Gastric Rupture Associated With Prolonged Crying In A Newborn Undergoing Circumcision

INTRODUCTION

Spontaneous rupture of a normal stomach is a rare event. Approximately 72 cases have been reported in adults,¹ and the problem is seldom encountered in pediatric centers. Gastric rupture in the newborn usually occurs within the first few days of life and is a known cause of pneumoperitoneum in the neonatal period.²

Von Siebold is credited with reporting the first newborn with spontaneous stomach perforation in 1826.³ In 1939, Thelander reviewed 85 cases of gastrointestinal perforation, including gastric rupture over a 114-year period and reported only one survivor.⁴ The first surgical survivor was reported in 1950,⁵ and in 1989 Tan et al recorded a 30% mortality in their seriesof 56 patients.⁶

Recently in our hospital, a 2-day-old infant developed a spontaneous gastric rupture while undergoing a routine newborn circumcision.

CASE REPORT

This male infant was born after a 40-week gestation to an 18-year-old who experienced a benign prenatal course. Birth weight was 2,750 g. Labor lasted three hours, and he was delivered vaginally. The amniotic fluid was stained with meconium, and the infants, mouth and nasopharynx were suctioned with both bulb and DeLee trap. The stomach was not suctioned. Apgar scores were 9 at one minute and 9 at 5 minutes. He was admitted to the well-baby nursery for routine care. He bottle-fed well and began urinating and defecating normally.

On the second day of life, he was fed 4 oz. of formula at 5 a.m. and was given nothing else, since he was scheduled for circumcision. At about 10 a. m. he was restrained in a dorsal recumbent position on a circumcision board and began crying. After the infant had been crying vigorously and steadily for half an hour, his abdomen became distended and he vomited. A nasogastric tube was passed; gastric contents, including formula, were removed. The abdomen remained distended but was soft, with normal bowel sounds. He then underwent routine unanesthetized circumcision using a Gomco bell. He cried vehemently for a total period of about 90 minutes.

At noon he refused to feed. On examination he showed increased abdominal distention and a tender, tympanitic abdomen. Bowel sounds were absent; a guaiac test for his stool was negative for occult blood.

Radiographs of the abdomen were taken with the infant in the supine anterior-posterior (Figure 1) and in the prone, cross-table lateral position (Figure 2). They demonstrated a large amount of free intra peritoneal air. At operation, a gastric rupture was found in the midportion of the anterior gastric wall, with spillage of formula and gastric contents into the left upper abdominal quadrant. The rupture was repaired, and a catheter was placed as a gastrostomy tube. He remained without oral feedings for two weeks and was treated with prophylactic antibiotics. Nutrition was given through a central venous line. He started gastrostomy tube and oral feedings and did well, with good weight gain. He was discharged 25 days after birth and continues to do well.

Discussion

The cause of this baby's spontaneous rupture is not known. In 1943, Herbert presented his theory that the predisposing factor, is a congenital absence of the muscle layer of the stomach.⁷ Shaw et al⁸ refuted this in 1965, reporting that the muscle layer retracts at the rupture site, giving the appearance of an absent muscular layer. Lloyd,⁹ in his 1969 study of 87 cases of gastrointestinal perforation in newborns, postulated that perforations of the gastrointestinal tract were the result of ischemic necrosis related to an asphyxial defense mechanism due to stress, hypoxia, or shock. Eighty percent of his patients had experienced a significant episode of asphyxia or shock during the perinatal period.

Our patient demonstrated no evidence of a congenital absent muscle layer, and there were no identifiable hypoxic perinatal events.

Speculation, then, centers on the possibility that the baby cried hard enough and long enough and swallowed enough air to rupture the stomach. Rupture of a normal stomach has been known to occur because of increased intragastric pressure, with such contributing factors as overeating, overdrinking, fermentation of gastric contents, and aerophagia.¹ Hood¹⁰ reported that in a supine subject, fluid would collect in the cardia and pylorus, the most dependent portions of the stomach. This creates a one-way fluid valve. As aerophagia occurs, the air is trapped and the pressure increases until the tensile strength of the stomach wall is exceeded.

The above explanation has been supported by Shaker et al,² who reported that the stomachs of puppies can be forcibly ruptured by distention. These authors suggested, based on clinical observation, that a newborn baby might swallow enough air to produce gastric rupture.

We assume the proximate cause of the gastric rupture in our patient was aerophagia secondary to prolonged vigorous crying. We are not aware of other cases documenting a temporal association of gastric rupture and circumcision-induced crying. Routine newborn circumcision continues to be criticised because of its associated complications. Because of the potential for gastric rupture, we recommend infants spend a minimal amount of time on the restraint board and that consideration be given to the use of a penile nerve block or other anesthetics or analgesics for pain control.

ACKNOWLEDGMENTS

We would like to thank William R. Freitas III and Pat Bolander for their contributions in preparing this manuscript.

Kevin P. Connelly, D. O.
Resident in Pediatrics

Lowry C Shropshire, M. D.
Assistant Professor of Pediatrics

Arnold Salzberg, M. D.
Professor of Surgery and Pediatrics
Medical College of Virginia
Richmond

Address correspondence to:
Arnold Salzberg, M. D.
Professor of Surgery and Pediatrics
 Medical College of Virginia
Richmond, VA 23298

• Connelly KC, Shropshire LC, Salzberg A. Gastric rupture associated with circumcision. Clin Pediatr 1992;31(9):560-1.

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