Lack of C-KIT+ mast cells and the development of idiopathic gastric perforation in neonates

Spontaneous gastric perforation: is it really common?

Background

Neonatal gastric perforation (NGP) is a rare, serious, and life-threatening condition which needs early recognition with prompt intervention for better prognosis. Its etiology is not yet well established, but multiple speculations have been put forth for its etiopathogenesis. Few most considered are traumatic, spontaneous, or secondary to inflammatory process like necrotizing enterocolitis. This study describes the etiological and prognostic factors for patients with NGP in our experience at a single center.

Results

A total of 46 neonates were included. Male gender predominated with M:F being 1.7:1. Most (n=36) neonates presented within 10 days of life whereas 8 neonates presented within 15 days. At presentation, gas under diaphragm was the most common radiologic finding in 25 (54.3%) neonates. On exploratory laparotomy, it was found that greater curvature was involved in maximum number of cases (n=27), followed by lesser curvature and anterior and posterior walls of the stomach. Most of perforations were within 1–5 cm in size. Gastrorrhaphy was done in all cases, and in two cases, feeding jejunostomy was done along with repair for feeding purpose. Finally, spontaneous NGP was diagnosed in 30 (60.8%), and NEC patches on other parts of the intestine were seen in 11 patients. Postoperatively, 28 neonates developed complications in the form of sepsis (n=13), wound infection (n=10), and burst abdomen (n=5). Regarding clinical outcome, 27 (58.7%) were discharged from the hospital whereas 19 (39.3%) patients died.

Conclusion

Our results show that spontaneous NGP is most commonly associated with NEC in our population, usually affecting the greater curvature. We observed a high mortality rate; however, good ICU care may improve the survival.

[Spontaneous gastric perforation complicating spontaneous acute bronchiolitis in an infant]

La perforation gastrique spontanée est une affection rare chez le nourrisson et les mécanismes de survenue demeurent mal compris. Nous rapportons le premier cas congolais. Il s'est agi d'un nourrisson de sexe féminin, âgée de 5 mois qui au 4^ème jour d'hospitalisation pour une bronchiolite aiguë sévère associée à une diarrhée compliquée de déshydratation aiguë modérée, a présenté de façon brutale une distension importante et douloureuse de l'abdomen associée à des signes de choc. La radiographie de l'abdomen sans préparation montrait un pneumopéritoine massif. La laparotomie avait permis de mettre en évidence une perforation arrondie sur la paroi postérieure de l'estomac qui a été suturée. Les suites opératoires étaient marquées par la survenue d'un choc septique et le décès du nourrisson.

Neonatal Gastrointestinal Perforations: the 10-Year Experience of a Reference Hospital

The aim of this study was to present our experiences with, as well as the factors that affect, the treatment and outcome of patients with neonatal gastrointestinal perforations (GIPs). Thirty-eight newborn cases that were operated on for GIP in our hospital's tertiary newborn intensive care unit between January 2005 and December 2015 were retrospectively evaluated. The patients were divided into the two following groups: group 1, perforations related to necrotizing enterocolitis (NEC), and group 2, non-NEC perforations. In total, 38 patients (16 males, 22 females) participated in this study. The perforations were related to NEC in 12 patients (group 1; 31.6 %), and the other 26 patients (group 2; 68.4 %) were classified as non-NEC perforation cases. The incidence of neonatal GIP was 0.53 % in all newborn patients, while the incidence of perforation in NEC cases was 20 %. Of all patients, 25 (65.7 %) were premature. Non-NEC pathologies were the most common cause of GIP (68.4 %) and included stomach perforation related to a nasogastric catheter (n = 5), volvulus (n = 4), intestinal atresia (n = 3), esophageal atresia and tracheoesophageal fistula (n = 2), cystic fibrosis (n = 2), Hirschprung's disease (n = 2), appendicitis (n = 2), congenital stomach anterior wall weakness (n = 1), duplication cyst (n = 1), invagination (n = 1), incarcerated inguinal hernia (n = 1), and idiopathic causes (n = 2). Primary surgical repair was performed in all cases without a conservative approach. The mortality rate related to GIP in newborn cases was 47.3 %. While the mortality rate in group 1 was 66.6 %, it was statistically insignificantly lower in group 2 (38.4 %) (p > 0.05). In group 1, the mortality rate of those with intestinal and colorectal perforations was 45.6 and 20 %, respectively (p > 0.05). Non-NEC pathologies are the most frequent causes of GIP in newborns, and primary surgical repair is the primary treatment choice for neonatal GIP. However, GIP remains one of the most significant causes of mortality in newborns. While the prognosis for neonatal colon perforation is good, that for stomach and jejunoileal perforations is worse.

Comparison of gastric and other bowel perforations in preterm infants: a review of 20 years' experience in a single institution

Purpose

In this study, we aimed to review the clinical presentation of preterm infants with gastrointestinal perforations and compare the clinical features of gastric perforation with other intestinal perforations.

Methods

The medical records of preterm neonates with pneumoperitoneum, admitted to the neonatal intensive care unit (NICU) between January 1994 and December 2013, were retrospectively reviewed.

Results

Twenty-one preterm infants underwent exploratory laparotomy to investigate the cause of the pneumoperitoneum. The sample consisted of five patients (23.8%) with gastric perforation and 16 patients (76.2%) with intestinal perforation. No statistical differences were found in the birth history and other perinatal factors between the two groups. Underlying necrotizing enterocolitis, bilious vomiting, and paralytic ileus preceding the perforation were statistically more common in the intestinal perforation group. All preterm infants with gastric perforation survived to discharge; however, six preterm infants with intestinal perforation expired during treatment in the NICU. In the gastric perforation group, sudden pneumoperitoneum was the most common finding, and the mean age at diagnosis was 4.4±1.7 days of life. The location and size of the perforations varied, and simple closure or partial gastrectomy was performed.

Conclusion

Patients with gastric perforation did not have a common clinical finding preceding the perforation diagnosis. Although mortality in previous studies was high, all patients survived to discharge in the present study. When a preterm infant aged less than one week presents with sudden abdominal distension and pneumoperitoneum, gastric perforation should first be excluded. Prompt exploratory laparotomy will increase the survival rates of these infants.

Neonatal gastric perforation: A single center experience

AIM: To determine the etiology and prognostic factors for neonatal gastric perforation (NGP), a rare but life-threatening disease.

METHODS: Between 1980 and 2011, nine patients underwent surgical intervention for NGP at Seoul National University Children’s Hospital. The characteristics and prognosis of the patients were retrospectively analyzed.

RESULTS: Among the nine patients, three (33.3%) were preterm babies and five (55.5%) had associated anomalies, which included diaphragmatic eventration (n = 2), congenital diaphragmatic hernia, esophageal atresia with tracheoesophageal fistula, and antral web. Three (33.3%) patients were born before 1990 and three (33.3%) had a birth weight < 2500 g. Pneumoperitoneum was found on preoperative images in six (66.7%) patients, and incidentally in the other three (33.3%) patients. Surgery was performed within 24 h after the onset of symptoms in seven (77.8%) patients. The overall mortality rate was 22.2% (2/9). The time between symptoms and surgical intervention was the only prognostic factor for survival, whereas premature birth and birth weight were not.

CONCLUSION: Early detection and advances in neonatal intensive care may improve the prognosis of NGP.

Noniatrogenic neonatal gastric perforation: the role of interstitial cells of Cajal

Noniatrogenic neonatal gastric perforation is a rare and life-threatening condition whose etiology is often unclear. Interstitial cells of Cajal act as gastrointestinal pacemaker cells and express the proto-oncogene c-Kit. Six new cases were identified at our institution which presented with no mechanical, pharmacologic, or otherwise medical-related intervention prior to rupture. The number of interstitial cells of Cajal in nonnecrotic muscularis propria from five random high-power fields per specimen was compared using immunohistochemical stains for c-Kit. The authors show that a lack of interstitial cells of Cajal in the stomach musculature may be implicated in the development of noniatrogenic gastric perforation (p = 0.008). Further large-scale studies, including molecular and genetic analysis, may help to better understand this phenomenon.

Etiology of neonatal gastric perforation: a review of 20 years' experience

PURPOSE

Gastric perforation (GP) of the newborn is a rare, serious, and life-threatening problem, and its etiology remains unclear. Although historically GP has often been described as "spontaneous'', some cases are non-spontaneous. The aim of the present study was to review cases of GP and to discuss its etiology in a single prefecture in Japan over a period of 20 years.

METHODS

Eleven cases with GP that underwent surgery in 4 institutions in the Chiba Prefecture from 1991 to 2010 were reviewed and divided into 2 groups: the early (1991-2000, n = 7) and late (2001-2010, n = 4) groups.

RESULTS

No factors were observed that could have caused GP other than malformations associated with distal obstruction (3 midgut volvulus, 1 jejunal stenosis, 1 diaphragm eventration). Distal obstruction was present in 1 case in the early group and all 4 cases in the late group (p = 0.015). While the incidence of GP did not change over the 20-year period reviewed, the incidence of GP without distal obstruction significantly decreased in the late group.

CONCLUSION

The proportion of patients with GP and distal obstruction increased and true "spontaneous" cases of GP decreased over time. The possible presence of distal obstruction should be evaluated during surgery for GP.

Idiopathic gastric perforation in neonates and abnormal distribution of intestinal pacemaker cells

BACKGROUND/PURPOSE

The etiology of idiopathic gastric perforation (IGP) in neonates is unclear. Interstitial cells of Cajal (ICC) express tyrosine kinase receptor C-kit, and act as gastrointestinal pacemaker cells. Stem cell factor (SCF) is a C-kit ligand and plays an important role in immune system homeostasis in the gastrointestinal tract. The authors hypothesized that abnormal distribution of ICC or SCF in the gastric wall (ie, abnormal motility or impaired immunity) could predispose the stomach to IGP.

METHODS

Stomachs obtained at postmortem from neonates who died of IGP (n = 7) and other causes (control group; n = 10) were used. Biopsy sections were taken at random from various sites in the stomach, including macroscopically intact areas, and labeled immunohistochemically using antibodies to C-kit(a marker for ICC) and SCF.

RESULTS

In all control specimens, ICC were present between the muscle layers and around the myenteric plexuses of the stomach wall. In contrast, ICC were absent in all biopsy sections from 3 of the 7 IGP stomachs. In the remaining 4 IGP stomachs, there were fewer ICC in the muscle layers compared with controls, and ICC were absent around the myenteric plexuses. The distribution of SCF immunoreactivity in IGP and control specimens was similar.

CONCLUSION

The findings suggest that a lack of ICC (ie, gastric hypomotility) may be implicated in the etiology of IGP in neonates.