Indian Pediatrics 1998;35:906-908 

Spontaneous Perforation of Meckel's Diverticulum in Neonate

Pravin Kumar
Purnendu Ojha
Utpal Kant Singh

From the New Born and Pediatric Surgery Center, Sri Ram Nursing Home, Kanker Bagh, Patna 800 020, India.

Reprint requests: Dr. Purnendu Ojha, Sri Ram Nursing Home, Near Biscomaun Coal Depot, Kanker Bagh, Patna 800 020, India.

Manuscript Received: November 15, 1996; Initial review completed: December 2, 1996; Revision Accepted: March 27,1998
 

Perforation of the gastrointestinal tract in a neonate is an uncommon but life threatening condition. It may be due to some identifiable cause like necrotising enterocolitis (NEC) or may occur spontaneously. Meckel's diverticulum is normally present in about 2% of general population. Only 3-4% of these become symptomatic(1), and only 10% of symptomatic diverticulum perforate(2). Perforation of Meckel's diverticulum is rare in the neonatal period. We are reporting a case of spontaneous perforation of Meckel's diverticulum in a 5-day-old child treated successfully by prompt surgical intervention.

Case Report

A 5-day-old male child was referred to our center with massive pneumoperitoneum. At the time of admission, there was history of abdominal distension, projectile vomiting and obstipation for 2 days. The child was born by Caesarian section because of persistent breech lie with no history of birth anoxia, delayed passage of meconium or maternal drug use like corticosteroid during antenatal period. Clinical examination revealed a 2.3 Kg child with signs of moderate dehydration, massive abdominal distension and features of generalized peritonitis. Plain X-ray abdomen showed free air occupying a major portion of peritoneal cavity. 'Laboratory values were within expected range.

After resuscitation, a laparotomy was done. Peritoneal cavity was full of gas, pus and flakes. Gentle mobilisation of gut revealed a Meckel's diverticulum perforated at its tip. A wedge resection of the diverticulum with double layer' closure was done. Abdomen was closed after thorough peritoneal lavage. The post-operative period was uneventful.

Discussion

Perforation of the gastrointestinal tract in neonates is commonly due to necrotising enterocolitis (NEC) or to some mechanical cause like gasterointestinal atresia(1), stenosis, meconium ileus or Hirschprungus disease(2). A significant number of perforations occur without evidence of NEC or mechanical obstruction. The Exact etiology of these spontaneous perforations is not known. Various factors have been implicated as possible causes of these spontaneous perforations. These include perinatal stress and anoxia(3), congenital absence of muscle in gastrointestinal wall(4), over feeding and trauma due to nasogastric tube(5), maternal use of corticosteroids and cocaine(6) and exchange transfusion for hemolytic disease of newborn(7).

Perforation of Meckel's diverticulum is usually. the result of diverticulitis or peptic ulceration due to presence of heterotopic gastric mucosa(8). Rarely ulceration leading to perforation may occur as a result of enteric coated slow release potassium tablets(9) or iron tablets(10). Another common cause in childhood is foreign bodies like fish bone, cheery stones, etc.(11). An un-common cause of Meckel's perforation is small gut volvulus around a vitello-umbilical cord or mesodiverticular band(12). Perforation of Meckel's diverticulum have also been reported due to mechanical ventilation in newborn with tracheo-esophageal fistula(13). There are also case reports of intrauterine perforations(14-16).

Although, perforation of Meckel's diverticulum is commonly the result of some underlying pathology, but it may occur spontaneously. In our case, the baby was normal and healthy at birth and passed meconium normally. There was no history of any predisposing factors like perinatal stress, birth anoxia or others. The diverticulum was well supplied by a separate artery. There was no evidence of small gut volvulus. All layers of gut wall were demonstrated on histological examination, without evidence of ectopic gastric or pancreatic mucosa. Perforation in this case thus appears to be spontaneous.

 

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