Spontaneous duodenal perforation in a neonate: A case report

Neonatal duodenal perforation is an extremely rare but life-threatening surgical emergency. Reported etiologies include prematurity, necrotizing enterocolitis, distal obstruction, trauma, and sepsis; however, in rare instances, no identifiable cause is found and the condition is described as spontaneous. Early diagnosis relies heavily on radiologic imaging, particularly plain abdominal radiographs demonstrating pneumoperitoneum. We report a 2-day-old full-term female neonate who presented with progressive abdominal distension, nonbilious vomiting, and low-grade fever of one day duration. Laboratory evaluation showed leukocytosis with a high absolute neutrophil count and mildly elevated C-reactive protein; blood culture grew Klebsiella pneumoniae, for which appropriate antibiotic therapy was initiated. Supine abdominal radiography revealed massive pneumoperitoneum with classic radiologic signs, including the football sign and Rigler's (double-wall) sign, consistent with gastrointestinal perforation. Exploratory laparotomy identified a solitary perforation on the anterior wall of the first part of the duodenum, with no evidence of distal obstruction, necrotizing enterocolitis, ischemia, or traumatic injury. The perforation was repaired by primary closure reinforced with a pedicled omental patch. Despite the presence of bacteremia, no intraoperative findings supported sepsis-related bowel necrosis, and the perforation was therefore classified as spontaneous. The neonate had an uneventful postoperative recovery. Although exceedingly rare, neonatal duodenal perforation carries significant morbidity and mortality. Prompt radiologic recognition of pneumoperitoneum and early surgical intervention are critical for favorable outcomes. This case highlights the diagnostic value of imaging and underscores the importance of carefully excluding infectious and secondary causes before labeling a duodenal perforation as spontaneous.