Further evidence for an ischemic origin of perforation of the appendix in the neonatal period

doi:10.1016/j.jpedsurg.2004.04.045

Journal of Pediatric Surgery

Volume 39, Issue 8, August 2004, Pages e11-e12

https://doi.org/10.1016/j.jpedsurg.2004.04.045 Get rights and content

Abstract

A full-term baby girl presented on the 14th day of life with an appendiceal abscess on a basis of appendicular perforation. Pathologic examination found focal transmural coagulation necrosis suggesting an ischemic origin for the perforation. It is argued that appendiceal perforation in the newborn period is a different disease entity than appendiceal perforation later in life. In the newborn, ischemia seems to be the leading pathogenetic factor, and neonatal appendiceal perfora-tion seems, therefore, related to neonatal necrotizing enterocolitis.

Section snippets

Case report

A girl was born at full term after an uneventful gestation and delivery. On the 14th day of life she presented with vomiting, poor feeding, and lethargy. She was ill and had a distended, tender abdominal. Laboratory studies found C-reactive protein (CRP) of 105 mg/L and mild leucocytosis. A plain abdominal x-ray showed diffusely dilated loops of bowel. She was admitted with a suspicion of septicemia and was treated with antibiotics. Because her condition did not improve over night, she was

Discussion

The rarity of appendicitis in the newborn infant has been attributed to several factors, including the funnel-shaped configuration of the appendix at birth, making it less prone to obstruction; the soft diet in the neonatal period; the recumbent position of infants; and the infrequent occurrence of intestinal and respiratory infections in the neonatal period.1, 2 Neonatal appendiceal perforation has been associated with Hirschsprung’s disease4, 5 and with other causes of bowel obstruction such

References (14)

L.W. Martin et al.
Prenatal appendiceal perforationA case report
J Pediatr Surg
(1986)
J. Arliss et al.
Neonatal appendiceal perforation and Hirschsprung’s disease
J Pediatr Surg
(1990)
J.L. Grosfeld et al.
Acute appendicitis in the first two years of life
J Pediatr Surg
(1973)
J.A. Bar-Maor et al.
Acute appendicitis located in a scrotal hernia of a premature infant
J Pediatr Surg
(1978)
M.N. Srouji et al.
Neonatal appendicitisIschemic infarction in incarcerated inguinal hernia
J Pediatr Surg
(1978)
J.Q. Trojanowski et al.
Fatal postoperative acute appendicitis in a neonate with congenital heart disease
J Pediatr Surg
(1981)
W.H. Snyder et al.
Appendicitis during first two years of lifeReport on 21 cases and review of 447 cases from literature
Arch Surg
(1952)

There are more references available in the full text version of this article.

Cited by (21)

Appendicitis in infants up to three months of age: A case series
2024, Journal of Pediatric Surgery Case Reports
Appendicitis is rare in young infants and often not timely recognized due to non-specific symptoms. We aimed to increase awareness and contribute to current knowledge by presenting two cases.
Case 1; a term boy presented at ten weeks of age with fever, vomiting and an enlarged translucent erythematous scrotum. The latter was interpreted as hydrocele and antibiotic treatment for suspicion of sepsis without patent source was started. Five days later, he developed abdominal distension and was transferred to our tertiary referral center. Imaging showed local pneumoperitoneum on ultrasound, and a covered intestinal perforation was suspected. Antibiotics were continued, obtained blood cultures were positive for Clostridium tertium. On day eight, ultrasound identified a tubular structure in the right lower quadrant. At laparotomy we found an interloop abscess in connection with the appendix and performed an appendectomy. The postoperative course was complicated by an intra-abdominal abscess, treated with antibiotics, with uneventful recovery thereafter.
Case 2; a preterm girl (gestational age 24 weeks) developed abdominal distension at 11 days of age due to pneumoperitoneum. Laparotomy showed perforated appendicitis and a fibrinous exudate on the sigmoid. An appendectomy was performed, and a protective split ileostomy was created as a micro-perforation could not be excluded. The postoperative course was complicated by recurrent peristomal bullous impetigo and septic thrombophlebitis requiring antibiotic treatment, with uneventful recovery thereafter.
Both cases underline that clinicians should include appendicitis in the differential diagnosis of young infants presenting with unexplained sepsis and/or gastrointestinal symptoms, despite the rare incidence.
Appendiceal perforation: A rare case of massive neonatal pneumoperitoneum
2023, Journal of Pediatric Surgery Case Reports
Citation Excerpt :
Thorough review of these neonatal case studies illustrated patients often clinically present with nonspecific symptoms ranging from emesis to poor feeding, and lethargy. Additionally, abdominal examination often reveals distension, tenderness, and erythema [3,4,8]. The patient in this case report had an unremarkable clinical history without abdominal symptoms and showed no sign of acute distress nor laboratory aberrations.
A pre-term newborn male was admitted to the pediatric cardiac intensive care unit with severe left ventricular and aortic hypoplasia. On day-of-life-13, massive pneumoperitoneum was incidentally identified on a chest radiograph after central line placement. Emergent exploration with thorough examination revealed only a focal perforation at the appendiceal tip. Standard appendectomy was performed; pathology showed appendiceal perforation with focal mucosal ulceration without inflammation.
Literature review demonstrated neonates with appendiceal perforation have nonspecific symptoms at presentation (emesis, poor feeding, abdominal erythema) which may be difficult to distinguish from other etiologies of perforation. Infants with concomitant cardiac pathology are at increased risk for spontaneous intestinal perforation due to malperfusion. However, appendiceal perforation does not lead the differential for neonatal massive pneumoperitoneum; rather, large volume pneumoperitoneum typically results from gastric perforation. The true incidence is unknown with fewer than 10 reported cases; importantly, the literature often lacks distinction between spontaneous-perforation versus appendicitis-with-perforation.
Given its rarity, discrete examination of the appendix and appendiceal pathology may be overlooked when evaluating neonates with pneumoperitoneum during a standard of care operative exploration. Particularly in patients with high-risk comorbidities where gastric or ileal pathology is not appreciated after thorough exploration, appendiceal perforation should be considered.
Perforated appendicitis in a pre-term newborn
2020, Journal of Pediatric Surgery Case Reports
Citation Excerpt :
Obstructive caecal distention in conditions such as Hirschsprung's disease or meconium ileus have also been reported to lead to appendiceal perforation [14]. Finally, vascular insufficiency (secondary to perinatal asphyxia, cardiac defects, extracorpeal membrane oxygenation dependence or any other low flow or hypoxic states) is also believed to cause appendiceal perforation in the neonate [2,15]. Although acute appendicitis is the most common surgical condition in childhood, it is rare in the neonatal period.
Neonatal acute appendicitis: A proposed algorithm for timely diagnosis
2011, Journal of Pediatric Surgery
Citation Excerpt :
The most common presenting clinical feature in the literature was abdominal distension, present in 75% of patients. Other presenting features are summarized in Fig. 2 [2-5,8-30]. Neonates presenting without sepsis or with free air on abdominal radiograph trended toward increased survival.
Neonatal appendicitis (NA) is a rare disease with a high mortality. The diagnosis has never been reported preoperatively and is notoriously difficult to make.
Charts since 1995 were retrospectively reviewed for discharge or death diagnoses of appendicitis in neonates younger than 28 days. We report 3 cases of NA seen at our institution during this period.
All 3 infants were previously well, born at term, and presented with signs consistent with abdominal sepsis. The first 2 diagnoses were not made until autopsy. The third case survived after having an urgent computed tomographic scan, exploratory laparotomy, and appendectomy.
The literature summarizing common presenting features of NA is reviewed. We present an algorithm to guide the workup of these neonates to facilitate earlier diagnosis and potentially improve outcomes.
Neonatal appendicitis: A diagnostic trap. A case report
2011, Archives de Pediatrie
L’appendicite néonatale est une affection rare de diagnostic difficile, grevée d’une lourde mortalité et morbidité. Nous rapportons le cas d’un nouveau-né à terme traité par antibiotiques pour un tableau infectieux. La non-régression du syndrome inflammatoire malgré un état clinique rassurant faisait rechercher une cause qui s’avérait être une appendicite néonatale. Chez tout nouveau-né présentant un syndrome inflammatoire fébrile inexpliqué traînant avec ou sans point d’appel digestif, une échographie abdominale doit être réalisée à la recherche d’un foyer infectieux profond, y compris d’une appendicite.
Neonatal appendicitis is an uncommon disease characterized by high mortality and morbidity. We report the case of a full-term newborn with infectious syndrome. The nonresponse to antibiotic therapy despite good clinical status led to a search for an etiology. Appendicitis with focal peritonitis was discovered on sonography. In each newborn, presenting with unexplained febrile inflammatory syndrome with or without gastrointestinal symptoms, a routine abdominal sonography should be performed to search for intraperitoneal sepsis, including appendicitis.
Neonatal appendicitis: a new look at an old zebra
2008, Journal of Pediatric Surgery
Citation Excerpt :
First, argument persists in the literature that appendicitis in the first weeks of life is an isolated form of NEC, which suggests impaired immunity may increase susceptibility to appendicitis [2,5]. Second, an extension of the first proposal implicates vascular insufficiency as an underlying cause of neonatal appendiceal perforation, as in conditions such as perinatal asphyxia, cardiac anomalies, patent ductus arteriosus, extracorporeal membrane oxygenation dependence, or other low-flow or hypoxic states [5,10]. This is the most likely scenario contributing to perforation of the appendix in our case, given the patient's cardiac anomalies and TEF, which may have predisposed the neonate to transient episodes of intestinal ischemia and resultant transmural perforation; this also could have caused the diffuse erosive mucosal inflammation seen histologically.
Acute neonatal appendicitis is a rare condition associated with significant morbidity and mortality. The severity of this disease is caused by its tendency to occur more frequently in premature infants, an increased perforation rate with rapid progression to peritonitis, and delay in diagnosis and intervention. Although appendicitis in the perinatal period may occur as an isolated event, in many cases it occurs in association with other pathologic states, including prematurity, inguinal hernia, and others. The presentation of neonatal appendicitis can be identical to necrotizing enterocolitis, leading to misdiagnosis. Here we report a case of perforated appendicitis in a 9-day-old boy with tetralogy of Fallot and esophageal atresia with tracheoesophageal fistula. In addition, we present a review of the clinical features of neonatal appendicitis and a discussion of previously described, associated conditions.

View all citing articles on Scopus

View full text

Further evidence for an ischemic origin of perforation of the appendix in the neonatal period

Abstract

Section snippets

Case report

Discussion

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Appendicitis during first two years of lifeReport on 21 cases and review of 447 cases from literature

Arch Surg