Diagnosis: Ruptured Neonatal Appendicitis

Abstract

What’s Your Diagnosis?Diagnosis: Ruptured Neonatal Appendicitis Nabil Mounla Nabil Mounla Search for more papers by this author Published Online:1 Jun 2006https://doi.org/10.5144/0256-4947.2006.249SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionThe plain radiograph demonstrates the falsiform ligament (Figure 1) which is not normally seen. However, when there is gas in the abdomen, the liver is pushed back from both sides of the ligament. The resulting contrast makes the ligament evident.1 To confirm the impression of pneumoperitoneum, a second plain film of the abdomen was taken while the infant was held in an upright position. It clearly showed the accumulation of gas under the diaphragm (Figure 2). Had the baby been very sick and if she could not be held upright, a cross-table or lateral decubitus x-ray film should have been taken. It would have shown a bubble of gas in the abdomen just under the umbilical stump. This approach is presently recommended so as not to disturb the patient.Figure 1 Falsiform ligament (arrow) on plain abdominal radiograph.Download FigureFigure 2 Pneumo-peritoneum.Download FigureDiscussionThe infant underwent a laparotomy one hour after noticing the abdominal distension. At the site of the appendix there was foam and bubbles. She underwent appendectomy. Breast milk was withheld and total parenteral nutrition and antibiotics restarted. She had an uneventful postoperative course, gained weight and was discharged 1 month later with a weight of 2 kilograms. Frequently, when abdominal radiographs are taken, the infant is sleeping on his/her back and signs of pneumoperitoneum may not be evident. Focusing on the falsiform ligament could give a clue to the diagnosis. Our differential diagnosis included necrotizing enterocolitis (NEC), ruptured viscus, perforated diverticulosis, accidental entry of a thermometer or catheter into the genital tract.2 NEC was ruled out because of the clinical course and negative laboratory tests. Rectal or vaginal perforations were considered unlikely as we do not use a rectal thermometer or probe in our nursery and as the bladder of the infant was not catheterized. Appendicitis is the most common abdominal condition requiring surgery in children.3 However, a ruptured appendicitis is rare and a ruptured neonatal appendicitis is even more rare. Finally, we would like to alert the reader that the falsiform ligament on the plain X-ray film is a positive sign for the diagnosis of perforation. However, one has to be aware that its absence does not rule out perforation. An acute sense of suspicion will ensure a quick intervention and a happy ending.ARTICLE REFERENCES:1. Field S, Morrison I. "The acute abdomen" . In: Sutton David. Textbook of Radiology and Imaging, 7th Edition. Edinburgh: Churchill Livingston; 2003;663-689. Google Scholar2. Berseth CL, Poenaru D. "Necrotizing Enterocolitis and Short Bowel Syndrome" . In: Taeusch , Ballard , Gleason . Avery’s diseases of the Newborn, 8th Edition. Philadelphia: Elsevier Saunders; 2005;1123-1133. Google Scholar3. Muehlstedt SG, Pharm TQ, Schmeling DJ. "The Management of Pediatric Appendicitis: A Survey of North American Pediatric Surgeons" . J Pediatr Surg. 2004; 39(6):875-879. Google Scholar Previous article Next article FiguresReferencesRelatedDetails Volume 26, Issue 3May-June 2006 Metrics History Published online1 June 2006 InformationCopyright © 2006, Annals of Saudi MedicineThis work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.