Gastric Rupture Associated With Prolonged Crying in a Newborn Undergoing Circumcision

GASTRIC RUPTURE ASSOCIATED WITH PROLONGED CRYING IN A NEWBORN
UNDERGOING CIRCUMCISION

Reprinted from:  Clinical Pediatrics, September 1992.

Authors:        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


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
series of 56 patients.(6)

Recently in our hospital, a 2-day- old male 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 pre-natal course.  Birthweight was
2,750 g.  Labor lasted three hours, and he was delivered vaginally.  
The amniotic fluid was lightly stained with meconium, and the infant's
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 five 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 of 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 intraperitoneal air.  At operation, a gastric rupture was found  
in the mid-portion 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 continued 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 al 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 congenitally absent
muscle layer, and there were no identifiable hypoxic perinatal
events.

Speculation, then, centers on the possibility that the baby cried
hard 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)   Hood(10) 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 rodents and 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 criticized because of its associated  
complications.  Because of the potential complication of 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 
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.


References

Due to time considerations, I have not typed out the references.  If
you require them, please e-mail me and I will take the time to enter 
the information and forward a copy to you:  Or, check the medical library
of your local hospital for a copy of Clinical Pediatrics, Sept. 1992.

E-mail:  Robert_Riley@Galaxy.com




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