In an analysis of surgical complications following 500 consecutive orthotopic liver transplants, we identified 12 patients who developed the syndrome of multiple bowel perforations that was not due to iatrogenic injury. All cases occurred in small children (mean weight: 9.0 kg), who represented 7% of the pediatric population. Each patient had a minimum of three perforations. The typical intra-operative findings were pin-point perforations in areas of normal-appearing bowel. With only one possible exception (a patient with cytomegalovirus enteritis), no specific etiology could be determined. Management was based on multiple exploratory laparotomies and individualized operative procedures. All patients are currently alive (mean follow-up: 34.9 months). The pathogenesis of the syndrome of multiple bowel perforations remains unclear but is possibly multifactorial or related to high doses of steroids. Aggressive surgical management with semiopen treatment of peritonitis and frequent explorations has afforded excellent results.
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