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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 3  |  Page : 189-191

Spontaneous duodenal perforation in a neonate: A rare case report


Department of Paediatric Surgery, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India

Date of Web Publication6-Aug-2019

Correspondence Address:
Dr. Jayalaxmi Shripati Aihole
Department of Paediatric Surgery, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.JCN_50_19

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  Abstract 


Spontaneous duodenal perforation in neonates (SDPN) is a rare surgical emergency. Only few cases have been reported occurring at the second part of the posterior part of duodenum. The author presents such a rare case of SDPN in a healthy female neonate managed successfully at a tertiary care institute.

Keywords: Duodenal, neonatal, perforation


How to cite this article:
Aihole JS. Spontaneous duodenal perforation in a neonate: A rare case report. J Clin Neonatol 2019;8:189-91

How to cite this URL:
Aihole JS. Spontaneous duodenal perforation in a neonate: A rare case report. J Clin Neonatol [serial online] 2019 [cited 2019 Aug 18];8:189-91. Available from: http://www.jcnonweb.com/text.asp?2019/8/3/189/264041




  Introduction Top


The exact etiology of spontaneous duodenal perforation in neonates (SDPN) has not been clearly identified till now. A possible etiology hypothesized is perforated duodenal ulcer. The author reported such a case of SDPN without any obvious etiology and its diagnostic challenges in its management.


  Case Report Top


A 30-day-old female baby born by full-term vaginal delivery with a birth weight of 3.15 kg to a gravid 3, para 2 mother was referred to us with abdominal distention for 10 days. She was clinically asymptomatic for the immediate 20 days postnatally. Antenatal history as well as ultrasonography scans was essentially normal. She developed progressive abdominal distention with excessive cry and poor feeding for 10 days. She was exclusively breastfed and did not have vomiting, jaundice, history of any drug intake, or any associated coexisting anomalies. She was evaluated in the local hospital with roentgenography and sonography, which were suggestive of a choledochal cyst. The patient was evaluated with ultrasonography and contrast-enhanced computed tomography with oral contrast, which were suggestive of a duodenal duplication cyst [Figure 1]a. With such varied imaging findings, open surgical intervention was contemplated; intraoperatively, the abdomen was essentially normal. However, on kocherization of the duodenum, the author found a tiny duodenal perforation of size 0.4 cm × 0.3 cm in the posteromedial aspect of the second part of the duodenum, with minimal local spillage of the bile in the lesser sac, which was contained [Figure 1]b. The perforation site had healthy edges, and hence closed with an absorbable suture [Figure 2]. She recovered well postoperatively and is on follow-up with us for 3 years.
Figure 1: Contrast-enhanced computed tomography images (a) Red-colored arrow pointing at a heterogeneous space-occupying lesion of size 2.5 cm × 2.2 cm between the first and third parts of the duodenum, abutting the second part of the duodenum, placed anterior to the right kidney and inferomedially to the liver. (b) Red-colored arrow pointing at the lesion displacing the second part of the duodenum medially without any evidence of leak

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Figure 2: (a) Intraoperative picture showing duodenal perforation with local spillage of bile. Blue-colored arrow showing the first part of the duodenum. Green-colored arrow showing spontaneous duodenal perforation at the posteromedial second part. (b) Intraoperative picture. Green-colored arrow showing sutured duodenal perforation

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  Discussion Top


Gastrointestinal perforations without any obvious cause have been described as spontaneous.[1] Neonatal perforations of the duodenum are rare. The suggested etiology is due to distal mechanical obstruction or keeping suction or feeding tubes; however, as per the nomenclature, SDPN is without any obvious etiopathogenesis.[1],[2] One of the probable etiologies suggested is a relatively high acid secretion in neonates during the first 10 days of life, due to high maternal gastrin.[2]

The diagnosis and management of SDPN is challenging because there will be no definitive clinical signs and symptoms of peritonism. The anticipated reason may be due to contained local inflammatory reaction and the resultant fibrosis limited to the retroperitoneal tissue sealing off these perforations, minimizing the signs and symptoms of peritonism,[3] which could be missed on routine examination and by investigations,[1],[3],[4] as witnessed in our case.

Various authors have labeled SDPN, stating it to be occurring spontaneously in an otherwise healthy neonate; however, their babies had some kind of perinatal stress and events as per their own publications. One more rarity we encountered in our case was that the preoperative imaging suggested it to be duodenal duplication and choledochal cyst, but surprisingly, we found a tiny duodenal perforation situated in the posteromedial aspect of the second part of the duodenum which could have been easily missed without proper kocherizing of the duodenum [Figure 2].[4],[5]

Considering all these factors, as per the definition mentioned in the literature, the author considers it to be the first-ever case of spontaneous duodenal perforation occurring in a healthy neonate reported so far in English literature.[3],[4],[5]


  Conclusion Top


Although the cause of SDPN is difficult to determine, it does carry higher mortality. Greater awareness along with higher suspicion from attending surgeon is necessary to allow for earlier identification and to facilitate better patient outcomes in spite of nonconclusive imaging studies.

Informed consent

The parents have given their informed consent.

Declaration of patient consent

The author certify that she has obtained all appropraite patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that the name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Acknowledgment

Author would like to thank all paediatric surgical collegues, paedaitric anesthetsits, OT staffs, radiology staffs of IGICH Bengaluru.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Novel Insights

New information 1

Spontaneous duodenal perforation occurring in a healthy female neonate without much clinical features and in conclusive imaging studies.

New information 2

Decision for surgical intervention in such neonates is challenging; when made, it has to be justified by thorough inspection of the whole of the gastrointestinal tract because the posteromedial aspect of the second part of duodenal perforations can be easily missed without kocherization.

Established Facts

Already-known fact 1

Spontaneous duodenal perforation in neonates (SDPN) is a rare surgical emergency without much definitive clinical signs and symptoms of peritonism.

Already-known fact 2

Published reports in the literature confirm the presence of perinatal stress in neonates leading to the so-called spontaneous duodenal perforation.



 
  References Top

1.
Miller BM, Kumar A. Neonatal duodenal perforation. J Pediatr Gastroenterol Nutr 1990;11:407-10.  Back to cited text no. 1
    
2.
Sarin YK, Jacob S, Bhatti W. Duodenal perforation in a neonate. Indian Pediatr 1998;35:1032-3.  Back to cited text no. 2
    
3.
Bell MJ. Perforation of the gastrointestinal tract and peritonitis in the neonate. Surg Gynecol Obstet 1985;160:20-6.  Back to cited text no. 3
    
4.
Al Omran Y, Anwar MO, Al-Hindi S. Duodenal perforation in a neonate: An unusual presentation and analysis of the cause. J Neonatal Surg 2015;1;4-19.  Back to cited text no. 4
    
5.
Sharma AK, Prabhakar G, Agarwal LD, Sharma CS, Sharma SC, Haldiya KN. Spontaneous duodenal perforation in neonates. Indian J Pediatr 1991;58:383-5.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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Abstract
Introduction
Case Report
Discussion
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