(878) Extensive Neonatal Intestinal Necrosis With Gastric Perforation: A Rare Case of Prolonged Survival

Introduction: Congenital intestinal malrotation (CIM) can lead to extensive intestinal necrosis in the neonatal population without early recognition. Extensive intestinal necrosis can be fatal, especially if combined with gastric perforation. Given the high mortality rate, early goals of care conversations with families are vital. To date, there are limited reports of extensive neonatal intestinal necrosis, particularly in those with prolonged survival past the initial diagnosis. We present the management of a rare case of neonatal intestinal necrosis with gastric perforation with prolonged survival.

Description: A full term infant female was admitted on day 4 of life in severe distributive shock with multi-organ failure requiring vasopressor therapy and mechanical ventilation secondary to CIM with gastric perforation. She underwent emergent surgery demonstrating extensive ischemic bowel injury (4 cm of viable small/large bowel) with liquefactive necrosis. Postoperatively, the patient’s multidisciplinary team and family had extensive goals of care discussions regarding her grave prognosis, including no options for future surgeries and recommendations for palliative care. During this time the patient demonstrated improved multi-organ failure. She was weaned off of vasopressors, extubated to room air, and was receiving parenteral nutrition. Despite organ recovery, she had persistent liquefactive gut necrosis from her open abdominal wound. After several weeks, the family decided to pursue comfort care within a hospital setting, deferring home hospice due to psychosocial stressors related to her abdominal wound care. At 6 weeks of age, the patient was transferred out of the intensive care unit to the pediatric floor for end of life care.

Discussion: Based on our literature review, our case is only the second reported case of extensive neonatal intestinal necrosis with gastric perforation with prolonged survival. In our case, prolonged survival may be due to the improvement and now lack of additional organ dysfunction as well as continued parenteral nutrition. This case also illustrates prognostic challenges that may arise when caring for rare neonatal diagnoses. Future studies describing cases of extensive neonatal intestinal necrosis are needed to further aid in prognostication and management.