Pediatric

New Roentgenographic Signs of Neonatal Radiology

Gastric Perforation'
RUBEM POCHACZEVSKY, M.D., and DAVID BRYK, M.D.

ABSTRACT-The roentgenographic findings in neonatal or congenital perfora-

tion of the stomach were reviewed in an attempt to distinguish gastric from
distal perforation in cases with spontaneous pneumoperitoneum. The absence
of a gastric air-fluid level on erect abdominal roentgenograms, together with
normal or decreased gas in the small and large bowel, favors gastric perforation.
Conversely, a gastric air-fluid level associated with significant small bowel
distension suggests a small or large bowel perforation.
INDEX TERMS: Infants, Newborn, digestive system. Pneumoperitoneum.
Stomach, perforation
Radiology 102:145-147, January 1972

is the most common site sis is usually made by the roentgenographic

T H E STOMACH
of congenital or neonatal gastro-
intestinal perforation (22). The diagno-
demonstration of air in the peritoneal
cavity, but this merely indicates perfora-

Fig. 1. CASE 1. Neonatal gastric perforation. Erect roentgenogram. Note the displacement of liver and
spleen toward the midline by the large pneumoperitoneum. The intraperitoneal air appears to be draped over
the centrally situated organs-"saddle-bag" sign (28). There is no air-fluid level in the stomach. Note paucity
of bowel gas .
Fig. 2. CASE II . Neonatal gastric perforation. Erect roentgenogram. Note free infradiaphragmatic air,
the absence of a gastric air-fluid level and the absence of bowel gas. Fluid in the peritoneal cavity results in a
long air-fluid level.

1 From the Department of Radiology, The Jewish Hospital and Medical Center of Brooklyn-Greenpoint
Hospital Affiliation and the State University of New York, Downstate Medical Center, Brooklyn, N . Y. Accepted
for publ ication in August 1971. kn

145
146 R UBEM POCHACZEVSKY AND DAVlD BRYK January 1972

Fig. 3 . CASE III. N eonatal gast r ic perforation . Erect ro entgen ogram. There is mode r a te ga stric and
bowel d ist ension but no a ir -flu id level is seen in the stomach. Note fa lciform ligament vi sualized by t he surro und-
in g gas (a r row).
Fig. 4 . Necr ot izing ent erocoli tis wit h perforation of the transverse colon , two-day- old boy . E rect r oentgen o-
gr a m . Note that b oth the stomach a nd sm all bow el are di stended . T he stomach show s a n o bvious ai r- fluid lev el.

tion somewhere in the gastrointestinal (F igs. 1 and 2) . This was ob served in

tract and not necessarily in the st om a ch .
To d ate, there have been no reliable criteria
on the plain abdominal ro entgenogram that
would suggest the site of perforation or its
pathogenesis. For instance, perforation
of the sm all or large bowel due to necrotiz-
ing en t erocolit is may occur in the absence
of the specific signs often associ ated with
this entity, i. e., pneumatosis intestinalis
and/or portal venous gas (30).
Since the stomach is the most common
sit e of perforation in the neonatal period,
it would be useful to h ave radiographic
signs that could help di stinguish gastric
from more distal p erforations.
W e therefore r eviewed reports of neo-
natal gas t ri c perforations (fro m 1954 to
1970) in which roentgenograms were pub-
lished. Only erect a bdominal ro entgeno-
grams demonstrating pneumoperitoneum
due to gast ri c perforation were analyzed.
Fifty-eight roentgenograms were reviewed,
including 55 publish ed and 3 current cases
(F igs. 1-3) . One signi fican t finding was
the lack of an air-fluid level in the stom ach
in 54 of these ca ses (1-9, 11-23,25-29 , 32-
45) (F igs. 1 to 3). An air -fluid level in the
st omach is frequently ob served on upright
vi ews of the abdomen in normal n eonates.
A gast ri c air-fluid level was present in only
4 (7%) of the cases of gast ri c perforation
studied (l0, 21, 29, 40). In addition, the
small and large intestines were usually
not dilated, and sh owed a paucity of gas
numerous infants older than one day of age.
T wenty-five ca ses of spont a neous perfor-
a tion of the small or large bowel in neo-
na tes in whom upright a bdom inal radio-
graph s were obtained were al so reviewed
(30). Pneumoperitoneum, mainly due to
necrotizing enterocolitis of infancy, was
demonstrated on all of these roentgeno-
grams . An air-fluid level in the stomach
was present in 22 (88 % ) of the cases (F ig .
4) and absent in only 3 (12%). Significant
small bowel distension was al so identified
in most instances. Cases of perforation due
to distal bowel obstruction, such as small
bowel atresia or midgut volvulus, were ex-
cluded since the obstruction itself can cause
stomach a nd proximal bowel dil atation.
It thus appears that a bsence of a gastric
air-fluid level on erect a bdom inal roent-
genogram s, associated 'wit h normal or
de creased gas in the sm all and large bowel ,
fa vors the diagnosis of gast ric perforation
in cases of spontaneous pne um operi t oneum
in neonates. Conversely , a gast ric air-
fluid level associated with significa n t sm all
bowel distension suggests spont aneous
sm all or large bowel perforation.
A possible explanation for the in frequent
presenc e of an air-fluid level in the st om ach
in cases of gastric neonatal perforation may
be that the perforation allows the gas and
fluid to leak into the p eritoneal cavity. In
the case reported by Wilson and Arcari
(45) a gastric air-fluid level disappeared

Vol. 102 NEW SIGNS OF NEONATAL GASTRIC PERFORATION
after the development of a pneumoperi-
toneum.
Department of Radiology
Greenpoint Hospital Affiliation
300 Skillman Avenue
Brooklyn, N. Y. 11211
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