Abdominal Problems in Children with Congenital Cardiovascular Abnormalities

Abstract

Background: Congenital cardiovascular abnormality is an important cause of morbidity and mortality in childhood. Both the type of congenital cardiovascular abnormality and cardiopulmonary bypass are responsible for gastrointestinal system problems. Aims: Intra-abdominal problems, such as paralytic ileus, necrotizing enterocolitis, and intestinal perforation, are common in patients who have been operated or who are being followed for congenital cardiovascular abnormalities. Besides the primary congenital cardiovascular abnormalities, ischemia secondary to cardiac catheterization or surgery contributes to the incidence of these problems. Study Design: Cross-sectional study. Methods: In this study, we aimed to screen the intra-abdominal problems seen in patients with congenital cardiovascular abnormalities who had undergone surgical or angiographical intervention(s). Patients with congenital cardiovascular abnormalities who had been treated medically or surgically between 2000 and 2014 were analyzed retrospectively in terms of intra-abdominal problems. The patients’ demographic data, type of congenital cardiovascular abnormalities, the intervention applied (surgical, angiographic), the incidence of intra-abdominal problem(s), the interventions applied for the intra-abdominal problems, and the results were evaluated. Results: Fourteen (Group I) of the 76 patients with congenital cardiovascular abnormalities diagnosis were operated due to intra-abdominal problems, and 62 (Group II) were followed-up clinically for intra-abdominal problems. In Group I (10 boys and 4 girls), 11 patients were aged between 0 and 12 months, and three patients were older than 12 months. Group II included 52 patients aged between 0 and 12 months and 10 patients older than 12 months. Cardiovascular surgical interventions had been applied to six patients in Group I and 40 patients in Group II. The most frequent intra-abdominal problems were necrotizing enterocolitis and intestinal perforation in Group I, and paralytic ileus in Group II. Seven of the Group I patients and 22 of the Group II patients died. The patients who died in both groups had more than three congenital cardiovascular abnormalities in the same patient, and 80% of these patients had been operated for congenital cardiovascular abnormalities. Conclusion: The gastrointestinal system is involved in important complications experienced by patients with congenital cardiovascular abnormalities. The mortality rate was higher in operated patients due to gastrointestinal complications. Gastrointestinal complications are more frequent in patients with cyanotic anomalies. The presence of more than one congenital cardiovascular abnormality in a patient increased the mortality rate.

Keywords

• Abdominal surgery, cardiopulmonary, congenital, cardiovascular abnormalities, intestinal ischemia

References

1. 1. McElhinney DB, Hedrick HL, Bush DM, Pereira GR, Stafford PW, Gaynor JW, et al. Necrotizing enterocolitis in neonates with congenital heart disease: risk factors and outcomes. Pediatrics 2000;106:1080-7. [CrossRef]
2. 2. Fatica C, Gordon S, Mossad E, McHugh M, Mee R. A cluster of necrotizing enterocolitis in term infants undergoing open heart surgery. Am J Infect Control 2000;28:130-2. [CrossRef]
3. 3. Cheng W, Leung MP, Tam PK. Surgical intervention in necrotizing enterocolitis in neonates with symptomatic congenital heart disease. Pediatr Surg Int 1999;15:492-5. [CrossRef]
4. 4. Rand T, Weninger M, Kohlhauser C, Bischof S, Heinz-Peer G, Trattnig S, et al. Effects of umbilical arterial catheterization on mesenteric hemodynamics. Pediatr Radiol 1996;26:435-8. [CrossRef]
5. 5. Pumberger W, Mayr M, Kohlhauser C, Weninger M. Spontaneous localized intestinal perforation in very-low-birth-weight infants: a distinct clinical entity different from necrotizing enterocolitis. J Am Coll Surg 2002;195:796-803. [CrossRef]
6. 6. Nankervis C, Giannone P, Reber K. The Neonatal Intestinal Vasculature: Contributing Factors to Necrotizing Enterocolitis. Semin Perinatol 2008;32:83-91. [CrossRef]
7. 7. Kumle B, Boldt J, Suttner SW, Piper SN, Lehmann A, Blome M, et al. Influence of prolonged cardiopulmonary bypass times on splanchnic perfusion and markers of splanchnic organ function. Ann Thorac Surg 2003;75:1558-64. [CrossRef]
8. 8. Maayan-Metzger A, Itzchak A, Mazkereth R, Kuint J. Necrotizing enterocolitis in full-term infants: case-control study and review of the literature. J Perinatol 2004;24:494-9. [CrossRef]

9. 9. Reber KM, Nankervis CA, Nowicki PT. Newborn intestinal circulation. Physiology and pathophysiology. Clin Perinatol 2002;29:23-39. [CrossRef]
10. 10. Powell RW, Dyess DL, Collins JN, Roberts WS, Tacchi EJ, Swafford AN Jr, et al. Regional blood flow response to hypothermia in premature, newborn, and neonatal piglets. J Pediatr Surg 1999;34:193-8. [CrossRef]
11. 11. Albanese CT, Rowe MI. Necrotizing enterocolitis. In: O’Neill JA, Jr (ed.), Pediatric Surgery 5th ed; Volume 2. St. Louis, Missouri, 1998, pp. 1297-320.
12. 12. Sweet DG, Craig B, Halliday HL, Mulholland C. Gastro-intestinal complications following neonatal cardiac catheterisation. J Perinat Med 1998;26:196-200. [CrossRef]
13. 13. Bolisetty S, Lui K, Oei J, Wojtulewicz J. A regional study of underlying congenital diseases in term neonates with necrotizing enterocolitis. Acta Paediatr 2000;89:1226-30. [CrossRef]
14. 14. Cozzi C, Aldrink J, Nicol K, Nicholson L, Cua C. Intestinal location of necrotizing enterocolitis among infants with congenital heart disease. J Perinatol 2013;33:783-5. [CrossRef]
15. 15. Simić O, Strathausen S, Hess W, Ostermeyer J. Incidence and prognosis of abdominal complications after cardiopulmonary bypass. Cardiovasc Surg 1999;7:419-24. [CrossRef]
16. 16. Tao W, Zwischenberger JB, Nguyen TT, Vertrees RA, McDaniel LB, Nutt LK, et al. Gut mucosal ischemia during normothermic cardiopulmonary bypass results from blood flow redistribution and increased oxygen demand. J Thorac Cardiovasc Surg 1995;110:819-28. [CrossRef]
17. 17. Mangi AA, Christison-Lagay ER, Torchiana DF, Warshaw AL, Berger DL. Gastrointestinal complications in patients undergoing heart operation: an analysis of 8709 consecutive cardiac surgical patients. Ann Surg 2005;241:895-901; discussion 901-4. [CrossRef]
18. 18. Gasz B, Lenard L, Racz B, , Benko L, Borsiczky B, Cserepes B, et al. Effect of cardiopulmonary bypass on cytokine network and myocardial cytokine production. Clin Cardiol 2006;29:311- 5. [CrossRef]
19. 19. Rothwell-Jackson RL. Idiopatic large bowel obstruction. Br J Surg 1963;50:797. [CrossRef]
20. 20. Narkevis CA, Giannone PJ, Reber KM. The Neonatal Intestinal Vasculature Contributing Factors to Necrotizing Enterocolitis. Semin Perinatol 2008;32:83-91. [CrossRef]
21. 21. Young C, Kingma S, Neu J. Ischemia-Reperfusion and Neonatal Intestinal Injury. J Pediatr 2011;158:25-8. [CrossRef]
22. 22. Allen BS. The clinical significance of the reoxygenation injury in pediatric heart surgery. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2003;6:116-27. [CrossRef]
23. 23. Hebra A, Brown MF, Hirschl RB, McGeehin K, O’Neill JA Jr, Norwood WI, et al. Mesenteric ischemia in hypoplastic left heart syndrome. J Pediatr Surg 1993;28:606-11. [CrossRef]
24. 24. Curzon CL, Milford-Beland S, Li JS, O’Brien SM, Jacobs JP, Jacobs ML, et al. Cardiac surgery in infants with low birth weight is associated with increased mortality: analysis of the Society of Thoracic Surgeons Congenital Heart Database. J Thorac Cardiovasc Surg 2008;135:546-51. [CrossRef]
25. 25. Malagon I, Onkenhout W, Klok G, van der Poel PF, Bovill JG, Hazekamp MG. Gut permeability in paediatric cardiac surgery. Br J Anaesth 2005;94:181-5. [CrossRef]
26. 26. Braun JP, Schroeder T, Buehner S, Dohmen P, Moshirzadeh M, Grosse J, et al. Splanchnic oxygen transport, hepatic function and gastrointestinal barrier after normothermic cardiopulmonary bypass. Acta Anaesthesiol Scand 2004;48:697-703. [CrossRef]
27. 27. Hashemzadeh K., Hashemzadeh S. Predictors and outcome of gastrointestinal complications after cardiac surgery. Minerva Chir 2012; 67:327-35.
28. 28. Laffey JG, Boylan JF, Cheng DC. The systemic inflammatory response to cardiac surgery: implications for the anesthesiologist. Anesthesiology 2002;97:215-52. [CrossRef]
29. 29. O’Dwyer C, Woodson LC, Conroy BP, Lin CY, Deyo DJ, Uchida T, et al. Regional perfusion abnormalities with phenylephrine during normothermic bypass. Ann Thorac Surg 1997;63:728-35. [CrossRef]
30. 30. Kumar M, Killingsworth C, McILwain RB, Timpa JG, Jagadeeswaran R, Namachivayam K, et al. Intestinal Epithelial Apoptosis initiates Gut Mucosal Injury during Extracorporeal Membrane Oxygenation in the Newborn Piglet. Lab Invest 2014; 94:150-60.[CrossRef