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CASE REPORT
Year : 2022  |  Volume : 27  |  Issue : 6  |  Page : 781-783
 

Acute appendicitis in infants – A report of two cases


1 Department of Radiology, Kanchi Kamakoti CHILDS Turst Hospital, Chennai, Tamil Nadu, India
2 Department of Paediatric Surgery, Kanchi Kamakoti CHILDS Turst Hospital, Chennai, Tamil Nadu, India

Date of Submission15-May-2022
Date of Decision02-Aug-2022
Date of Acceptance12-Sep-2022
Date of Web Publication11-Nov-2022

Correspondence Address:
Kanimozhi C Vendhan
Department of Radiology, Kanchi Kamakoti Childs Trust Hospital, 12A Nageswara Road, Tirumurthy Nagar, Chennai - 600 034, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaps.jiaps_66_22

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   Abstract 


Acute appendicitis is the most common surgical emergency in children. However, it is uncommon in neonates and infants. Often it can be challenging to diagnose acute appendicitis in children due to atypical clinical presentation and nonspecific symptoms. This is particularly true in neonates and infants. A high level of clinical suspicion is needed to diagnose infantile appendicitis. Delayed diagnosis is associated with higher perforation rates and increased disease-related morbidity. Imaging plays a key role in the prompt diagnosis of acute appendicitis and its complications. We report two cases of perforated appendicitis in babies <6 months old.


Keywords: Appendicular abscess, infantile appendicitis, ultrasound


How to cite this article:
Vendhan KC, Akhtarkhavari A, Kathirvelu G, Subramanian B. Acute appendicitis in infants – A report of two cases. J Indian Assoc Pediatr Surg 2022;27:781-3

How to cite this URL:
Vendhan KC, Akhtarkhavari A, Kathirvelu G, Subramanian B. Acute appendicitis in infants – A report of two cases. J Indian Assoc Pediatr Surg [serial online] 2022 [cited 2022 Dec 7];27:781-3. Available from: https://www.jiaps.com/text.asp?2022/27/6/781/360969





   Introduction Top


Acute appendicitis is the most common surgical emergency in children. However, it is uncommon in infants representing only 0.25% of all surgical emergencies. In neonates and infants, it can be challenging to diagnose acute appendicitis due to atypical clinical presentation and non-specific symptoms.

We present two cases of perforated appendicitis in babies <6 months old that we have treated at our institution.


   Case Reports Top


Case 1

A 3-month-old female baby presented with high-grade fever for 6 days. On examination, the chest was clear; the abdomen was soft with tenderness in the right lumbar region. Laboratory investigations: hemoglobin (Hb) – 9.3, total count (TC) – 26,500, and differential count (DC) – N 64% L – 27%; C-reactive protein (CRP) was positive; platelet count was 6.32 lakhs; urine routine was 10–15 pus cells, urine culture – there was no growth.

In view of the abdominal tenderness and suspicion of urinary tract infection (UTI), an ultrasound abdomen was done which showed a 2.3 cm × 2.6 cm collection adherent to the undersurface of the liver. A tubular structure, representing the appendix, was seen within this collection along with adherent bowel loops. Computed tomography (CT) showed a well-defined lesion (measuring 3.2 × 3.4 cm) with an air-fluid level in the subhepatic region [Figure 1] suggestive of a subcapsular liver abscess.
Figure 1: (a) High-frequency ultrasound image of the subhepatic region shows a collection (black arrows) adherent to the undersurface of the liver. The appendix (white arrow) is seen as a tubular structure within the collection. (b) Axial CT image at the subhepatic level shows a collection (white arrow) with an air-fluid level. CT: Computed tomography

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At laparotomy, there was a large abscess cavity with thick purulent pus in the subhepatic region. The superior wall of the abscess cavity was stuck to the lower surface of the liver; the inferior wall of the abscess cavity was stuck to the cecum and terminal ileum. The appendix was completely necrosed. The base of the appendix could not be identified at the IC junction. The necrotic tissue was removed and pus was drained. A thorough wash was given and a corrugated drain was placed. The postoperative period was uneventful and the baby was discharged home on a postoperative day (POD) 6. Histopathology of the small bits of the tissue revealed intact lining epithelium of the appendix with congested lamina propria and many lymphoid follicles, consistent with appendicular abscess.

Case 2

A 4-month-old female baby presented with high-grade fever, loose stools, and vomiting for 5 days. There was an associated loss of appetite. On examination, the chest was clear; the abdomen was soft with no tenderness; there was no guarding or rigidity. Laboratory investigations: Hb – 11, TC – 19,800, and DC – N 46% L – 50%; CRP was positive; platelet count was 4.52 lakhs; urine routine was normal.

As there was continued fever with loose stools, an ultrasound abdomen was done to look for a focus of infection. The ultrasound showed a small thick-walled collection, measuring 1.7 cm × 0.9 cm, stuck to the undersurface of segment VI of the liver. Within the collection locules of gas and two calcific foci indicative of liths were seen. A tubular structure, representing the appendix, was seen, leading to this collection. Adherent bowel loops were noted in the subhepatic region. The ultrasound features were suggestive of appendicular perforation with phlegmon stuck to the undersurface of the right lobe of the liver. CT abdomen showed a subhepatic appendix with inflammatory changes extending up to segment VI of the liver [Figure 2].
Figure 2: (a) High-frequency ultrasound image at the level of the inferior edge of the liver shows a collection (white arrow) adherent to the undersurface of the liver. Two liths are seen within the collection. (b) A coronal CT image shows a collection containing liths at the undersurface of the liver with surrounding inflammatory changes. CT: Computed tomography

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At laparotomy, an appendicular mass was seen at the undersurface of the liver with part of the appendix adherent to the undersurface of the liver. The base of the appendix was identified, transfixed, and ligated. The appendix was removed piecemeal in bits and pus was drained from the subhepatic region. A thorough wash was given and a corrugated drain was placed. Recovery was smooth in the postoperative period and the baby was discharged on POD 4. Histopathology was suggestive of acute appendicitis with serositis.


   Discussion Top


It has been traditionally taught that the diagnosis of acute appendicitis is primarily made on clinical grounds. In children with a classical presentation and typical signs, the clinical diagnosis is straightforward. However, in preschool children, acute appendicitis can pose a diagnostic challenge as the presentation is frequently atypical. Nonspecific symptoms such as fever, lethargy, and irritability are common. Hence, differentiation between nonsurgical pediatric diseases and acute appendicitis becomes difficult. Conditions that may mimic acute appendicitis in young children and in infants include gastroenteritis, UTI, intussusception, upper and lower respiratory tract infections, sepsis, and NEC in neonates.[1],[2] Due to this wide range of differential diagnoses, there is often a delay in diagnosis. This delay in diagnosis may be one of the factors resulting in a high incidence of perforation in infants and toddlers.[3] In neonates, perforated appendicitis can be associated with Hirschsprung's disease and necrotizing enterocolitis.

Ultrasound is the imaging modality of choice for the evaluation of infants presenting with fever and abdominal symptoms to determine if there is a surgical abdomen or if the symptoms are due to nonsurgical causes. Despite being operator dependent, ultrasound is a valuable tool in the diagnosis of acute appendicitis, particularly when the clinical presentation is equivocal. Ultrasound features of nonperforated acute appendicitis include visualization of a noncompressible dilated appendix (>6 mm in diameter), presence of an appendicolith, periappendiceal fluid, echogenic mesenteric fat stranding, and increased flow in the wall of the appendix.[4] Ultrasound features of perforated appendicitis include loss of submucosal echogenic layer, periappendiceal inflammatory mass, complex-free fluid, and the presence of an abscess.[5]

The two cases we have reported were initially evaluated by a physician and a surgical abdomen was not considered at presentation. In view of the abdominal symptoms and signs, an ultrasound abdomen was obtained. In our cases, ultrasound demonstrated a phlegmon adherent to the undersurface of the liver. On imaging, one may misinterpret this as a primary liver abscess. The identification of a tubular structure, leading to this phlegmon along with inflammatory changes in the right iliac fossa will point toward appendiceal disease rather than a primary liver pathology. Prompt laparotomy and drainage of pus led to a quick recovery in both our cases.

CT abdomen can serve as a problem-solving tool in instances where the ultrasound is indeterminate, the ultrasound findings do not correlate with the clinical features, or when there is a lack of confidence in the ultrasound report. It is recommended that CT be used judiciously; its indiscriminate use for the diagnosis of acute appendicitis in children should be discouraged.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given her consent for images and other clinical information to be reported in the journal. The guardian understands that her names and initials will not be published and due efforts will be made to conceal the patient's identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Marzuillo P, Germani C, Krauss BS, Barbi E. Appendicitis in children less than five years old: A challenge for the general practitioner. World J Clin Pediatr 2015;4:19-24.  Back to cited text no. 1
    
2.
Almaramhy HH. Acute appendicitis in young children less than 5 years: Review article. Ital J Pediatr 2017;43:15.  Back to cited text no. 2
    
3.
Alloo J, Gerstle T, Shilyansky J, Ein SH. Appendicitis in children less than 3 years of age: A 28-year review. Pediatr Surg Int 2004;19:777-9.  Back to cited text no. 3
    
4.
Krishnamoorthi R, Ramarajan N, Wang NE, Newman B, Rubesova E, Mueller CM, et al. Effectiveness of a staged US and CT protocol for the diagnosis of pediatric appendicitis: Reducing radiation exposure in the age of ALARA. Radiology 2011;259:231-9.  Back to cited text no. 4
    
5.
Tulin-Silver S, Babb J, Pinkney L, Strubel N, Lala S, Milla SS, et al. The challenging ultrasound diagnosis of perforated appendicitis in children: Constellations of sonographic findings improve specificity. Pediatr Radiol 2015;45:820-30.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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