Not all that drains is gut - umbilical venous catheter extravasation masquerading as intestinal perforation: A case report

Abstract

BACKGROUND

Umbilical venous catheterisation (UVC) is frequently used in neonates but may be complicated by malposition or migration. Extravasation is rare and can mimic other abdominal pathologies.

CASE SUMMARY

We report a preterm infant, born at 27 weeks’ gestation, who developed bilateral pneumothorax and spontaneous intestinal perforation requiring drainage. On day 8, the infant clinically deteriorated with persistent high-volume clear peritoneal drain output and worsening dehydration despite fluid escalation. Abdominal radiography confirmed UVC migration into the liver with possible extravasation. Following catheter removal, peritoneal drainage reduced dramatically, and the infant improved rapidly. He was discharged at 38 weeks’ corrected age and remained well with age-appropriate development.

CONCLUSION

UVC extravasation can masquerade as high-output peritoneal drainage in the setting of intestinal perforation, thereby delaying diagnosis. Persistent, unusually high peritoneal drainage should prompt consideration of catheter leakage. This rare presentation expands the spectrum of UVC-related complications described in the literature and emphasizes the importance of prompt recognition and management.

Key Words: Umbilical line; Preterm; Spontaneous intestinal perforation; Peritoneal drain, complications; Umbilical venous catheterization; Case report

Core Tip: We describe the first case of umbilical venous catheterization extravasation masquerading as high-output peritoneal drainage in the context of spontaneous intestinal perforation. Unlike typical presentations of abdominal distension or metabolic derangements, our patient exhibited persistently clear drain output, delaying diagnosis. Radiographic confirmation and prompt catheter removal led to rapid recovery. This case underscores the need for vigilance, early imaging, and multidisciplinary collaboration when managing unexplained peritoneal drainage in preterm infants with central lines.

INTRODUCTION

Umbilical venous catheterisation (UVC) is a common procedure in neonatal intensive care units (NICU). It is quick to perform, requires less technical expertise compared to peripherally inserted central catheters, and allows safe delivery of total parenteral nutrition and hyperosmolar fluids[1]. Correct placement of the UVC tip, at the junction of the inferior vena cava and right atrium, is essential to avoid complications, and is usually confirmed radiographically[2]. Migration or malposition of the catheter may lead to serious complications, including vascular, hepatic, and gastrointestinal injuries[2,3]. We report a preterm neonate with spontaneous intestinal perforation in whom UVC migration led to the rare and unexpected presentation of markedly elevated peritoneal drain output. Prompt recognition and management were life-saving for this extremely low birth weight infant.

CASE PRESENTATION

Chief complaints

The infant was born at 27 weeks’ gestation with a birth weight of 890 g via emergency caesarean section in view of prolonged preterm premature rupture of membranes and anhydramnios.

History of present illness

The neonate had poor respiratory drive at birth and required ventilation and surfactant therapy. Umbilical venous access was secured, and total parenteral nutrition was initiated soon after admission to the NICU. The UVC was confirmed to be in the central position by radiograph (body of T8 vertebra) (Figure 1A). The catheter was then sutured in place, and additional tape was used to further secure the catheter to the infant’s abdomen. At around 3 hours of life, the infant developed desaturation episodes with reduced air entry on auscultation. Chest radiography revealed a right-sided pneumothorax, for which an intercostal drain was inserted. Soon, the infant developed a left-sided pneumothorax, requiring insertion of a left intercostal drain.

Figure 1 Abdominal radiograph. A: Chest and abdominal radiograph (anteroposterior view) obtained on the first day of life, demonstrating the central position of the umbilical venous catheter; B: Chest and abdominal radiograph (anteroposterior view) obtained on the seventh day of life, demonstrating the penumoperitoneum (football sign) and position of the umbilical venous catheter.

History of past illness

Since it is a newborn, there is no past medical history.

Personal and family history

Since it is a newborn, there is no personal or family history.

Physical examination

Respiratory status improved on ventilator support over the next few days. Feeds were not initiated in view of dark brown gastric aspirates noted from the orogastric tube. On day 7, the infant developed acute abdominal distension with fluctuating oxygen saturation. Transillumination was suggestive of pneumoperitoneum, for which a peritoneal glove drain was inserted, resulting in drainage of gas and around 3 mL of serous fluid. Abdominal radiograph confirmed pneumoperitoneum and outward migration of UVC (L1-L2 vertebra level), with a straight course (Figure 1B). Since the baby was unstable and had poor perfusion, establishing a new vascular access was difficult. Lipid infusion was stopped, and calcium was removed from the parenteral fluid. Partial parenteral nutrition with dextrose, amino acids, and electrolytes was continued through the low-lying UVC. It was planned to insert a new peripherally inserted central catheter after 1-2 days, once the neonate was stable. Neonate improved clinically post insertion of the glove drain.

Laboratory examinations

Blood test performed on day 7 showed sodium 135 mEq/L, potassium 4.2 mEq/L, and glucose 78 mg/dL. There was minimal peritoneal drain (total 2 mL) over the next 24 hours. However, on day 8, around 30 hours post the drain insertion, the peritoneal drain volume started increasing (30 mL in 24 hours). In response, the total parenteral fluid volume was increased. Repeat blood tests showed sodium 132 mEq/L, potassium 3.9 mEq/L, and sugar level 64 mg/dL. However, by the next day, the peritoneal drain output had increased to 120 mL/day. The fluid was clear, and over the next 24 hours, the drain output further increased in proportion to the escalation of parenteral fluids. The neonate started showing signs of dehydration and low blood sugar levels. Blood tests revealed hyponatremia (sodium 127 mEq/L), potassium level 3.6 mEq/L, and borderline-low sugar levels (48 mg/dL).

Imaging examinations

Repeat abdominal radiograph on day 8 confirmed further UVC migration into the liver (Figure 2A). An abdominal ultrasound was performed, which showed deviation of the UVC tip toward the portal vein along with inflammation/edema of the surrounding liver parenchyma. Blood tests showed elevated alanine transaminase levels of 129 U/L, with other liver function tests showing normal results.

Figure 2 Chest and abdominal radiograph. A: Chest and abdominal radiograph (anteroposterior view) obtained on day 8 of life, showing the migrated umbilical venous catheter positioned within the liver. The radio-opaque gauze pieces were placed at the site of the peritoneal drain on the right iliac region; B: Chest and abdominal radiograph (anteroposterior view) shows central position of the peripherally inserted central catheter with improvement in bowel gas pattern after removal of the umbilical venous catheter.

FINAL DIAGNOSIS

These findings supported the possibility of total parenteral nutrition extravasation secondary to UVC migration.

TREATMENT

The UVC was promptly removed, and fluid replacement was provided with a peripheral intravenous catheter. Within 12 hours of removing the UVC, the peritoneal drain output reduced. Parenteral nutrition was provided by a peripherally inserted central catheter inserted over the left arm (Figure 2B). Over the next three days, the intestinal perforation healed, and the glove drain could be removed. Feeds were initiated the following week, and the neonate had a smooth NICU course thereafter. Blood reports, including alanine transaminase levels, normalized after one week.

OUTCOME AND FOLLOW-UP

The neonate was discharged at 38 weeks corrected gestational age. At 9 months of age, he demonstrated age-appropriate developmental milestones and is on regular follow-up. No abnormalities in liver function were observed at 9 months of age.

DISCUSSION

Umbilical venous catheterization remains an indispensable intervention in the management of critically ill neonates, providing reliable central access for fluid resuscitation, parenteral nutrition, and medications. Although generally safe, UVCs are prone to malposition and migration, particularly in preterm infants, due to vessel fragility and anatomical variability[4]. The UVC has a dwell time of 7-10 days, reducing the need for invasive, painful vascular procedures[5]. A prospective study of 65 preterm infants showed that UVC tip migration occurred in 50% of neonates at any time during the first week[6]. Migration of UVC may result in complications, including hepatic parenchymal injury, vascular perforation, and extravasation of infusate[7-9]. Neonatal cases of UVC extravasation presenting with ascites and electrolyte imbalance have been described[10,11], but the co-existence of spontaneous intestinal perforation has not been previously reported as a diagnostic confounder.

In our patient, the simultaneous presence of an intraperitoneal drain obscured the clinical picture, leading to a delay in recognizing UVC extravasation. The neonate first developed pneumoperitoneum on day of life 7, for which glove drain insertion was performed at bedside. After the abdominal drain insertion, only 2 mL of fluid was obtained for the first 24 hours, with predominantly air drainage. During this period, the abdominal distension improved, and the neonate had normal blood sugar and electrolytes. Approximately 30 hours after the glove drain insertion, the peritoneal drain output started increasing, likely due to UVC extravasation. The following day (day of life 9), drain output increased significantly, leading to hypoglycemia, dehydration, and decreased urine output. This could be related to displacement of the UVC tip, resulting in vessel injury and subsequent leakage of infusate into the peritoneal cavity. Unlike previously reported cases, where extravasation typically presented with progressive abdominal distension, fluid retention, or metabolic derangements[12], our neonate exhibited persistently high-output clear peritoneal drainage. Edison et al[12] reported a premature baby that presented on day 7 of life with abdominal distension and migration of UVC to below the T10 level. Abdominal radiograph was suspicious of ascites, and aspiration revealed around 100 mL of milky peritoneal fluid[12]. In our case, due to the presence of a peritoneal drain, we noted the high peritoneal drain output that mimicked an ongoing gastrointestinal pathology and contributed to diagnostic uncertainty. Ultimately, the combination of excessive drain output and refractory dehydration despite fluid replacement raised suspicion of catheter leakage, which was confirmed by radiography and ultrasound. Prompt catheter removal resulted in rapid clinical improvement, underscoring the reversibility of this complication when identified early.

This case highlights several key learning points. First, persistent or disproportionately high peritoneal drainage in neonates should raise suspicion, even in the presence of concomitant gastrointestinal pathology. Second, prompt use of radiography to recheck catheter position is critical, particularly when the clinical course deviates from expectations. The potential role of ultrasound as a valuable adjunct for initial confirmation and subsequent assessment of catheter tip position also needs to be explored. Finally, multidisciplinary collaboration among neonatologists, radiologists, and surgeons is vital to avoid morbidity and ensure timely intervention.

CONCLUSION

To our knowledge, this is the first reported case of UVC extravasation masquerading as high-output peritoneal drainage in the setting of spontaneous intestinal perforation. Recognition of this rare presentation expands the spectrum of UVC-related complications described in the literature and emphasizes the importance of vigilance in the ongoing care of preterm neonates with central lines.