case reports 2018; 4(1)

https://doi.org/10.15446/cr.v4n1.65326 GASTROSCHISIS. CASE REPORT AND MANAGEMENT IN PRIMARY CARE SERVICES

Keywords: Gastroschisis; Congenital Abnormalities; Primary Health Care. Palabras clave: Gastrosquisis; Anomalía congénita; Atención primaria de salud.

Ricardo Ibarra-Calderón, MD Oscar Octalivar Gutiérrez-Montufar, MD Department of Pediatrics - Faculty of Health Sciences - Universidad del Cauca - Popayán - Colombia. General Medicine Service - Hospital Universitario San José - Popayán - Colombia.

Jhan Sebastián Saavedra-Torres Luisa Fernanda Zúñiga Cerón Faculty of Health Sciences - Grupo de Investigación en Salud (GIS) - Universidad del Cauca - Popayán - Colombia.

Corresponding author: Ricardo Andrés Ibarra-Calderón. Departamento de Pediatría, Facultad de Ciencias de la Salud, Universidad del Cauca. Popayán. Colombia. Email: [email protected].

Received: 29/05/2017 Accepted: 19/02/2018 gastroschisis and primary care services

ABSTRACT RESUMEN 11

Introduction: Gastroschisis is a low-prev- Introducción. La gastrosquisis es una enfer- alence disease with a very good prognosis, medad de baja prevalencia, pero de muy buen if initial management is adequate. This paper pronóstico si se realiza un adecuado manejo attempts to describe the disease and highlight inicial. El presente escrito tiene como objeti- the importance of correct treatment at the pri- vo realizar una descripción de esta patología, mary care level. destacando la importancia de su correcto ma- nejo en el primer nivel. Case presentation: Newborn child diag- nosed with gastroschisis in a primary care Presentación del caso. Neonato a término center, referred to the Service of con hallazgo de gastrosquisis en primer nivel a tertiary care institution. He received interdis- quien fue remitido al servicio de neonatología ciplinary management and underwent gradual de una institución de tercer nivel. El infante re- surgical closure, with favorable outcome after cibió manejo interdisciplinario y cierre quirúr- a three-month hospitalization. gico gradual y tuvo evolución favorable tras 3 meses de hospitalización. Discussion: There is no clarity about the ex- act cause of gastroschisis, since it is a multi- Discusión. No existe claridad sobre la causa factorial disease. It can be diagnosed during exacta de la gastrosquisis, ya que es una en- the prenatal stage by means of ultrasonogra- fermedad multifactorial. Su diagnóstico puede phy, which has high sensitivity and specificity realizarse desde la etapa prenatal mediante for its detection. la ultrasonografía, un método que posee alta sensibilidad y especificidad para su detección. Conclusion: Gastroschisis is a disease that requires adequate knowledge from both spe- Conclusión. La gastrosquisis es una enfer- cialized and primary care personnel, as it en- medad que para su diagnóstico y tratamiento sures a correct initial management and avoids requiere de personal especializado en primer future complications. nivel, lo que garantiza un correcto manejo ini- cial y evita futuras complicaciones.

INTRODUCTION and sometimes the , colon or gonads. (1,3) As they are not covered by membranes, Gastroschisis can be defined as a congenital the eviscerated structures are exposed to am- defect of the anterior abdominal wall, char- niotic fluid and external substances after birth, acterized by evisceration of the abdominal which increases the risk of infection and inju- organs through an opening in the absence ries. (1,3,4) This is a low-prevalence disease of membranous coverage; this defect is usu- (5-7) of great importance due to the excellent ally observed to the right of the navel (1-3), prognosis and survival of patients (8-10) when involving, in all cases, the (3) providing adequate management. (11,12) case reports Vol. 4 No. 1: 10-8

12 CASE PRESENTATION perimeter was not assessed due to the pro- trusion of intestinal loops). The thorax showed This paper reports the case of a full-term male a slight intercostal retraction and the abdo- infant born at 37 weeks, who was transferred men, a protrusion of intestinal loops covered from Florencia, Colombia to the Neonatology with a viaflex container, pink, well perfused Service. The child was born by vaginal delivery and with a foul odor; the skin was pale and at a primary care center, with an incidental find- poorly perfused. ing of protruding, violaceous and wet intestinal loops, associated with respiratory distress. Table 1. Synthesis of the evolution of the patient. The patient received oxygen therapy through cannula and nasogastric tube. Ophthalmic Days Event prophylaxis was performed and then, he was Day 1 Birth and primary care referred to a secondary care institution, where Admission to tertiary care institution gastric lavage was performed, a polyethylene Day 3 First surgery. in viaflex bag was placed, and antibiotic treatment with container ampicillin-gentamicin was initiated. Ringer’s Day 6-8 Three plications of viaflex container lactate solution and dextrose 10% in distilled Day 14 Total closure of the wall water at 100 cm3/kg/day were administered Since day 15 Favorable evolution Discharged with interdisciplinary with a metabolic flow of 6.7 mg/kg/min, and Day 109 inotropic management was initiated due to follow-up recommendations hemodynamic instability. The child was referred Source: Own elaboration based on the data obtained in the study to a tertiary care institution for management by . Based on clinical findings, gastroschisis, The child was the firstborn of a teenager respiratory distress syndrome and early neo- (17 years old) with O+ blood type, who under- natal sepsis were diagnosed. Renal ultrasound went eight prenatal care checkups, serology and echocardiogram were requested to rule and protocol blood tests with negative results. out associated congenital malformations; Obstetric ultrasounds at weeks 19 and 29 of the results were normal. Clinical genetics pregnancy did not report alterations and fetal determined a chemical teratogenic disruptive movements were positive since month two. process during the first trimester of pregnancy The infant was a vaginal delivery product with as probable etiology. Taking into account his cephalic presentation and without premature history, a k-band karyotype was requested, rupture of ovular membranes; Apgar: 6/8/10. which was not authorized by the health service The child was fully vaccinated. No pathological, provider, so it was not possible to use it as a infectious, pharmacological or transfusion history diagnostic tool to establish management. This were observed other than maternal poisoning case report does not address the importance during the first trimester of pregnancy with of the denied examination. insecticide, since the mother lives in an area The patient required mechanical ventilation where constant fumigations are performed. and inotropic support. The Pediatric Surgery On physical examination, the patient Service proposed closing the abdominal wall presented with stable vital signs and normal gradually and adding metronidazole to antibiotic anthropometric measurements (abdominal management. During surgery, severe gastro- gastroschisis and primary care services

schisis was found with exposure of stomach, A second surgery was planned 24-48 hours 13 small and large intestines, after the last plication. However, chest x-ray with thickened meso, and leaky and thickened findings were interpreted as possible acute intestine due to intrauterine exposure. disseminated candidiasis, so the procedure The umbilical border was cleared, the um- was postponed. Pediatric Pneumology ruled bilical and vesical arteries were ligated and a out said infection, so the second surgery Bogota bag was attached to the skin covered was performed 4 days after the last plication with gauze impregnated with Furacin®. (Figure 1). During the procedure, gastro- The procedure was well tolerated at first, schisis was corrected with myocutaneous but a deterioration of the clinical condition was and fasciocutaneous flap. After removing the observed subsequently with hemodynamic viaflex container, a thickened, dysmorphic and instability, which required inotropic support malrotated intestine was observed. with dopamine and dobutamine; mechanical If gastroschisis is a small defect (only a ventilation with high parameters; sedation with part of the intestines protrudes from the ab- fentanyl and morphine; relaxation with rocu- domen), it is usually treated with surgery soon ronium, and follow-up with antibiotic therapy after birth (Figure 1). However, if gastroschisis with ampicillin-gentamicin and metronidazole. is a large defect (many organs protrude from The Pediatric Surgery Service decided to the abdomen), repair could be done slowly, perform plications of the viaflex container. The in stages, covering the exposed organs with a first was done 3 days after the first surgery special material and placing them slowly in the and the second and third were performed at abdomen. After the organs have been arranged intervals of 24 hours after the first plication. inside the abdomen, the opening is closed.

Figure 1. Secong surgery. Source: Own elaboration based on the data obtained in the study.

In the postoperative period, the patient analgesic doses. Mechanical ventilation was remained hemodynamically stable, achieving continued in a controlled assisted manner inotropic and vasoactive weaning. Pharmaco- with minimal parameters and intra-abdomi- logical relaxation and morphine were discon- nal pressure between 6-11 mmHg. Trophic tinued and fentanyl was administered only at stimulation with dextrose at 5% was initiated. case reports Vol. 4 No. 1: 10-8

14 The patient remained hospitalized for 109 EPIDEMIOLOGY days; his evolution was satisfactory and the food was well tolerated with normal stools and In recent decades, the incidence of gastro- adequate weight gain (reaching 3 875 grams). schisis has increased worldwide (1,5,10) and The patient was discharged with breastfeeding is observed in 1/3 000 to 1/10 000 births. A on demand, supplemented extensively with review of the 1991-2001period in the Clini- hydrolyzed milk formula. Currently, the child cal Hospital of the University of Chile showed continues to be monitored by High-risk Pedi- that the figure was 2.1/10 000 births. (1-4) atrics, Clinical Genetics, Pediatric Cardiology In Colombia, an incidence of 7.8/10 000 and Nutrition. births was reported, more frequently seen in 37-week-old male newborns. (13,14) The DISCUSSION risk factors associated with the disease are prematurity; small for gestational age new- The first gastroschisis report was published borns; maternal age <20 years; being born in 1773. (4,6) Around 1894, Taruffi coined to a primigravida mother; Caucasian race; this term to group diseases of different etiolo- Hispanic mothers; maternal malnutrition; ex- gy (, bladder exstrophy, amniotic posure to nitrosamines; teratogens and ag- , gastroschisis). (4) The distinction be- rochemicals; consumption of nonsteroidal tween gastroschisis and other abdominal wall anti-inflammatory drugs and acetaminophen defects, especially omphalocele, was success- in the first trimester; cigarette, alcohol and fully achieved at the beginning of the 21st cen- illicit drugs consumption; low socioeconom- tury with the implementation of the International ic class; absence of prenatal checkups, and Classification of Diseases, tenth edition (ICD- short cohabitation with the father of the child. 10). (4) Table 2 summarizes the differences be- (1,2,5,7-11,13) The average age of mothers tween gastroschisis and omphalocele. (1-3,5,6) with affected children is 21.1 years; women aged 14 to 19 have a 7.2 times higher risk of Table 2. Differences between gastroschisis and omphalocele. having a child with gastroschisis compared Gastroschisis Omphalocele to 25 to 29-year-old mothers. (15) Location: right side Location: center It should be noted that the mother of the Content not covered Presence of peritoneum-am- studied patient was 17 years old, primigravida, by membranes niotic membrane exposed to a toxic substance (insecticide) Umbilical cord inserted in in the first trimester of pregnancy and of low No umbilical cord caudal area of the hernial sac socioeconomic status. Embryopathy Fetopathy Content: intestine Content: intestine, (in ETIOPATHOGENESIS (100%), colon, blad- most cases); spleen, colon, der, gonads (occa- bladder (occasionally) There is no certainty about the exact cause of sionally) gastroschisis, since it is a multifactorial disease. Rarely associated Frequently associated with Embryologically, the abdominal wall originates with other congenital other congenital anomalies anomalies (15%) (40-80%) from the lateral mesoderm and by the fusion of four folds (cephalic, caudal and two lateral Source: Own elaboration based on (1,3,5,6) foldings), which grow towards the midline, con- gastroschisis and primary care services

verging in the umbilical ring that is completed Prenatal detection of this disease is 15 around the fourth week. (2,12) important because it allows timely genetic Current accepted causal theories affirm that counseling, since performing a karyotype is gastroschisis is caused by vascular disruptions, not recommended in these patients given the either by intrauterine occlusion of the ompha- limited association of this defect with other lomesenteric artery or by early atrophy (<28 genetic syndromes. (9) Furthermore, diagnosis days) of the right umbilical vein, which causes facilitates a better monitoring of pregnancy, wall infarction with rupture of the umbilical ring which avoids complications. (19,23) and eventration of the intestine. (2,16-18) There are useful ultrasound predictors to A new theory proposes that there is a estimate the possibility of neonatal complica- defect in the inclusion of the yolk sac in the tions, such as . (7,23) Some fetal body stem, with the consequent forma- predictors are intra-abdominal dilation of the tion of an additional opening through which bowel (7,8), intrauterine growth restriction the intestine is eventracted, instead of doing (8), thickness of the abdominal wall (8) and it through the umbilical cord. (16-18) The liver herniation. (8) final outcome is the eventration of abdominal contents in utero that, regardless of the size MANAGEMENT OF GASTROSCHISIS and quantity of viscera exposed, is associated AT PRIMARY CARE with a mortality of 5% and 3-15% after birth. (5,7,8,12) However, these deaths may be Once the prenatal diagnosis is made, a multidis- associated with complications and significant ciplinary approach (obstetrician, neonatologist, morbidity, prolonged hospital stays, need for pediatric surgeon) and bi-monthly sonographic mechanical ventilation, prolonged parenteral controls are required to monitor markers to pre- nutrition, multiple surgical interventions and dict complications. (23) Although some studies diseases such as intestinal atresia, short bowel postulate that there are no differences in the syndrome, neonatal sepsis and necrotising outcome of neonates in relation to prenatal di- enterocolitis. (7-9,12) agnosis (20), these reports come from devel- oped countries, where care delivery is done in DIAGNOSIS centers of medium or high complexity, while in Colombia undetected cases may be handled in A gastroschisis diagnosis can be achieved in centers that do not have technological resourc- the prenatal stage by means of an ultrasonog- es and adequate personnel, as in this case. raphy, which has high sensitivity and specific- Several studies suggest that early caesarean ity for its detection. Detecting the disease is section (36-37 weeks) decreases morbidity with possible since week 12 (19) with rates of up respect to vaginal delivery due to the supposed to 90%, depending on the quality of the equip- risk of infection or perforation of the viscera ment used, the institution were the examination exposed during the latter, while other authors is performed and the experience of the staff do not find significant differences. (20,23,24) (19-22), which would explain why, in this case, The scheme presented below should be the pathology was not detected prenatally, de- followed after the birth of a child without a spite the adequate number of controls and two prenatal diagnosis, which is similar to what ultrasound scans taken after week 12. was presented in this clinical case. case reports Vol. 4 No. 1: 10-8

16 First, adequate resuscitation and oxygen umbilical cord. Several studies have found support should be initiated, for which up to 170 that this technique has an effectiveness profile mL/kg of dextrose solutions may be required similar to conventional closure, and that, in within the first 24 hours, since the metabolic fact, in low-risk patients, it is associated with demands of these patients are greater due to a lower requirement of mechanical ventilation the exposure of intestinal loops, with conse- and a decrease in the incidence of surgical quent loss of fluids and hypothermia. (23-25) wound infections. Then, gastric decompression is performed In addition, the closing without sutures using a probe, washing the intestinal loops with technique, using flaps with autologous tissue, 0.9% saline and covering them with plastic can be performed outside the operating room, bags or sterile viaflex (23,24), thus reducing decreasing anesthesia requirements and costs the risk of infection. (23-25) The patient is for health institutions. (15,29,30) placed in the right lateral decubitus position to reduce the risk of intestinal ischemia (24) ETHICAL CONSIDERATIONS and empirical antibiotic management is ini- tiated, preferably with ampicillin-gentamicin, According to bioethical parameters, the ef- adding vasoactive support if required. These forts during any procedure should be directed basic measures help to decrease mortality in to achieve the optimal resolution of the benefi- patients —a study in Africa found that 25% cence, nonmaleficence, autonomy, justice and of neonatal deaths with gastroschisis were equity principles, which guarantee adequate related to some deficiency in initial manage- interdisciplinary management. (31) ment in primary care. (26) Once stabilized, the When analyzing the conflict of principles, patient should be referred to a more complex the lack of a timely prenatal diagnosis was evi- level with Pediatric Surgery and Neonatology dent (20), thus preventing adequate follow-up Services, maximum 4-7 hours later, since this at an appropriate level of complexity and the is the preferred time to perform the surgical choice of early cesarean section, which has closure. (23) shown effects on mortality. (23,24) This leads There are two types of closures: primary to an initial transgression of the justice and and gradual. Some of the factors associated equity principles, since no adequate equip- with the success of primary closure include ment or human resources were available for patients classified as low risk and born in- prenatal diagnosis in ultrasound after week 12. trainstitutionally and in reference centers. Regarding the management of this case, it is (27) On the other hand, gradual closure has worth highlighting the optimal initial treatment, some advantages over the primary closure, timely referral from the primary care institution, such as lower incidence of compartment adequate information to relatives and the suc- syndrome and intra-abdominal hypertension, cessful interhospital communication, which lower requirement of mechanical ventilation demonstrate full support to the beneficence and vasoactive support. (28) Regarding the and autonomy principles. surgical technique, in recent years the suture- This research was authorized by the le- less closure technique has been implemented gal guardian of the minor and respected the using flaps with autologous tissue, mainly confidentiality of the patient and his relatives. gastroschisis and primary care services

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