Journal of Postgraduate Medicine
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Year : 1989  |  Volume : 35  |  Issue : 4  |  Page : 226-7  

Neonatal colonic perforation with low anorectal anomaly--(a case report).

SS Khope, SS Vivekanand 
 

Correspondence Address:
S S Khope





How to cite this article:
Khope S S, Vivekanand S S. Neonatal colonic perforation with low anorectal anomaly--(a case report). J Postgrad Med 1989;35:226-7


How to cite this URL:
Khope S S, Vivekanand S S. Neonatal colonic perforation with low anorectal anomaly--(a case report). J Postgrad Med [serial online] 1989 [cited 2020 Nov 27 ];35:226-7
Available from: https://www.jpgmonline.com/text.asp?1989/35/4/226/5677


Full Text



 INTRODUCTION



In infancy and childhood, perforations of the colon are second only to the ileum;[1] but their occurrence in the newborn period is rare,[3],[9],[12] Atresias, Hirchsprung's disease, enterocolitis and instrumentation are the commonly described etiological factors.[9],[12] In a case of low anorectal anomaly with cutaneous fistula, the diagnosis of colonic perforation is hardly made; such a rare case is being presented below.

 CASE REPORT



A 3.2 kg, new born, mate child was referred after 24 hours, for increasing abdominal distension. The antenatal as well as perinatal course was normal and uncomplicated. The baby cried soon after birth and had passed clear urine within 24 hours. On physical examination, the child was found to be dyspnoeic, acidotic and dehydrated. The abdomen was silent, distended, erythematous and tender. Perineal examination revealed a covered anus with a mid-line raphae cutaneous fistula, discharging meconium [Fig. 1]. The penis was normal with the urethra opening at the tip and both the testes were palpable in the scrotum. A nasogastric tube was passed. The child was resuscitated with intravenous fluids and plasma transfusions. Antibiotics were started. Plain X-ray of the abdomen and invertogram were done. The former showed free intraperitoneal gas with evidence of peritonitis, while the latter confirmed the diagnosis of a low anorectal anomaly.

After stabilizing the general condition, a laparotomy was done using a supra-umbilical, right, transverse incision. About 25 ml of infected meconium were present with fibrinous flakes over the loops of the small bowel and the colon. The ascending colon showed an area of seromuscular tear, just distal to the caecum, with a central perforation with free leak of meconium [Fig. 2]. A thorough peritoneal lavage was done. After draining the paracolic gutter with a corrugated rubber drain, the perforation was exteriorized and the opening was made into a formal colostomy after closing the abdominal wound. The patient had a stormy post-operative period but he recovered completely and was discharged after 15 days. He achieved normal milestones and the weight gain was satisfactory. Excision of the fistula and anoplasty were done on elective basis at the age of one year. One year follow-up of the patient did not reveal any complications.

 DISCUSSION



Perforation of colon in the new born is the most serious and rare complication.[2] Review of the literature reveals a few case reports.[1],[2],[3],[7],[10],[12] In the Mast, at least in two-thirds of cases, colonic perforations have been found secondary to atresias, Hirschsprung's disease and necrotising enterocolitis. In the remaining cases no cause could be found and hence they are termed idiopathic.[1] Only one case described previously[1] had a high anorectal anomaly. Its occurrence in a low anorectal anomaly with a cutaneous fistula has not been described, to our knowledge.

Efforts to explain the etiology have given rise to various speculations such as trauma, infection, Schwartzmann's phenomenon or hypoxia-induced ischaemia leading to colonic wall weakness.[5] The perforation associated with gastro-intestinal malformations can be explained on the basis of closed loop obstruction with diastasis rupture;[9] but its occurrence in a low rectal anomaly with a fistula is difficult to explain. A multitude of factors may be operational. A closed loop type of obstruction with rupture of colon may occur if the fistulous tract is narrow and the ileo-caecal valve competent.

The first patient to survive, who had colonic atresia proximal to the splenic flexure, was reported by Lee and MacMillan[7] in 1950. Absence of associated congenital anomalies is, probably, the most important factor in the survival.

A prompt diagnosis and early vigorous management are mandatory.[2] A combination of free intraperitoneal gas[6] and silent, tender, and erythematous abdominal wall usually make the diagnosis evident. Water soluble contrast examinations are not advisable in sick neonates and they are also hazardous.[4],[8] After a quick resuscitation of the septic neonate, surgical intervention should be the rule. The treatment may vary from a primary closure of the defect[10] and primary anastomosis to resection with colostomy.[2],[11] Though the choice of surgical manoeuvre is left to the surgeon, with peritoneal contamination it is safer to exteriorize the perforation and subsequently, stage the correction of the anorectal anomaly at a later date, as was done in our case. It is mandatory to use broad spectrum antibiotics to achieve optimum survival.

References

1Cruze, K. and Snyder, W. H. Jr: Acute perforation of the alimentary tract in infancy and childhood. Ann. Surg., 154: 93-99, 1961.
2Georgy, F. M. and Friedberg, M. J.: Neonatal perforation of the colon. Amen. J. Obstet. Gynaecol., 122: 788-789, 1975.
3Haas. L.: Neonatal perforation of the colon. Arch. Dis. Child., 33: 362-363, 1958.
4Harris, P. D., Neuhauser, E. B. D. and Gerth, R.: The osmotic effect of water soluble contrast media on circulating plasma volume. Amer. J. Roentgenol.. 91: 694-698, 1968.
5Hermann, R. E.: Perforation of the colon from necrotizing colitis in the newborn: report of a survival and a new etiologic concept. Surgery, 58: 436-441, 1965.
6Kaufman, R. A., Kuhns, L. R., Poznanski, A. K. and Holt, J. F.: Gastrointestinal perforation without intraperitoneal air-fluid level in neonatal pneumoperitoneum. Amer. J. Roentgenol., 127: 915-921, 1976.
7Lee, C. M. Jr. and MacMillan, S. G.: Rupture of the bowel in the newborn infant. Including case report of rupture in the large intestine with recovery. Surgery, 28: 48-66, 1950.
8Lutzger, L. G. and Factor, S, M.: Effects of some water-soluble contrast media on the colonic mucosa. Radiology, 118: 545-548, 1976.
9Rikham, P. P., Lister, J. and Irving, I. M.: Necrotising enterocolitis: bacterial and meconium peritonitis. In, "Neonatal Surgery". Edt. J. Lister and P. P. Rikham, Butterworth Publ. Co., London, 1978, pp. 411-428.
10Sabransky, R.: Perforation of the colon in a neonate who recovered. J. Amer. Med. Assoc., 175: 619-620, 1961.
11Standard, J. E.: Perforation of colon in the newborn infant: Recovery following operation. Amer. J. Surg,. 83: 107-111, 1952.
12Thelander, H. E.: Perforation of the gastrointestinal tract of the newborn infant. Amer. J. Dis. Child.. 58: 371-393, 1939.

 
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