Spontaneous Intestinal Perforation in Neonate

Spontaneous Intestinal Perforation (SIP) have been documented to occur in as many as 8.4 percent of Very Low Birth Weight (VLBW) newborns. SIP can be characterized by a sudden onset and a lack of infectious. However, the presentation in infants affected SIP varies and the etiology is yet to be definitively determined. Yet the consequences of intestinal perforation are potentially severe enough that clinicians should be aware of the possible causes and symptoms. Two main treatments exist for intestinal perforation: peritoneal drainage and laparotomy with resection. We are presenting a case of 2 days old female newborn with SIP, diagnosed by clinical manifestation, abdominal x ray. Patient underwent abdominal drainage and got clinical improvement.


INTRODUCTION
Spontaneous Intestinal Perforation (SIP) have been documented to occur in as many as 8.4 percent of very low birth weight (VLBW) newborns.
1 Gastrointestinal (GI) perforations first appeared in the literature in 1825 when siebold described a gastric perforation in an estimated 34 week gestational age infant. 2 Thelander in 1939 described the first cases of spontaneous perforation in three stillborn infants as perforations proximal to the ileocecal valve.
It was not until the late 1980s that a specific subset of these perforations was defined as SIP.
Aschner et al and Zamir et al were among the first to claim that SIP is an entity with manifestations and outcomes different from those of necrotizing enterocolitis (NEC). 4,5SIP appears to be occurring with increasing frequency as a disease process distinct from NEC.This is perhaps a result of the increasing rate of survival of the VLBW infant,in whom SIP more frequently occurs.

6
SIP can be characterized by a sudden onset and a lack of infectious.However, the presentation in infants affected SIP varies, and the etiology is yet to be definitively determined.The staining is easy to see in premature infants because they lack subcutaneous tissue.This blueblack discoloration of the abdomen has been noted by other investigators. 4This finding was also the most consistent symptom reported by the authors of the studies reviewed for this manuscript. 13In several of the  health condition and concomitant pathologies and is higher in patients with NEC treated surgically.17

CONCLUSION
The incidence of SIP is increasing as more VLBW infants are surviving and since SIP has been identifed as a separate disease from Necrotizing Enterocolitis (NEC).SIP potential to increase morbidity and mortality in premature infants warrants further research to improve outcomes

11
These factors along with the organ immaturity of the neonate can lead to the focal ischemia of the intestinal wall.Umbilical vessels catheterization and therapy with Indomethacine used in profylaxis of haemorrhage to the central nervous system or as a treatment of persistent ductus arteriosus can be the reasons, among other, of intestinal ischemia.9 Mechanical ventilation with nasal prongs or face mask has also been identifed as a risk factor for SIP.The distending pressure transmitted to the intestines could lead to perforation.In a 1985 study, Garland et al reviewed the cases of 15 infants who were ventilated with either face mask or prongs and developed a GI perforation not related to NEC.In this matched case control study, infants ventilated with either mask or prongs were found to be 30 times more likely to experience both upper and lower GI perforations than were infants ventilated with endotracheal tubes.Risk factors for patient were low birth weight and used CPAP.12 The onset of SIP is often insidious,and the patient is clinically stable.Aschner et al reviewed the cases of six LBW neonates with SIP.When compared with neonates with NEC,who generally present with signifcant clinical deterioration, the six infants in this review were remarkably stable.The consistent finding in the review was a blue-black discoloration of the abdominal wall.The reviewers proposed that this discoloration occurs secondary to staining of the underlying tissues by meconium in the peritoneal fluid.

14 The
most common procedure performed in neonates with SIP is two-stages operation.The first stage includes resection of the intestine with perforation with ileostomy performance.Haemodynamic instability during operation is the indication for temporary exposure of the intestine with perforations into the skin.The continuity of the digestive system was restored 3-6 months later which depended on patient' general condition and his/her -tolerance‖ of intestine enterostomy.Final diagnosis of spontaneous intestinal perforation is confrmed by histological assessment.Lymphocyte infltrations, haemorrhagic necrosis, muscle layer defect and multipole thinwalled vessels close to the perforation are characteristic fndings in microscopic evaluation.16 The relevant factor for prognosis in SIP is frequent occurrence of other diseases in neonates with low birth body weight.The most important are concomitant neurological disturbances (intracranial haemmorhages, leucomalation), respiratory distress (broncho-pulmonary dysplasia) and cardiologic disorders (congenital heart diseases).Taking into account above factors the outcome of surgical treatment of the patients with SIP is good.Survival rate ranges from 70 to 100% depending on the patient'