|Year : 2018 | Volume
| Issue : 1 | Page : 8-9
Spontaneous rupture of the stomach in nonneonatal period
Verica Misanovic1, Edin Begic2
1 Pediatric Intensive Care Unit, Pediatric Clinic, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina, Balkans
2 Department of Cardiology, General Hospital “Prim.dr. Abdulah Nakas”; Department of Pharmacology, Faculty of Medicine, Sarajevo School of Science and Technology, Sarajevo, Bosnia and Herzegovina, Balkans
|Date of Web Publication||10-Oct-2018|
Pediatric Clinic, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
Source of Support: None, Conflict of Interest: None
This study aimed to show the spontaneous rupture of the stomach in a 3-year-old girl. The patient was admitted to the pediatric clinic due to poor general condition that occurred suddenly with severe abdominal pain, vomiting, and the development of hypovolemic shock (blood pressure was unmeasurable, in acidosis), and after the ultrasound and abdominal X-ray, she was operated by the pediatric surgeon within 6 h of admission. During surgery, multiple defects of stomach mucosa with transmural bleeding without pathohistological changes in the muscle layer were found in the large stomach blood vessels. Treatment was continued in the pediatric intensive care unit with the development of life-limiting complications: peritonitis, sepsis, intracranial hemorrhage, and outcome of death. Rupture of the stomach caused by acute distension is rarely seen outside the neonatal period with fast clinical course and high mortality rate. Early diagnosis and rapid surgical procedures are a prerequisite to avoid the development of life-limiting complications that lead to a fatal outcome.
Keywords: Acute distension, fatal outcome, stomach rupture
|How to cite this article:|
Misanovic V, Begic E. Spontaneous rupture of the stomach in nonneonatal period. Saudi Crit Care J 2018;2:8-9
| Introduction|| |
Rupture of the stomach caused by acute distension rarely occurs in children after neonatal period, with the rapid development of the clinical picture and a high mortality rate. The most common cause of the condition is elevated intra-abdominal and intragastric pressure, as well as stomach thrombosis.
| Case Report|| |
A 3-years and 3-months-old girl weighing 14.5 kg was referred to the pediatric clinic. Anamnestic data of the patient were regular, and the symptoms occurred 2 days before. She had altered consciousness, was somnolent, dehydrated, with tachycardia, tachy-dysphonic (capillary refill time >5 s, distal part of the extremities were cold, acid–base balance: pH 7.1, PCO2 3.17 kPa, PO2 15.8 kPa, HCO3 8.8 mmol/L, base excess (BE) 17.5, Na 121 mmol/L, K 6.1 mmol/L, and lactate 5.45 mmol/L). On admission, two venous pathways were established, and reanimation was performed, with success. Native X-ray of the abdomen showed the presence of free air, which led to suspicion of stomach rupture, and indicated an emergency surgery of a vitally endangered child. After surgery, she was placed on controlled mechanical ventilation (CMV) and received infusion fluids and triple antibiotic therapy (meropenem, metronidazole, and amikacin), with analgosedation. She was successfully extubated on the 2nd postoperative day. Initially, a gradual decline of inflammatory parameters was present, but on the 2nd postoperative day, pleural effusion developed, followed by spontaneous pneumothorax. On the 5th postoperative day, deterioration occurred with clinical and laboratory characteristics of a septic shock, so she had to be sedated, intubated, and placed on CMV. She was cardiocirculatory unstable, and boluses of crystalloids, colloids, and inotropes were administered in continuous infusion accordingly. Enterobacter cloacae was isolated in hemocultures, and the therapy was included according to the antibiogram. Acute renal insufficiency developed, and hemodialysis was performed for 5 days, after which stabilization of the general condition occurred, and regular diuresis was established. In the laboratory results, a decrease of inflammatory parameters was present with thrombocytopenia. However, in control hemocultures, Pseudomonas species has been isolated repeatedly despite the adequate antibiotic therapy. Due to the inability to control the infection, repeated abdominal ultrasound examinations and consultations with pediatric surgeons, infectious disease specialists, as well as secondary opinions from other medical centers were performed on several occasions. Computed tomography (CT) showed apical pneumothorax, atelectasis of the posterobasal part of the pulmonary parenchyma, and pleural effusion on the left. The nasogastric probe was located in the fundus area of the stomach. After a consultative examination, another surgical procedure was performed, where the abdominal cavity was entered laparoscopically, lavage was performed, potential focal point was not found, and abscess and two abdominal drainage tubes were placed. Despite adequate therapy, hemocultures were positive and platelets were very low, which were compensated daily and sometimes twice a day at appropriate doses. In the abdominal drain content, Candida albicans was isolated. Two days later, the patient was nonreactive, and an examination of the fundus oculi was performed: extensive hemorrhage of the retina to the right. CT of the head showed brain edema. She was not sedated. During the entire electroencephalography registration, the application of the electrocortical brain activity, the so-called electrocortical silence, was present. In the further course, there was a gradual deterioration, resulting in death.
| Discussion|| |
Reports of stomach perforation in children from 3 to 5 years of age are not common. There is a wide range of symptoms such as sudden abdominal pain and distension, vomiting, hematemesis, metabolic acidosis, peritonitis, respiratory insufficiency, poor perfusion, and shock development. All of these symptoms were present in our patient. Stomach rupture is most common in premature babies, postpartum traumas, and hypoxia, but these data were not present in our patient's history. A healthy stomach rupture may occur with excessive intake of food and drink, in gastric content fermentation., If the stomach wall is thinned, the blood vessels are elongated, vasoconstriction occurs and also sometimes obstruction, resulting in ischemia., Blood flow is slowed down in the beginning, followed by disseminated intravascular coagulation, atrophy occlusion, and necrosis of the gastric wall. In our patients, there is a history of excessive intake of food. Increased intra-abdominal pressure also occurs in severe cough, persistent vomiting, and abdominal pain in patients with ulcerative disease and tumors. Furthermore, intra-abdominal pressure can be increased during cardiopulmonary resuscitation or after performing Heimlich maneuver. In our patient, there is evidence of persistent vomiting 2 days before stomach rupture occurred.
Literature research suggests that perforation along the lesser curvature of the stomach is usually a consequence of gastric distension, whereas vomiting is usually associated with a cardiac rupture. In our patients, rupture was located on a greater curvature of the stomach. There are literary data, suggesting that at poorer peristalsis, there may be accumulation of fluid in the cardiac and pylori region leading to an increase in the intragastric pressure, which could be the cause of perforation in patients with verified epilepsy. In our patient, there is no information that she had epilepsy, but there are data that the patient's mother has epilepsy and is under treatment. Stomach perforation is a condition that must undergo emergency surgical treatment. It should be included in the differential diagnosis of any patient who has symptoms of sudden severe abdominal pain, distention, and peritoneal signs.
Rupture of the stomach caused by acute distension is rarely seen outside the neonatal period with fast clinical course and high mortality rate. Early diagnosis and rapid surgical procedures are a prerequisite to avoid the development of life-limiting complications that lead to a fatal outcome.
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Conflicts of interest
There are no conflicts of interest.
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