH, Fan WL, Chu YD, Liang KH, Yeh YM, Chen CC, Chiu CH, Lai MW. Whole-Exome Sequencing Identified Novel CLMP Mutations in a Family With Congenital Short Bowel Syndrome Presenting Differently in Two Probands. Front Genet 2021; 11:574943. [PMID: 33384711 PMCID: PMC7770137 DOI: 10.3389/fgene.2020.574943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 11/23/2020] [Indexed: 11/13/2022] Open
Abstract
Congenital short bowel syndrome (CSBS) is a rare condition characterized by an inborn shortening of bowel length with loss of intestinal functions, which often combines malrotation. CXADR-like membrane protein (CLMP) and filamin A (FLNA) gene mutations are the two major causes of this inherited defect. We presented two siblings with the older brother suffering from a laparotomy for bowel obstruction due to malrotation on the 17th day after birth. The younger sister encountered a laparotomy for lactobezoar at 6 months old. CSBS was diagnosed by measurement of the bowel length during the operations. Compound heterozygous CLMP mutations with the paternal allele harboring a long deletion across exon 3-5 and the maternal allele bearing a non-sense mutation of exon 3 (c.235C > T, p.Q79∗) were identified in both cases. They are the first reported familial CSBS caused by novel CLMP mutations in Taiwan.
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Affiliation(s)
- Yao-Hung Chuang
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Children's Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Wen-Lang Fan
- Genomic Medicine Research Core Laboratory, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Yu-De Chu
- Liver Research Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Kung-Hao Liang
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Food Safety and Health Risk Assessment, National Yang-Ming University, Taipei, Taiwan.,Institute of Biomedical Informatics, National Yang-Ming University, Taipei, Taiwan
| | - Yuan-Ming Yeh
- Genomic Medicine Research Core Laboratory, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Chien-Chang Chen
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Children's Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Cheng-Hsun Chiu
- Genomic Medicine Research Core Laboratory, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, Taiwan.,Division of Pediatric Infectious Disease, Department of Pediatrics, Chang Gung Children's Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Ming-Wei Lai
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Children's Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,Liver Research Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
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Zeidan S, Akkary R, Jawad N, Al Hamod D, Haidar Z, Diab N. Lactobezoar causing neonatal gastric perforation. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2019. [DOI: 10.1016/j.epsc.2019.101192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Longardt AC, Loui A, Bührer C, Berns M. Milk Curd Obstruction in Human Milk-Fed Preterm Infants. Neonatology 2019; 115:211-216. [PMID: 30646004 DOI: 10.1159/000494625] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 10/17/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Milk curd obstruction as a cause of intestinal obstruction has been known since 1959, but has nearly disappeared. However, in recent years it has experienced a revival in small premature infants. OBJECTIVE The aim of this study was to evaluate the clinical characteristics of milk curd obstruction (lactobezoar) in preterm infants. METHODS Data of preterm infants with milk curd obstruction cared for at a large tertiary neonatal intensive care unit between 2012 and 2016 were retrieved from the electronic registry and paper records. RESULTS A total of 10 infants (2 girls, 8 boys) were identified: the median birth weight was 595 g (range 270-922), gestational age was 24.4 weeks (23.4-27.0), weight-for-gestational age percentile was 16 (0-62), and age at diagnosis was 28 days (16-64). Five infants (50%) were small for gestational age. All neonates had received fortified human milk (added protein 2.0 g/100 mL, range 0-2.8; added calcium 2,400 µmol/100 mL, range 0-6 844; added phosphate 2,400 µmol/100 mL, range 0-5,178). Seven neonates underwent surgery, and 2 infants died. Hyperechoic masses in extended bowel loops, visualised by abdominal ultrasound, and pale/acholic faeces were hallmarks of milk curd obstruction. CONCLUSIONS In this study, milk curd obstruction occurred exclusively in infants with a birth weight < 1,000 g (2.2%) and < 28 weeks' gestational age (2.4%). Male and small for gestational age infants appeared to be at increased risk. Paying attention to the colour of the faeces of infants at risk might help to diagnose milk curd obstruction at an early stage.
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Affiliation(s)
- Ann Carolin Longardt
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany,
| | - Andrea Loui
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Bührer
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Monika Berns
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Iacusso C, Boscarelli A, Fusaro F, Bagolan P, Morini F. Pathogenetic and Prognostic Factors for Neonatal Gastric Perforation: Personal Experience and Systematic Review of the Literature. Front Pediatr 2018; 6:61. [PMID: 29670869 PMCID: PMC5893822 DOI: 10.3389/fped.2018.00061] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Accepted: 03/02/2018] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION Neonatal gastric perforation (NGP) is a rare entity. Our aim was to report our experience and review the recent literature to characterize NGP, describe associated factors, and define prognostic factors. MATERIALS AND METHODS Retrospective review of all consecutive patients with NGP treated between June 2009 and December 2017 in a third level pediatric hospital. In addition, a systematic review of Medline and Scopus database was performed using a defined strategy. All articles referring to NGP published between 2005 and 2017 were retrieved. Variables considered: prematurity (<37 weeks gestation), birth weight (BW), Apgar score, prenatal complications, age at diagnosis, bag ventilation, pathogenetic events, site of perforation, treatment of perforation, sepsis, and outcome. Mann-Whitney or Fisher's test were used as appropriate. Results are median (range) or prevalence. RESULTS Between 2009 and 2016 we treated 8 consecutive patients for NGP and 199 further cases were retrieved from the systematic review (total of 207 patients). Overall survival was 73%. Most frequently reported pathogenesis: iatrogenic (20 patients), hypoxic/ischemic or infection stress (13 patients), duodenal/jejunal obstruction (11 patients), drugs (11 patients), esophageal atresia (10 patients). 60% patients had only primary repair of the perforation as gastric surgery. Sepsis developed in 56 patients (34%). CONCLUSION Although the pathogenesis of NGP is pleomorphic, prematurity and low BWs are frequent in these patients. Reviewing our experience and the available literature, none of the variables considered, but sepsis was associated with mortality.
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Affiliation(s)
- Chiara Iacusso
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alessandro Boscarelli
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Fabio Fusaro
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Pietro Bagolan
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Francesco Morini
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Treatment of a gastric lactobezoar with N-acetylcysteine. Case Rep Gastrointest Med 2014; 2014:254741. [PMID: 25505999 PMCID: PMC4258365 DOI: 10.1155/2014/254741] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 10/28/2014] [Indexed: 12/17/2022] Open
Abstract
Lactobezoars are a rare finding with potentially serious sequelae in pediatric patients with feeding intolerance. Aggressive treatment may be preferred to traditional treatments to avoid complications in medically complex patients. In our patient, N-acetylcysteine lavage was a safe and effective alternative that resulted in rapid resolution of his feeding intolerance.
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Bos ME, Wijnen RMH, de Blaauw I. Gastric pneumatosis and rupture caused by lactobezoar. Pediatr Int 2013; 55:757-60. [PMID: 23789736 DOI: 10.1111/ped.12164] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Revised: 04/12/2013] [Accepted: 06/11/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Lactobezoar is a compact mass of inspissated, undigested milk. Most often it is located in the stomach but it may also be located in other parts of the intestine. It is the most common type of bezoar in infancy. Reported herein are two cases of this rare condition mimicking necrotizing enterocolitis. METHOD Data on two complicated cases of lactobezoar were retrospective analyzed. RESULTS The first case involved a female infant, born at 37 weeks 2 days gestation with a birthweight of 3050 g, and multiple antenatal known congenital defects. Due to esophageal atresia she was given a gastrostomy on the second day of life. After 20 days of continuous feeding with formula feeding she developed food intolerance and clinical signs of a severe sepsis. On examination the abdomen was severely distended and tender at palpation. No palpable mass was noted at examination. Signs of hemodynamic instability and sepsis evolved. Plain abdominal X-ray showed a pneumatosis of the stomach matching necrotizing enterocolitis (NEC). During emergency laparotomy a gastric bezoar was seen and removed. The postoperative course was complicated by prolonged motility disturbance of the stomach. For a long time she was fed through a jejunostomy. The second case involved a female infant born at 26 weeks 4 days (birthweight 1040 g) who became progressively septic on the day 6 of life. On examination she had a tender and distended abdomen, and abdominal X-ray showed intra-abdominal air, consistent with a gastrointestinal perforation. On emergency laparotomy a perforation was seen at the back of the stomach, due to a lactobezoar, with only a little necrosis surrounding it. Surgical treatment consisted of extraction of the lactobezoar and closure of the perforation at the back of the stomach. Two days after the initial surgery, she developed a leakage of the suture anastomosis and another laparotomy was performed. A drain was left near the stomach. After 2 weeks she recovered quickly and feeding was initiated at day 21 with good outcome after 3 months. CONCLUSION Factors associated with the development of lactobezoar are prematurity, low birthweight, disturbed gastric emptying, hypercaloric and hyperosmolaric milk compositions. It is important to realize that lactobezoar formation can occur in preterm and full-term infants, receiving either breast milk or formula, even when only minimal enteral feeding is given. Early recognition and treatment of this condition is critical. If a lactobezoar is not detected in an early phase, patients can deteriorate very quickly into a condition mimicking NEC.
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Affiliation(s)
- Marthel E Bos
- Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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Murase M, Miyazawa T, Taki M, Sakurai M, Miura F, Mizuno K, Itabashi K, Toki A. Development of fatty acid calcium stone ileus after initiation of human milk fortifier. Pediatr Int 2013; 55:114-6. [PMID: 23409991 DOI: 10.1111/j.1442-200x.2012.03630.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We report a case who was born with extremely low birth weight infant and had experienced abdominal operation for necrotizing enterocolitis, eventually developed ileus due to fatty acid calcium stones after giving human milk fortifier. He had developed necrotizing enterocolitis on day 30 of his age, such that we performed enterectomy and ileostomy. He could not tolerate enteral feeding fully, because intestinal fistula infection was repeated. Although we administered hindmilk, he grew up slowly and he suffered cholestasis as well. We performed end-to-end anastomosis to prevent fistula infections on day 87. After this operation, breast milk feeding volume was increased easily. However, we started to add HMF of half-strength on day 124, because his body weight gain remained very poor. And we confirmed to intensify the ratio of HMF full-strength on day 128. After that his abdomen had distended on day 131. As there is no effect of conservative therapy to occlusive ileus, we did emergency laparotomy on day 139. Intestinal calculi were impacted at anastomic portion. Although all stones were removed, he died on 144 days due to disseminated intravascular coagulation and renal failure. Calculi analysis revealed that all of them were fatty acid calcium stones. There is no report about like our case. We speculate that the construction of fatty acid calcium result from either high concentration of calcium/phosphorus or rapid increase in the fortification. We could have prevented this case happened by slower increment of fortification.
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Affiliation(s)
- Masahiko Murase
- Departments of Pediatrics Pediatric Surgery, Showa University School of Medicine, Tokyo, Japan.
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Caballero Mora F, Martos Moreno G, Martínez Gómez M, Argente J. Lactobezoar en el inicio clínico de diabetes mellitus tipo 1 con enfermedad celíaca. An Pediatr (Barc) 2012; 76:366-7. [DOI: 10.1016/j.anpedi.2012.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 01/04/2012] [Indexed: 10/28/2022] Open
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Heinz-Erian P, Gassner I, Klein-Franke A, Jud V, Trawoeger R, Niederwanger C, Mueller T, Meister B, Scholl-Buergi S. Gastric lactobezoar - a rare disorder? Orphanet J Rare Dis 2012; 7:3. [PMID: 22216886 PMCID: PMC3307440 DOI: 10.1186/1750-1172-7-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Accepted: 01/04/2012] [Indexed: 12/16/2022] Open
Abstract
Gastric lactobezoar, a pathological conglomeration of milk and mucus in the stomach of milk-fed infants often causing gastric outlet obstruction, is a rarely reported disorder (96 cases since its first description in 1959). While most patients were described 1975-1985 only 26 children have been published since 1986. Clinically, gastric lactobezoars frequently manifest as acute abdomen with abdominal distension (61.0% of 96 patients), vomiting (54.2%), diarrhea (21.9%), and/or a palpable abdominal mass (19.8%). Respiratory (23.0%) and cardiocirculatory (16.7%) symptoms are not uncommon. The pathogenesis of lactobezoar formation is multifactorial: exogenous influences such as high casein content (54.2%), medium chain triglycerides (54.2%) or enhanced caloric density (65.6%) of infant milk as well as endogenous factors including immature gastrointestinal functions (66.0%), dehydration (27.5%) and many other mechanisms have been suggested. Diagnosis is easy if the potential presence of a gastric lactobezoar is thought of, and is based on a history of inappropriate milk feeding, signs of acute abdomen and characteristic features of diagnostic imaging. Previously, plain and/or air-, clear fluid- or opaque contrast medium radiography techniques were used to demonstrate a mass free-floating in the lumen of the stomach. This feature differentiates a gastric lactobezoar from intussusception or an abdominal neoplasm. Currently, abdominal ultrasound, showing highly echogenic intrabezoaric air trapping, is the diagnostic method of choice. However, identifying a gastric lactobezoar requires an investigator experienced in gastrointestinal problems of infancy as can be appreciated from the results of our review which show that in not even a single patient gastric lactobezoar was initially considered as a possible differential diagnosis. Furthermore, in over 30% of plain radiographs reported, diagnosis was initially missed although a lactobezoar was clearly demonstrable on repeat evaluation of the same X-ray films. Enhanced diagnostic sensitivity would be most rewarding since management consisting of cessation of oral feedings combined with administration of intravenous fluids and gastric lavage is easy and resolves over 85% of gastric lactobezoars. In conclusion, gastric lactobezoar is a disorder of unknown prevalence and is nowadays very rarely published, possibly because of inadequate diagnostic sensitivity and/or not yet identified but beneficial modifications of patient management.
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Affiliation(s)
- Peter Heinz-Erian
- Department of Pediatrics, Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria.
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