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APSP J Case Rep 2010; Vol. 1 (2)
Pneumoscrotum: A Rare Presentation of Gastric Perforation in a
Yousuf Aziz Khan,* Jamshed
Department of Pediatric Surgery, National Institute of Child
Health Karachi, Pakistan
*Corresponding Author's E-mail address:
APSP J Case Rep 2010; 1:
Pneumoperitoneum in neonates is not an uncommon
condition. Free air in peritoneum may be secondary to host of pathological
lesions. Usually the patient presents with signs of intraperitoneal sepsis,
however presence of air in the scrotum as a concomitant sign is a rare event.
Herein we report a 4-day-old neonate who presented with 2 days history of fever
and scrotal swelling. Abdominal signs were subtle. Scrotum was hugely distended
and tense. Workup of the patient revealed free intraperitoneal gas with air in
the scrotum. At exploration, two perforations were found near the greater
curvature of stomach and repaired. Post-operative course was
Gastric perforation, Pneumoscrotum, Neonate
HOW TO CITE
Khan YA, Akhtar J. Pneumoscrotum:
A rare presentation of gastric perforation in a neonate. APSP J Case Rep
Free intraperitoneal gas on
abdominal x-rays, the pneumoperitoneum, is not an uncommon presentation in
neonates. Mostly it is taken as a sign of gut perforation and laparotomy is
generally required . It may also be found in neonates with severe
respiratory distress, after aggressive resuscitation or with mechanical
Pneumoperitoneum presenting as pneumoscrotum
secondary to gastric perforation without abdominal findings is rare. We report a
case of neonate who presented with scrotal swelling and was found to have
gastric perforations at laparotomy.
days old (1.8 kg) full term male neonate presented with fever and gross scrotal
swelling for two days. The baby was delivered at home and nothing significant
found in perinatal history. He passed meconium within few hours of birth and had
examination, the baby was febrile (100 ºF), irritable, reluctant to feed, with
heart rate of 130/min, and respiratory rate of 42/min. Chest was clear on
auscultation and abdomen was non distended and soft. The umbilical stump was
infected. There was a huge, irreducible, soft swelling at the right
hemi-scrotum, extending proximally to the inguinal region. The scrotal skin was
tense and shiny [Image 1]. Right testis could not be palpated. Initially a
diagnosis of irreducible inguinal hernia was made.
were within normal limits. X-ray abdomen and pelvis in erect posture revealed
free gas under the right dome of diaphragm and in the scrotum [Image 2]. With
the suspicion of gut perforation, laparotomy was performed.
The scrotal swelling spontaneously reduced as the peritoneal cavity
was opened. Two small perforations were found at the posterior wall of stomach
near the greater curvature. Rest of the peritoneal cavity was clean and gut
appeared healthy. Primary repair of the perforations was done. Post-operative
course was uneventful. Baby was allowed orally on 6th post-operative
day and discharged on 8th day.
Pneumoperitoneum in neonates has multiple causes and varied
presentations ranging from a vitally stable newborn with minimal or no abdominal
signs to a sick baby with gross abdominal distension. Mostly it is taken as a
sign of gut perforation. Rarely, extra abdominal cause may be the source of free
intraperitoneal air [2-4]. Very rarely it may be without any surgical or medical
cause, termed as benign pneumoperitoneum .
perforation in neonates is a rare event and represents immediate surgical
emergency. It usually occurs in premature neonates in intensive care setting.
Proposed mechanisms of this perforation are trauma, ischemia, and one occurring
spontaneously . Traumatic perforations are usually iatrogenic, occurring due
to vigorous nasogastric tube placement or massive gastric distension associated
with aggressive resuscitation with bag mask ventilation or in newborns with
respiratory distress and on mechanical ventilation . Severe birth asphyxia,
prematurity and sepsis are the common risk factors associated with ischemic
perforations of stomach in newborns . Spontaneous perforations occur usually
in healthy newborns without gastrointestinal conditions, presenting within 2 - 7
days of life. No exact predisposing or risk factor can be identified in such
newborns. Rarely congenital muscular deficiency of stomach may be the cause of
gastric perforation. It has also been reported secondary to distal obstruction
and atresias . No such etiological factors were found in our patient and it
may be suggested that the gastric perforations were spontaneous in
Clinically, a newborn with gastric perforation presents with
gross abdominal distension compromising ventilation along with signs of
hypovolemic shock and sepsis and radiologically, massive pneumoperitoneum is
noticed [5, 6]. In our case, the baby had clinically normal abdomen and very
small amount of free intraperitoneal air on x-ray.
pneumoscrotum has been reported secondary to perforation of Meckels
diverticulum, perforation of ileum secondary to atresia, after aggressive
resuscitation, and with mechanical ventilation; scrotal pneumatocele secondary
to gastric perforations and without signs of intraperitoneal sepsis is rarely
reported. As processus vaginalis is patent in 80 - 95 % newborn males, free air
in the peritoneum passing through the patent process vaginalis, causing gaseous
distension of the scrotum is the possible explanation of pneumoscrotum in this
case. Other mechanisms postulated in the development of pneumoscrotum are
subcutaneous or retroperitoneal air dissecting down the dartos lining of the
scrotal cord into the scrotal wall or may result from local production of gas
secondary to infections [3, 6-10].
In conclusion, pneumoscrotum along with pneumoperitoneum
without significant abdominal distension may be a presentation of neonatal
gastric perforation and demands high index of suspicion to manage the condition
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