Appendicitis in the neonatal period is rare. Its diagnosis is difficult
with most cases being diagnosed only during postmortem examination. The
rarity of the disease and the delay in diagnosis are largely responsible
for the high mortality. We report an unusual presentation of
appendicitis with inguinal symptoms in a neonate.
Case Report
A preterm (33 wk) male child born to a primigravida
mother by vaginal delivery developed feed intolerance in the form of
abdominal distension and vomiting on day 4 of life. Baby had passed
meconium within 24 hours of birth and was apparently normal for the
first 3 days, accepting and tolerating paladai feeds well.
Necrotising enterocolitis (NEC) was suspected; abdominal radiograph
showed only dilated bowel loops. He was kept nil-by-month, and was
started on intravenous fluids and antibiotics. Over the next few hours,
he developed tenderness and erythema over the left inguinal region. As
he also had undescended testis on the left, torsion testis was
suspected, and he was taken for emergency inguinal exploration.
Left inguinal exploration revealed the undescended
testis to be healthy and viable without any evidence of torsion, but
there was feco-purulent fluid draining from the peritoneal cavity into
the patent processus vaginalis. Orchidopexy of the left testis was done
and laparotomy was performed to find the source of the feco-purulent
fluid. At laparotomy, he was found to have appendicitis with apical
perforation causing feco-purulent ascites. Rest of the bowel was healthy
and there was no evidence of NEC. Peritoneal lavage was given and
appendectomy was done. Histological assessment of the resected appendix
showed extensive ulceration, with mucosa replaced with slough and acute
inflammatory exudate extending transmurally upto the serosa, suggestive
of pan-appendicitis.
Postoperatively, the child was ventilated for 36
hours. His blood culture was sterile but C-reactive protein (CRP) was
positive; antibiotics were given for 7 days. He was started on gavage
feeds on the 4th post-operative day, breastfeeds were started on day 16
and he was discharged on day 20 of life. The child was well with
adequate weight gain after two months.
Discussion
Neonatal appendicitis is rare with a reported
incidence of 0.04% [1], and is more common in preterm males [2,3]. It
usually presents with non-specific signs like abdominal distension,
vomiting or mass in the abdomen, and is commonly misdiagnosed as NEC,
resulting in delay in surgery and high mortality. Appendicitis within
the inguinal hernia, called Amyand’s hernia, presents early with
symptoms suggestive of incarcerated hernia or torsion testis. This leads
to early surgical exploration and a better prognosis.
Our patient had abdominal appendicitis with
perforation, and presented initially with non-specific symptoms of feed
intolerance. The feco-purulent ascitic fluid in the patent processus
vaginalis along with the left undescended testis, and erythema and
tenderness over the left inguinal region mimicked torsion of the
undescended testis. This led to early surgical exploration and timely
management.
The etiopathogenesis of appendicitis in the neonatal
period is not clear. The vast diversity of associated conditions
reported so far shows that it is likely to be multifactorial. Some of
the suggested etiologies are immune, vascular, hypoxic, and obstructive
[4]. The risk of perforation is high in neonatal appendicitis [2]. Delay
in diagnosis, thin appendiceal wall and indistensible cecum are some of
the factors implicated in the higher incidence of perforation. Small
size of the peritoneal cavity and poorly developed, functionally
non-existent omentum in a newborn result in more rapid and diffuse
peritonitis after perforation contributing to the high morbidity and
mortality.
Investigations and imaging modalities are not very
useful. Abdominal radiograph shows only non-specific features,
ultrasound Doppler and computerized tomography (CT) scan are also not
reliable. A high index of clinical suspicion and early laparotomy or
laparoscopy are the key for timely diagnosis. We would suggest that in a
preterm infant with non-specific abdominal findings and no classical
features of NEC on abdominal radiograph, appendicitis should be
considered as a differential diagnosis, especially if the baby does not
seem to improve with conservative management.
1. Buntain WL, Krempe RE, Kraft JW. Neonatal
appendicitis. Ala J Med Sci. 1984;21:295-9.
2. Karaman A, avusoglu YH, Karaman I, Cakmak O. Seven
cases of neonatal appendicitis with a review of the English language
literature of the last century. Pediatr Surg Int. 2003;19:707-9.
3. Stiefel D, Stallmach T, Sacher P. Acute
appendicitis in neonates: Complication or morbus sui generis? Pediatr
Surg Int. 1998;14:122-3.
4. Jancelewicz T, Kim G, Miniati D. Neonatal appendicitis: A new look
at an old zebra. J Pediatr Surg. 2008; 43:e1- e5.