Acute Appendicitis in Infants: Still a Diagnostic Dilemma

Abstract

Case ReportsAcute Appendicitis in Infants: Still a Diagnostic Dilemma Mathew Punnachalil Cherian, MD, DCH, FRCPI Khalid A. Al Egaily, and MD, FAAP Thekkanath Paul JosephMCH, FRACS Mathew Punnachalil Cherian Correspondence to: Dr. M. Cherian, P.O. Box 1356, Ras Tanura 31311, Saudi Arabia From the divisions of Primary Care, Pediatrics and Pediatric Surgery; Ras Tanura Health Center, Dhahran Health Center, Saudi Aramco Medical Services Organization (SAMSO), Saudi Arabi Search for more papers by this author , Khalid A. Al Egaily From the divisions of Primary Care, Pediatrics and Pediatric Surgery; Ras Tanura Health Center, Dhahran Health Center, Saudi Aramco Medical Services Organization (SAMSO), Saudi Arabi Search for more papers by this author , and Thekkanath Paul Joseph From the divisions of Primary Care, Pediatrics and Pediatric Surgery; Ras Tanura Health Center, Dhahran Health Center, Saudi Aramco Medical Services Organization (SAMSO), Saudi Arabi Search for more papers by this author Published Online:1 May 2003https://doi.org/10.5144/0256-4947.2003.187SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionAcute appendicitis is the most common pediatric surgical emergency, constituting 10% of all children admitted to the pediatric emergency department.1 However, appendicitis, in infants under 2 years of age is uncommon, constituting only 2% of all cases.2,3 Its incidence is much lower in neonates and young infants. Since the diagnosis is uncommon and hence unsuspected in this younger age group, treatment is often delayed and perforation is almost certain. Although the mortality rate has been significantly reduced by improvements in pre-operative fluid resuscitation, anesthetic and surgical techniques, post-operative care and the use of broad-spectrum antibiotics, late recognition has lead to increased post-operative morbidity and prolonged hospitalization.4 We report a case of acute appendicitis and perforation in a 78-day old infant, who presented with fever, irritability and abdominal distension.CASE REPORTA 78-day old male infant presented to the emergency room (ER) with a history of fever, refusal of feeds, constipation, irritability and excessive crying for 24 hours. There was no vomiting. The infant was the product of an uneventful full-term pregnancy and cesarian delivery performed because of fetal distress and shoulder dystocia. The mother had premature rupture of membranes 15 days prior to delivery for which she received intravenous antibiotics. His birth weight was 1850 grams. A septic work up was negative and neonatal screening showed G6PD deficiency. When the patient was seen in the ER, his temperature was 39.2°C, heart rate was 160 per minute and respiratory rate was 34 per minute. He was irritable and crying, and hence examination was difficult.The abdomen was distended, but not rigid. Peristalsis was heard. No mass could be palpated and digital examination of the rectum was unremarkable. Urine examination was normal. His white cell count was 7.7 x 103 with 46% neutrophils. Blood chemistry as well CSF analysis was normal. Plain abdominal radiograph showed gas-filled small bowel loops in the central abdomen suggestive of ileus. There was no obvious wall or mucosal thickness nor any intraabdominal calcification. The infant was admitted for further management. Ultrasound examination of the abdomen waslimited due to significant abdominal distension and a large amount of bowel gases; however, no fluid collection or masses were found. Barium enema failed to show any gross abnormality of recto-sigmoid or appendix. There was no evidence of intussusception. A laparotomy was performed seven hours after admission. The appendix was found inflamed showing perforations at the tip as well as the base and the area of right lower quadrant was filled with a fibrinous material. The peritoneal cavity contained free purulent fluid. Appendectomy was performed followed by copious saline washing into all the four quadrants and insertion of Penrose drains. Post-operative CT scan of the abdomen ruled out any intra-peritoneal abscesses. Microscopic examination of the appendix revealed marked luminal dilatation with inspissated fecal material, acute necrotizing appendicitis and peri-appendicitis. Peritoneal swab cultures grew Eschericiacoli, Klebsiella pneumoniae and Citrobacter freundi. The infant was given a course of intravenous antibiotics consisting of ampicillin, gentamycin, and clindamycin and was discharged after 11 days without any post-operative complications. The infant was doing well on follow-up clinic visits.DISCUSSIONMany of the clinical manifestations in appendicitis are age-related. The patient in this study was 78 days old and discussion pertaining to this infant could be more related to the neonatal group rather then the age group of older infants and children. The anatomy of the appendix and pathogenesis of appendicitis differ in infants when compared to older children and adults. Though the appendix is often described as a long and thin diverticulum arising from the cecum, it is funnel-shaped in neonates and young infants, making it less prone to become obstructed. By age 1 to 2 years, the appendix assumes the normal adult shape.Appendicitis in older children and adults is typically precipitated by luminal obstruction due to lymphoid hyperplasia (which could be secondary to viral infections, including upper respiratory tract infections, mononucleosis or gastroenteritis), fecaliths, foreign bodies or parasites. Fecaliths develop from inspissated feces, which act as a nidus with progressive layering of calcium salts and fecal debris over time. The younger age of the patient in our report would explain the microscopic examination of the appendix showing inspissated fecal material rather than a fecalith.The anatomic funnel shape, a soft-food diet and less effective lymphoid tissue in neonates and young infantsaccounts for the lower incidence of appendicitis in that age group. More than 120 cases of neonatal appendicitis have been reported in the world literature.4 Most cases occur in premature neonates and a pathologic cause for inflammation or obstruction is found in one-third.5,6 Fecaliths causing luminal obstruction and appendicitis are not reported in neonates.6Instead, appendiceal inflammation secondary to distal colonic obstruction from Hirschsprung’sdisease7 blockage from internal or external hernias8,9 appendicitis and perforation from meconium plugs2 and from necrotizing enterocolitis5 have been reported. A survey of the world literature by Buntainet al in 1984 showed 67 cases of appendicitis in the neonatal group; perforation was found in 76% and mortality was as high as 64%.8Abdominal pain classically originating from the periumbilical region and migrating to the right lower quadrant is the common presenting symptom in older children and adults. Anorexia, nausea and vomiting are often associated. However, the presenting features of appendicitis in young infants are non-specific with abdominal distension in 60% to 90%, vomiting in 59%, a palpable mass in 20% to 40%, irritability in 22%, abdominal wall erythema and cellulitis, right hip stiffness, hypotension, hypothermia or fever and respiratory distress in a small percentage of cases. 4,5,6,8,9 Although the early symptoms of pain and nausea probably exist in infants as in older children and adults, they are not appreciated. An upper respiratory tract infection and/or gastroenteritis does not uncommonly coexist with appendicitis in infancy. The presence of abdominal distension and irritability in a sick infant with vomiting should raise the suspicion of appendicitis.The commonest presenting symptoms in older infants and children under 3 years are fever, vomiting (80% to 82%) and abdominal pain (60% to 80%).2,9,10 The occurrence of diarrhea varied from 8% to 30%.2,11 In a study of 63 children under 3 years who underwent appendectomy for acute appendicitis during 1983-1994, Horwitz et al found that a history of diarrhea at presentation and perforation and/or gangrene at laparotomy were the only independent predictors of prolonged hospitalization.11 Vomiting, diarrhea and irritability could be attributed to other conditions occurring in this age group such as gastroenteritis, upper respiratory tract infections and otitis media. Associated symptoms such as cough/coryza, irritability/crying, right hip stiffness and limping gait could be misleading.The clinical signs in this age group include diffuse abdominal tenderness (50% to 100%), localized right lower quadrant tenderness (< 50%), abdominal distension (20% to 65%), and a palpable abdominal mass (19% to 50%).2,9–11 Though abdominal tenderness is the most frequent finding in appendicitis in children under 3 years, a study of 26 children by Paajanen and Somppi found that presence or absence of tenderness had no diagnostic value in completely ruling out appendicitis.12 Prompt recognition of appendicitis in infants is still a challenge. Because of the non-specificityof the presenting symptoms, there is considerable delay in reaching the correct diagnosis. Infants are unable to either verbalize any discomfort or localize pain. Parents are reluctant to contact physicians early for what they consider to be an “upset stomach”.The value of a WBC count in diagnosing appendicitis is debated.12 Either a WBC count or neutrophil percentage is elevated in the majority of patients, although the specificity of using these parameters is uncertain.4 Also, leukocytosis may occur in conditions simulating appendicitis in infants such as gastroenteritis and mesenteric adenitis. C-reactive protein (CRP) has been reported as 43% to 92% sensitive and 33% to 95% specific for appendicitis and it may be more sensitive than the WBC count in detecting appendiceal perforation and abscess formation.4,12,13 Urine analysis may show abnormalities in some cases; however, it will be more helpful to exclude a urinary infection.Plain abdominal roentgenograms are routinely performed in most cases of suspected appendicitis. Radiographic findings believed to be suggestive of appendicitis in older infants and children include localized ileus, soft tissue masses, right lower quadrant abdominal masses, bowel obstruction, scoliosis and appendicoliths.2–4,11The presence of extraluminal gas indicates perforation. In earlier reports, a calcified fecalith was generally accepted as a definite sign of appendicitis with a 28% to 33% incidence in pediatric appendicitis.8 However, more recent studies indicated that plain abdominal radiographs were normal or even misleading in 77% of children with appendicitis.14,15 The infant in the present study showed evidence of ileus only.Ultrasonography has been extensively used in the diagnosis of acute appendicitis in children and some studies have found a sensitivity of 90% to 92% and a specificity of 97% to 98%.16,17 Recently, computerized tomography (CT) has also been used in the diagnosis, especially when ultrasound has failed to identify the inflamed appendix. A recent study found a CT examination to be 97% sensitive and 97% specific for appendicitis.18 However no accurate data is available at present on the sensitivity and specificity of imaging in the diagnosis of neonatal and infantile appendicitis.Barium enema has been found useful in 43%.11 As controlled contrast enemas are useful in diagnosing appendicitis in older children and adults, they should be of value in neonates and young infants because of their funnel-shaped appendix. Other diagnostic tools have been used recently such as MRI scans, radioactive-tagged leukocyte scans, blood cytokine assays and laparoscopy; however, their role in decreasing the frequency of negative explorations in pediatric appendicitis remains to be seen.19–22Delay in reaching the correct diagnosis of appendicitis, as well as its surgical management in the young infants, results in an increased rate of perforation and peritonitis. Perforation rates in infants have been reported between 55% and 94% by several authors.23,9–12,23 Byrne et al showed that the duration of symptoms influenced the outcome of appendicitis. If symptoms were present from 0 to 11 hours, 13% of patients perforated, while 12 to 13 hours’ duration produced a 23% perforation rate and if symptoms persisted for more than 72 hours, up to 100% perforated.24 The high perforation rates in the series of Grosfeld and Barker (94% and 92%, respectively) could be related to the significant delay in diagnosis and appendectomy.2,23Conventional open appendectomy has generally been accepted as the immediate treatment for appendicitis. In perforated appendicitis, many institutions have adopted a more vigorous approach, consisting of immediate appendectomy, irrigation of peritoneal cavity, transperitoneal drainage through the wound and a 10-day course of intravenous antibiotics. Laparoscopic appendectomy in children has become popular in some centers, but there are conflicting reports on its merits over operative appendectomy in terms of relief of pain, length of hospital stay, complications and overall cost.25,26 Initial conservative medical management followed by elective appendectomy at a later stage has been practiced in some centers in the past on infants presenting with an abdominal mass detected either by palpation or by imaging and this approach has shown a satisfactory outcome. 9,10The mortality rate in appendicitis has been significantly reduced with early diagnosis, use of broad-spectrum antibiotics, fluid resuscitation and better anesthetic as well as surgical skills. The mortality rate of 59 neonates surveyed by Buntainet al. was 64%, while the study on pre-school children of Finland by Paajanen and Somppi showed zero mortality.8,12 Although the use of prophylactic antibiotics in uncomplicated appendicitis is controversial, recent studies stress the significance of administering broad-spectrum antibiotics post-operatively in cases of gangrenous and perforated appendix in children.27–29 Traditional therapy consists of ampicillin, gentamycin and clindamycin, although single-drug formulations including ampicillin/sulbactam, ticarcillin/clavulanate, cefoxitin or piperacillin/tazobactam are equivalent to the traditional drug regimens in preventing complications from ruptured appendix.28,29In conclusion, appendicitis in young infants is uncommon and is difficult to diagnose as evidenced by the high perforation rates in this age. The symptomatology is obscure and the possibility of appendicitis should be suspected in each infant presenting with an acute abdomen. Diagnosis requires a high index of suspicion, a careful history and a complete physical examination, which may require sedation at times. It is suggested that an “admit and observe” policy with frequent re-evaluation of the infant may reduce morbidity and mortality. The diagnostic advantages of modern invasive and non-invasive imaging techniques including computerized tomography, MRI scan and ultrasonography remain to be seen.ARTICLE REFERENCES:1. Reynolds S, Jaffe D. "Diagnosing abdominal pain in a pediatric emergency department" . Pediatr Emerg Care. 1992; 8:126–8. Google Scholar2. Grosfeld J, Weinberger M, Clatworthy W. "Acute appendicitis in first 2 years of life" . J Pediatr Surg. 1973; 8:285–93. Google Scholar3. Bartlett R, Eraklis A, Wilkinson R. "Appendicitis in infancy" . Surg Gynecol Obstet. 1970; 130:99–105. Google Scholar4. 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Pediatr Infect Dis J. 1998; 17:1047–48. Google Scholar29. Lund DP, Murphy EU. "Management of perforated appendicitis in children: a decade of aggressive treatment" . J Pediatr Surg. 1994; 29:1130–34. Google Scholar Previous article Next article FiguresReferencesRelatedDetails Volume 23, Issue 3-4May-July 2003 Metrics History Accepted1 January 2003Published online1 May 2003 ACKNOWLEDGEMENTSThe authors wish to thank Dr. FahedAl Dossary, pediatric infectious disease specialist, and Dr. Bernard Gallacher, anesthesiologist, for their valuable assistance in managing the case. We also acknowledge the use of Saudi Aramco Medical Services Organization (SAMSO) facilities for the research data utilized in this manuscript. Opinions expressed in this article are those of the authors and not necessarily of SAMSO.InformationCopyright © 2003, Annals of Saudi MedicinePDF download