weekly_question 5/9/2021

[Admin]

A 3-day old 900-gm, unfed premature baby suddenly develops abdominal distension. An abdominal X-ray demonstrates intraperitoneal free air, without pneumatosis intestinalis or portal venous gas. An abdominal drain is placed at the bedside, releasing gas and enteric contents. The following day the baby is hemodynamically stable and the enteric drainage has stopped. The most appropriate next step in care is:

A observation

B laparoscopy

C placement of a second drain

D laparotomy and primary anastomosis

E laparotomy and stoma

[Admin]

correct answer

A observation

Spontaneous or focal intestinal perforation (SIP or FIP) occurs primarily in premature infants of very low birth weight (VLBW, birth weight less than 1500 g) or extremely low birth weight (ELBW, birth weight less than 1000 g) with an incidence of approximately 3% in the ELBW population. The distal ileum is the most commonly affected site, followed by the cecum and jejunum. Although SIP can be difficult to distinguish clinically from necrotizing enterocolitis (NEC), its distinctive histopathology suggests a different disease process, and indeed the presenting features of abrupt abdominal distension often prior to the initiation of enteral feeds is not typical for NEC. In addition to extreme prematurity, the concurrent use of early postnatal indomethacin and steroids are identified risk factors. Other clinical associations include maternal chorioamnionitis and the presence of Staphylococcus epidermidis and Candida in peritoneal cultures, which may be a reflection of enteral colonization.

Animal models of SIP suggest that risk factors converge on signaling pathways - nitric oxide synthases (NOS), insulin-like growth factor and epidermal growth factor. The hypothesized end result is skewed trophism of the ileum - defined as thinning of the submucosa concomitant with hyperplasia of the mucosa. Global depletion of NOS is associated with disturbed intestinal motility and diminished transforming growth factor alpha in the muscularis externa. This constellation of insults seems to make the distal intestine vulnerable to perforation during recovery of motility.

Options for treatment include peritoneal drainage or laparotomy, with a number of factors including lower birth weight and surgeon bias appearing to favor drain in the majority of studies. In a large multicenter study, 64% of 171 SIP patients were treated with peritoneal drainage, and of these, 71% avoided a subsequent laparotomy. Late strictures requiring resection are also infrequent. Therefore bedside peritoneal drainage in a baby with SIP who avoids subsequent septic deterioration, recurrent pneumoperitoneum or bowel obstruction has a high probability of being definitive treatment.

[Medhat Tello]

Answer A

[Radwan suleiman abukarsh]

A

[Admin]

correct answer

A observation

Spontaneous or focal intestinal perforation (SIP or FIP) occurs primarily in premature infants of very low birth weight (VLBW, birth weight less than 1500 g) or extremely low birth weight (ELBW, birth weight less than 1000 g) with an incidence of approximately 3% in the ELBW population. The distal ileum is the most commonly affected site, followed by the cecum and jejunum. Although SIP can be difficult to distinguish clinically from necrotizing enterocolitis (NEC), its distinctive histopathology suggests a different disease process, and indeed the presenting features of abrupt abdominal distension often prior to the initiation of enteral feeds is not typical for NEC. In addition to extreme prematurity, the concurrent use of early postnatal indomethacin and steroids are identified risk factors. Other clinical associations include maternal chorioamnionitis and the presence of Staphylococcus epidermidis and Candida in peritoneal cultures, which may be a reflection of enteral colonization.

Animal models of SIP suggest that risk factors converge on signaling pathways - nitric oxide synthases (NOS), insulin-like growth factor and epidermal growth factor. The hypothesized end result is skewed trophism of the ileum - defined as thinning of the submucosa concomitant with hyperplasia of the mucosa. Global depletion of NOS is associated with disturbed intestinal motility and diminished transforming growth factor alpha in the muscularis externa. This constellation of insults seems to make the distal intestine vulnerable to perforation during recovery of motility.

Options for treatment include peritoneal drainage or laparotomy, with a number of factors including lower birth weight and surgeon bias appearing to favor drain in the majority of studies. In a large multicenter study, 64% of 171 SIP patients were treated with peritoneal drainage, and of these, 71% avoided a subsequent laparotomy. Late strictures requiring resection are also infrequent. Therefore bedside peritoneal drainage in a baby with SIP who avoids subsequent septic deterioration, recurrent pneumoperitoneum or bowel obstruction has a high probability of being definitive treatment.