Aust. Paediatr. J. (1978), 14: 18Q-181
Gastric Haemorrhage and Perforation m the Newborn T. P. JOSEPH' Department of Paediatric Surgery, The Adelaide Children's Hospital, North Adelaide, S.A. 5006
Joseph, T. P. (1978). Aust. Paediatr. J., 14, 180-181. Gastric: haemorrhage and perforation in the newborn. Gastric perforation of the newborn is a well documented entity, but very few cases of massive gastric haemorrhage leading lo gastric perforation have been documented. The present report is of two such cases.
CASE REPORTS 1. B.J., an apparently normal girl weighing 2.2 kg was born at 38 weeks of gestation following uneventful labour. Her condition at birth was considered satisfactory, and she was given 1 mg of vitamin K. At 24 hours of age she vomited about 20 ml of dark blood and this was followed by repeated vomits of small amounts of fresh blood. She was given a transfusion of fresh blood followed by intravenous fluids. Bleeding and clotting studies were normal. At 36 hours of age she developed melaena and 12 hours later abdominal distension and marked respiratory distress. No bowel sounds were audible on auscultation. At 72 hours of age abdominal distension had increased and oedema of the abdominal wall and lower limbs was noted. X-ray of the abdomen demonstrated massive pneumoperitoneum but the infant was thought to be too ill to withstand surgery and died shortly
1. Senior Surgical Registrar First received September t9, 1977.
afterwards. Post-mortem examination revealed generalised peritonitis with multiple intraperitoneal abscesses. There was a haemorrhagic area 2 x 1 em in size on the anterior surface of the stomach and at the centre was a large perforation. No other abnormalities were detected. 2. C. D., a girl weighing 3.36 kg was born at 40 weeks gestation after an uneventful pregnancy. At birth, liquor was meconi urn stained and the apgar score was normal. She was given 1 mg of vitamin K. At 2 hours of age she vomited mucus mixed with blood and vomited fresh blood three times in the next 24 hours. On examination at that time there were no abnormal findings except for altered blood in the rectum. Studies of peripheral blood count, bleeding and clotting were normal. X-ray of the abdomen was thought to be normal, and barium meal studies were inconclusive. Blood transfusion and then intravenous fluids were given. At 33 hours of age the abdomen became suddenly distended and she developed tachypnoea and tachycardia. X-ray of the abdomen revealed a massive pneumoperitoneum. Laparotomy at 34 hours of age revealed free air and fluid in the
GASTRIC HAEMORRHAGE AND PERFORATION IN THE NEWBORN peritoneal cavity. A perforation measuring 2-3 mm In diameter was identified on the posterior surface of the stomach towards the centre of the greater curvature. As the surrounding area of the stomach was healthy, the perforation was oversewn. At this stage fresh blood was still being aspirated through the nasogastric tube and so a bilateral truncal vagotomy and pyloroplasty were done. She recovered well and was discharged home on the fifteenth postoperative day. At 2 years of age she is thriving well, her weight is above the 50th centile and she has normal bowel habits. DISCUSSION
Massive haemorrhage and perforation are rare during the neonatal period (Bird et at., 1941; Moncrief, 1954). Bird collected 37 newborn babies presenting with bleeding and/or perforation. Since then there have been very few reports of neonatal gastroduodenal ulceration causing bleeding and/or perforation. (Seagram et at., 1973; Curci et at., 1976). Gastric haemorrhage alone can usually be managed by non-operative treatment with adequate blood transfusion (Sherman and Clatworthy, 1967; StanleyBrown and Stevenson, 1965). Operation is indicated if continuous whole blood replacement fails to keep up with blood loss or gastric perforation ensues. The operation of choice is not yet established, but gastrotomy and suture ligation of the bleeding point may be sufficient. The efficacy of vagotomy and pyloroplasty in the newborn has yet to be evaluated and because of the rarity of the condition being treated an answer may not be forthcoming. However,
181
in Case 2 (C.D.), vagotomy and pyloroplasty was successful in stopping the bleeding which had continued until this procedure was carried out. SUMMARY
Two cases of neonatal gastric ulcer complicated by haemorrhage and perforation are reported. In the first case, the diagnosis was confirmed at postmortem. In the second case, surgical intervention with suture ligation, vagotomy and pyloroplasty was successful. Bleeding gastric ulcers are unusual in the newborn period and It is rare that the condition be further complicated by perforation. REFERENCES Bird, C. E., Limper, M. A., and Mayer, J. M. (1941), Surgery of peptic ulceration of stomach and duodenum In Infants and children, Ann. Surg., 114: 526. Curci, M. R., Little K., Sieber, W. K., and Kieswettar, W. B. (1976), Peptic ulcer disease in childhood re-examined. J. Pediatr. Surg., 11: 329. Moncrief, W. H. (1954), Perforated pepllc ulcer In the newborn: report of a case with massive bleeding, Ann. Surg., 139: 99. Seagram, c. G. F., Stephen&, C. A., and Cuming, w. A. (1973), Popllc ulceration at the Hospital for Sick Children, Toronto, J. Ped/atr. Surg., 8: 407. Sherman, N. J., Clatworthy, H. W. Jr. (1967), Gastro-Intestinal bleeding In the neonates: a study of 94 cases, Surgery, 82: 614. Stanley-Brown, E. G., and Stevenson, S. S. (1955), Massive gastro-intestinal haemorrhage In the new bam Infant, Pediatrics, 35: 482.
Correspondence to Dr. T. P. Joseph, 108 Blackwell Point Road, Chlswick, N.S.W. 2046.
Gastric Haemorrhage and Perforation m the Newborn T. P. JOSEPH' Department of Paediatric Surgery, The Adelaide Children's Hospital, North Adelaide, S.A. 5006
Joseph, T. P. (1978). Aust. Paediatr. J., 14, 180-181. Gastric: haemorrhage and perforation in the newborn. Gastric perforation of the newborn is a well documented entity, but very few cases of massive gastric haemorrhage leading lo gastric perforation have been documented. The present report is of two such cases.
CASE REPORTS 1. B.J., an apparently normal girl weighing 2.2 kg was born at 38 weeks of gestation following uneventful labour. Her condition at birth was considered satisfactory, and she was given 1 mg of vitamin K. At 24 hours of age she vomited about 20 ml of dark blood and this was followed by repeated vomits of small amounts of fresh blood. She was given a transfusion of fresh blood followed by intravenous fluids. Bleeding and clotting studies were normal. At 36 hours of age she developed melaena and 12 hours later abdominal distension and marked respiratory distress. No bowel sounds were audible on auscultation. At 72 hours of age abdominal distension had increased and oedema of the abdominal wall and lower limbs was noted. X-ray of the abdomen demonstrated massive pneumoperitoneum but the infant was thought to be too ill to withstand surgery and died shortly
1. Senior Surgical Registrar First received September t9, 1977.
afterwards. Post-mortem examination revealed generalised peritonitis with multiple intraperitoneal abscesses. There was a haemorrhagic area 2 x 1 em in size on the anterior surface of the stomach and at the centre was a large perforation. No other abnormalities were detected. 2. C. D., a girl weighing 3.36 kg was born at 40 weeks gestation after an uneventful pregnancy. At birth, liquor was meconi urn stained and the apgar score was normal. She was given 1 mg of vitamin K. At 2 hours of age she vomited mucus mixed with blood and vomited fresh blood three times in the next 24 hours. On examination at that time there were no abnormal findings except for altered blood in the rectum. Studies of peripheral blood count, bleeding and clotting were normal. X-ray of the abdomen was thought to be normal, and barium meal studies were inconclusive. Blood transfusion and then intravenous fluids were given. At 33 hours of age the abdomen became suddenly distended and she developed tachypnoea and tachycardia. X-ray of the abdomen revealed a massive pneumoperitoneum. Laparotomy at 34 hours of age revealed free air and fluid in the
GASTRIC HAEMORRHAGE AND PERFORATION IN THE NEWBORN peritoneal cavity. A perforation measuring 2-3 mm In diameter was identified on the posterior surface of the stomach towards the centre of the greater curvature. As the surrounding area of the stomach was healthy, the perforation was oversewn. At this stage fresh blood was still being aspirated through the nasogastric tube and so a bilateral truncal vagotomy and pyloroplasty were done. She recovered well and was discharged home on the fifteenth postoperative day. At 2 years of age she is thriving well, her weight is above the 50th centile and she has normal bowel habits. DISCUSSION
Massive haemorrhage and perforation are rare during the neonatal period (Bird et at., 1941; Moncrief, 1954). Bird collected 37 newborn babies presenting with bleeding and/or perforation. Since then there have been very few reports of neonatal gastroduodenal ulceration causing bleeding and/or perforation. (Seagram et at., 1973; Curci et at., 1976). Gastric haemorrhage alone can usually be managed by non-operative treatment with adequate blood transfusion (Sherman and Clatworthy, 1967; StanleyBrown and Stevenson, 1965). Operation is indicated if continuous whole blood replacement fails to keep up with blood loss or gastric perforation ensues. The operation of choice is not yet established, but gastrotomy and suture ligation of the bleeding point may be sufficient. The efficacy of vagotomy and pyloroplasty in the newborn has yet to be evaluated and because of the rarity of the condition being treated an answer may not be forthcoming. However,
181
in Case 2 (C.D.), vagotomy and pyloroplasty was successful in stopping the bleeding which had continued until this procedure was carried out. SUMMARY
Two cases of neonatal gastric ulcer complicated by haemorrhage and perforation are reported. In the first case, the diagnosis was confirmed at postmortem. In the second case, surgical intervention with suture ligation, vagotomy and pyloroplasty was successful. Bleeding gastric ulcers are unusual in the newborn period and It is rare that the condition be further complicated by perforation. REFERENCES Bird, C. E., Limper, M. A., and Mayer, J. M. (1941), Surgery of peptic ulceration of stomach and duodenum In Infants and children, Ann. Surg., 114: 526. Curci, M. R., Little K., Sieber, W. K., and Kieswettar, W. B. (1976), Peptic ulcer disease in childhood re-examined. J. Pediatr. Surg., 11: 329. Moncrief, W. H. (1954), Perforated pepllc ulcer In the newborn: report of a case with massive bleeding, Ann. Surg., 139: 99. Seagram, c. G. F., Stephen&, C. A., and Cuming, w. A. (1973), Popllc ulceration at the Hospital for Sick Children, Toronto, J. Ped/atr. Surg., 8: 407. Sherman, N. J., Clatworthy, H. W. Jr. (1967), Gastro-Intestinal bleeding In the neonates: a study of 94 cases, Surgery, 82: 614. Stanley-Brown, E. G., and Stevenson, S. S. (1955), Massive gastro-intestinal haemorrhage In the new bam Infant, Pediatrics, 35: 482.
Correspondence to Dr. T. P. Joseph, 108 Blackwell Point Road, Chlswick, N.S.W. 2046.
