Unusual cases of large bowel perforations in term or near term newborn.

INTRODUCTION Bowel perforation is a tragic event in newborns, especially in VLBW. Intestinal perforation usually involves small intestine while colon is rarely affected. Colon perforation is associated with higher mortality rate, so prompt surgical treatment is mandatory. We report on 2 cases of female near term neonates with unusual colon perforations. MATHERIAL/METHODS CASE A: a six day-old female babe presented with acute abdomen and evidence of free air on the abdominal x-ray. She was born at 34th weeks of gestation (birth weight 2000gr) and her mother suffered for placenta previa. She passed meconium at birth and was regularly feeded. An emergency operation was performed through an upper abdominal transverse incision and four sites of extended perforations were found at descending and sigmoid colon with purulent abdominal fluid. Left emicolectomy was necessary because of large perforations. Colostomy on transverse colon was made. There weren’t signs of other associated conditions(NEC or trauma/mechanical bowel obstruction or intestinal duplication).Stoma was closed 1 month later with a transverse-sigmoid T-T anastomosis. CASE B: a twelve day-old female babe born at 38th weeks of gestation(birth weight 2850gr)with intestinal malrotation, tetralogy of Fallot and Patau’s syndrome developed abdominal distension without any local or systemic signs of peritonitis. In the suspect of bowel obstruction secondary to malrotation, a Ladd’s procedure was started. Murky fluid as well as fibrinous purulent exudate was noted in bilateral lower quadrants. Appendix with “pig tail” shape was apparently mildly inflamed and perforated at tip. So appendectomy and Ladd’s procedure were done. Aggressive antibiotic therapy was started. Unfortunately, 3 months later the babe died for cardiovascular complications associated to her syndrome. RESULTS In case A histology report showed ulceration/necrosis and inflammation of the colon. Ganglion cells were normally distributed and not signs of cystic fibrosis were found on genetic analysis and on sweat test. The post-operative course was uneventful and at 5-mo follow-up the infant is growing well. In case B the histology report showed signs of purulent appendicitis with peri-appendix inflammatory response. CONCLUSIONS Spontaneous colon perforation is usually observed in neonates VLBW and cystic fibrosis. Its occurrence in term or nearly term neonates is rare and sometimes without apparent risk factors. Neonatal appendicitis has been described in few reports, some in association with cardiac anomalies such as tetralogy of Fallot. Despite these two cases may appear different with clear signs of intra-abdominal inflammation we believe that pre-or perinatal ischemic events could be the primary etiology. This hypotesis may be supported by the risk factors for ischemia present in both patients, placenta previa and complex cardiac malformations.