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Perforated stress ulcer in infants: a silent threat
Insights
Perforation of stress ulcers is a severe complication in critically ill infants. Early diagnosis and prompt surgical intervention are crucial for survival, even in debilitated neonates.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Neonatology
Background:
- Stress ulcers are a significant clinical concern with serious complications like bleeding and perforation.
- Perforation, though less common, poses a formidable management challenge, especially in critically ill infants.
Observation:
- Four critically ill infants experienced stress ulcer perforation, with two surviving surgery.
- Diagnosis was delayed, often requiring radiological confirmation due to absent peritonitis signs in severely ill infants.
- All perforations occurred in the posterior duodenal wall; two infants had prior bleeding episodes.
Findings:
- Two infants developed intraoperative cardiac complications, possibly linked to debilitation and anesthesia.
- Survival was achieved in 50% of cases despite severe illness and complex presentations.
- Simple and expedient surgical closure is recommended for duodenal perforations.
Implications:
- Highlights the need for vigilance in monitoring sick infants for stress ulcer complications.
- Suggests prophylactic antacids for infants on steroid therapy and routine abdominal girth monitoring.
- Emphasizes the importance of early radiological evaluation for suspected perforations in non-responsive infants.
Abstract:
Stress ulcer has become an important clinical entity and its two major complications--bleeding and perforation--are among the most baffling problems, in terms of management, in clinical practice. Perforation, though the less common of the two, is perhaps the most formidable particularly when this occurs in a very sick infant. Four such infants (cyanotic heart disease, gastroenteritis and two severe pneumonias) all developed this severe complication of their illness and after surgery two survived. Two of these infants presented with bleeding prior to perforation of their stress ulcer. The perforation diagnosis was initially not apparent and was first made after radiological examination. Clinical signs of peritonitis were absent as these infants were too sick for such signs to be elicited. All four ulcers were situated in the posterior wall of the duodenum. Two of these infants developed cardiac complications on the operating table, the cause of which was not very clear. It may have been due to the debilitation of these babies with the additional effect of anesthesia perhaps leading to myocardial toxicity. It is therefore recommended that: all sick infants on steroid therapy be placed on prophylactic antacids; abdominal girth measurements be taken frequently in sick infants to appreciate any unexplained increase in girth; such increase in abdominal girth must be evaluated with an upright abdominal x-ray; operative closure of the perforation must be simple and expedient.