A 2-year-old with a hepatic abscess secondary to an ascending retrocecal appendicitis: case report and review of the literature

Gregory M Taylor,Matthew A Warpinski,Eric L Mcdowell,Ethan R Saffer

doi:10.1186/s12245-019-0260-9

Gregory M Taylor, Matthew A Warpinski + Show 2 more

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https://doi.org/10.1186/s12245-019-0260-9

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Abstract

BackgroundDiagnosing appendicitis within the pediatric population can be challenging, whether it be a neonate with irritability or a toddler with flank pain. Symptoms may mimic a viral illness, constipation, urinary tract infection, or intussusception, all of which are more common in this age group when compared with appendicitis. While a ruptured appendicitis can result in an intra-abdominal abscess, peritonitis, and/or shock, the development of a pyogenic hepatic abscess is extremely rare.Case presentationWe present the case of a 2-year-old male who initially presented to the emergency department (ED) with fever and non-specific abdominal pain and was diagnosed with a urinary tract infection (UTI). He returned to the ED days later with rigors, worsening abdominal pain, and was diagnosed with a pyogenic hepatic abscess secondary to an ascending retrocecal appendicitis. In our patient, he did not just have a UTI with cultures growing Escherichia coli, but a hepatic abscess that was polymicrobial. He was started on broad-spectrum antibiotics and a 10 French pigtail catheter was placed. The patient was ultimately discharged on day 8 with continued antibiotics. After his antibiotic course, he underwent an elective laparoscopy appendectomy and is currently doing well post-operatively.ConclusionOur case report illustrates the significance in identifying atypical features of appendicitis, broadening the differential of non-specific abdominal pain in pediatric patients, and depending on the clinical situation, ruling out other potential intra-abdominal infections even in the presence of a true urinary tract infection.

Highlights

ConclusionOur case report illustrates the significance in identifying atypical features of appendicitis, broadening the differential of non-specific abdominal pain in pediatric patients, and depending on the clinical situation, ruling out other potential intra-abdominal infections even in the presence of a true urinary tract infection
Appendicitis is common in children, occurring in 7% of the total population with a mean age between 8 and 10 years old [1]
In the case of the rare development of a potentially life-threatening pyogenic hepatic abscess, the clinical presentation is atypical and complex, with a reported annual incidence of < 0.03%, with < 10% of cases the result of appendicitis [2]. It is for this reason that an ascending retrocecal appendicitis may be clinically indistinguishable from acute

Summary

Conclusion

Diagnosing acute appendicitis in pediatrics can be truly challenging, rather it be a neonate with irritability, a toddler with non-specific flank pain, to various atypical clinical presentations that mimic other disease processes. Depending on the location of the appendix, the classic presentation (right lower quadrant abdominal pain, nausea/vomiting, and fever) may not be present at all. In those patients that go on to develop the extremely rare complication and potentially life-threatening pyogenic hepatic abscess, the clinical presentation continues to diversify. This can result in a delayed diagnosis. As such, creating a broad differential of pediatric abdominal pain, maintaining a high index of clinical suspicion, thorough history/laboratory evaluation, and appropriate imaging are crucial in reducing morbidity and mortality

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