Perforated appendix in a neonate: a review of literature and case report from northern Tanzania
Introduction
Acute appendicitis is the commonest surgical condition among children and the cause remains elusive (1). The appendix is like a tubular structure at the caecum with an average length of 4.5 cm in neonates and 9.5 cm in adults (2). The base of the appendix is wider in neonates and infants therefore the chances of luminal obstruction are rare (2). We present an unusual case of a premature neonate with perforated appendicitis where diagnosis was made intra operatively. This is an uncommon phenomenon with atypical presentations.
Case presentation
A premature male baby who was referred to us with presenting complaints of being born before term and difficulty in breathing since birth. This baby was the second twin, born vaginally and had an APGAR score of 8 and 10 in the first and fifth minutes respectively. The mother reported that the pregnancy was uneventful. At admission, diagnosis of a preterm baby at 32 weeks of gestation age by Finstorm was made as well as idiopathic respiratory distress syndrome. The patient was started on intravenous ampicillin and gentamycin to prevent infections, intramuscular vitamin K to prevent hemolysis and oxygen therapy.
On the fifth day it was reported that the baby was breastfeeding poorly, started to develop jaundice, had gradual abdominal distension and failure to pass stools. The patient was started on phototherapy for jaundice. An urgent plain erect abdominal x-ray was done which revealed free air under the right hemi diaphragm (Figure 1). The baby was then taken for an emergency laparotomy where intra-operatively, there was approximately 25 milliliters of ascitic fluid contaminated with fecal matter and a hyperemic appendix with a perforation at its tip (Figure 2). Other viscera were normal. Appendectomy was done and taken for histopathological analysis (which later confirmed appendicitis [Figure 3]). Thorough lavage of the abdominal cavity was done and an abdominal drain was inserted. Post operatively the baby developed surgical site infection on the eighth day for which daily dressing was done and the patient recovered. On day 18 the patient was discharged from hospital. The baby was then seen at the neonatal outpatient clinic two weeks after discharge with good recovery and growth.
Discussion
Acute neonatal appendicitis is rare, and rate of perforation is higher in premature infants resulting in peritonitis (2,3). The incidence of neonatal appendicitis has been reported to be 0.04-0.2% by El-Gohary and this is infrequent because of the wide appendix at the base, soft liquid diet, recumbent posture and infrequent viral infections (3,4). The author also continues to state that of all reported cases, 25-50% is of premature infants and this is due to the underdeveloped immunity, thin appendiceal wall and indistensible caecum (3,5). Similar to our case, the diagnosis of perforation of the appendix is usually made operatively (3).
Primary neonatal appendicitis may present as an isolated entity where the etiology remains unclear but secondary causes include Hirschprung’s disease, necrotizing enterocolitis, meconium plug syndrome or cystic fibrosis (2,4,5,6). Complications such as perforation are due to the thin walled appendix, and the infection spreads to the whole abdomen due to the small omentum and small capacity of the abdominal cavity therefore early diagnosis and management is important to reduce morbidity and mortality (4). Complications are also partly because of the atypical clinical presentations of acute appendicitis (and perforation) compared to what would be elicited in older children and adults (4,5,6). As reported by Gupta, different symptoms include vomiting and abdominal distension (as was present in our case). Pneumoperitoneum due to perforated appendix was present in our case (Figure 1), however reported to be a rare finding by Roshan Ali et al. The reason for features of intestinal obstruction in our patient was due to the peritoneal contamination causing intestinal ileus (7).
The management of a perforated appendix remains to be surgery as it was done in our case (6). Surgery includes appendectomy with abdominal wash out and the appendix taken for histological analysis to rule out other causes of perforation (2,6). Generally, management outline of appendicitis is by clinical evaluation of signs and symptoms with laboratory and radiological adjuncts and by Alvarado and Pediatric Appendicitis Score (PAS) scoring system low risk patients can be discharged with watchful waiting (2). C-reactive protein (CRP) and computed tomography (CT) are considered gold standard to confirm clinical suspicion of appendicitis with relatively high sensitivity and specificity (1,8). Currently laparoscopic surgery has been increasingly popular among paediatric surgeons along with other means like percutaneous drainage of appendicular abscesses (2).
Conclusion
Acute appendicitis is a rare entity in neonates and due to the uncommon presentation and diagnosis is difficult to make therefore causes delay in the management which may lead to high morbidity and mortality.