Ruptured Appendicitis in a Two A Case Report Year Case Report

Case Report
Ruptured Appendicitis in a Two-Year-Old Child:
A Case Report
Ching-De Cheng1 Lung-Huang Lin1,2,* De-Fang Chen3
Appendicitis is the most common indication for emergent abdominal surgery in childhood,
and early diagnosis followed by an appendectomy before gangrene or perforation develops is
important for a good prognosis. But diagnosing appendicitis in children is challenging, because
symptoms such as fever, abdominal pain, vomiting, and irritability are neither sensitive nor specific
in children, and a physical examination can be difficult in an apprehensive and uncomfortable
young child. Delayed diagnoses are common in young children. Laboratory testing and imaging
studies, such as ultrasound and computed tomography, are helpful in evaluating appendicitis in
children. In this study, we present a 2-year-old boy diagnosed with acute enterocolitis and acute
tonsillitis whose appendicitis progressed to rupture with abscess formation during
hospitalization. His condition improved after surgical intervention. ( FJJM 2010; 8 (2): 97-103 )
Key words: appendicitis, ruptured appendicitis, small child
Appendicitis is still the most common surgical
emergency requiring an abdominal operation in
pediatric patients[1]. The key to successful outcomes
has always been early diagnosis followed by an
Although laboratory studies and modern
imaging techniques, including sonography, x-ray
and computed tomography (CT), greatly help in
diagnosing acute appendicitis in pediatric patients,
none of these tools provides definitive diagnostic
criteria. Diagnosing acute appendicitis still principally
relies on history taking and a physical examination,
so that very young children represent a diagnostic
challenge, particularly since the differential diagnosis
includes such nonspecific symptoms as abdominal
pain, fever, and vomiting. An early diagnosis of
acute appendicitis heavily influences the rate of
complications and the treatment prognosis.
Nevertheless, confirming the diagnosis of appendicitis
and avoiding the risks of unnecessary surgery are
particularly challenging in young children[2].
A 2-year-old boy was brought to our pediatric
outpatient department at Hsinchu, Taiwan in May
2009. A fever of up to 38~39°C had been noted for
about 1 week and had not improved under oral
Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan1 College of Medicine, Fu-Jen Catholic University, Hsinchuang, Taipei,
Taiwan2 Department of Surgery, Cathay General Hospital, Taipei, Taiwan3
Submitted April, 14, 2010; final version accepted June, 15, 2010.
*Corresponding author: [email protected]
第 8 卷 第 2 期 2010
Ching-De Cheng
Lung-Huang Lin
De-Fang Chen
medication prescribed by other physician. On the
day before admission, the patient had vomited 4
times and had 3 bouts of diarrhea at home, his
activity and appetite had decreased, and he had
an intermittent fever. At the outpatient department,
the patient looked ill and his abdomen was mildly
distended. Gastroenterocolitis with dehydration
due to a Salmonella infection was the impression,
and the patient was admitted to the local pediatric
At admission, the patient had a soft, distended
abdomen on palpation, and hyperactive bowel
sounds were noted by auscultation. Tenderness
was noted in the periumbilical area without rebound
pain. Infected and enlarged tonsils were also noted
bilaterally on the physical examination. The pulse
rate was 132 beats/min, respiratory rate was 32
breaths/min, and body temperature was 37.3 °C.
The plain abdominal radiograph taken at
admission (Fig. 1) showed a gaseous bowel with
a dilated transverse and descending colon, and no
fecalis around the right lower quadrant (RLQ) or
Fig 1. Plain abdominal radiograph on day 1.
any signs of bowel perforation. Lab data at admission
revealed leucocytosis (white blood cell count of
20,170/ L) with neutrophils dominant (2% bands
and 88% segments), and elevated C-reactive protein
(CRP; 10.527 mg/dL), while other lab data were
within normal ranges.
After admission, oral intake was suspended
and we arranged intravenous fluid support. Ampicillin
was prescribed as an empirical antibiotic for the
suspected Salmonella infection. However, the fever
remained intermittent, and a bacterial culture from
a throat swab showed Haemophilus parainfluenzae
resistant to ampicillin, so the ampicillin was replaced
with cefuroxime (Zinacef) on day 3. On the same
day, a bacterial culture from the stool revealed
Escherichiacoli, notSalmonellasp. Abdominal sonography
showed ileus, a gaseous bowel, and a thickened
bowel wall, but no signs of appendicitis or bowel
perforation (Fig. 2). Bacterial infection of the
pharynx and tonsils was considered the main cause
of the high fever at that time.
After antibiotic treatment, the intermittent
fever remained. Although the infected throat and
tonsils improved daily during admission, the high
fever remained. Watery diarrhea also persisted,
about 3~5 times per day. A physical examination
Fig 2. Sonography of the abdomen (right lower
quadrant) on day 2.
Fu-Jen Journal of Medicine Vol.8 No.2 2010
Ruptured Appendicitis: A Case Report
showed a distended abdomen which prompted
irritated crying when palpated. Lab data from day
6 showed leucocytosis (white blood cell count of
19,170/ L) with neutrophils dominant (0% bands
and 66% segments), but the CRP had decreased
(5.727 mg/dL). Because Salmonella infection was
suspected, the antibiotics were replaced again by
ceftriaxone (Rocephine). Since bowel perforation
and abscess formation could not be ruled out, CT
was arranged the next day (day 7).
Abdominal CT on day 7 showed a 2.8 x 3.3cm abscess at the pelvis, and a 0.8 x 0.7-cm
calcification in the RLQ (Figs. 3-6). Acute appendicitis
with bowel perforation and abscess formation was
Fig 3. Computed tomography of the abdomen
(enhanced) on day 7.
Fig 4. Computed tomography of the abdomen
(enhanced) on day 7.
Fig 5. Computed tomography of the abdomen
(enhanced) on day 7.
Fig 6. Computed tomography of the abdomen
(enhanced) on day 7.
第 8 卷 第 2 期 2010
Ching-De Cheng
Lung-Huang Lin
De-Fang Chen
highly suspected, with the calcification perhaps
the cause of the appendicitis. The patient was
transferred to our main hospital at Taipei for
surgical intervention. After being transferred, an
exploratory laparotomy in the early hours of day
8 revealed an inflamed and ruptured appendix with
pus formation. An appendectomy and debridement
were therefore performed. After surgery, the patient
was transferred to the pediatric ward.
After surgery, ceftriaxone (Rocephine) and
metronidazole (Anegyn) were added as empirical
antibiotics. The fever subsided on day 10, the wound
remained clean, and his activity increased. Bacterial
culture of the abdominal abscess revealed multiple
organisms, including Pseudomonasaeruginosa,Klebsiella
pneumoniae, viridans Streptococcus, and E. coli. The
pathology report indicated appendicitis with abscess
formation. After his activity and appetite had
returned to normal, the patient was discharged on
day 13 with oral medication, then followed-up in
our outpatient department. He developed no
complications in the subsequent months of followup.
Appendicitis is caused by obstruction of the
appendix lumen. Obstruction may caused by include
fecal material, undigested food, other foreign material,
an enlarged lymphoid follicle in the epithelial lining,
a tumor, or a twisted appendix. The obstruction
causes localized abdominal pain, the appendix
lumen dilates, and its wall thickens. After the
mucosal barrier breaks down, bacterial invasion
causes inflammation, ischemia, and gangrene,
eventually leading to perforation. Bacteria include
the usual fecal flora, mainly aerobic and anaerobic
gram-negative rods. The most common are E. coli,
Peptostreptococcus spp., B. fragilis, and Pseudomonas
Inflammation of the wall of the appendix
causes peritonitis, which produces localized
abdominal pain and tenderness, which are clinical
signs of acute appendicitis. Perforation releases
bacteria into the peritoneal cavity. Perforation is
rare in the first 12 hours but increasingly common
thereafter, especially after 72 hour. Generalized
peritonitis develops if the infection is not covered
by bowel loops and the omentum.
Appendicitis is the most common indication
for emergent abdominal surgery in childhood and
was diagnosed in 1%~8% of children with abdominal
pain evaluated in urgent care settings[4]. The
incidence increases from an annual rate of 1 to 2
per 10,000 children between birth and 4 years of
age to 19~28 per 10,000 children who are < 14 years
old[5]. It presents most frequently in the second
decade of life. Fewer than 5% of patients diagnosed
5 years old[6]. Boys are
with appendicitis are
more often affected than girls (with lifetime risks
of 9% and 7%, respectively).
Delayed diagnoses are common, particularly
in young children, and were reported in as many
as 57% of cases in children < 6 years of age[7]. This
may be related to the atypical presentation of
appendicitis in this age group. Perforation is strongly
correlated with a delayed diagnosis[8]. The risk of
perforation is highest in the first 4 years of life and
was reported in > 70% of children in this age group
. By comparison, the rate of perforation in
adolescents is 10%~20%.
A combination of historical information,
physical findings, selective laboratory testing, and
imaging studies can lead to a correct diagnosis of
appendicitis in most patients. However, in children,
classic clinical features of appendicitis such as
fever, anorexia, migration of pain to the RLQ, and
rebound tenderness are neither sensitive nor specific
. This was demonstrated in a prospective series
describing children evaluated in an emergency
Fu-Jen Journal of Medicine Vol.8 No.2 2010
Ruptured Appendicitis: A Case Report
department for suspected appendicitis[13]. Half
(50%) had no migration of pain to the RLQ, 40%
Diagnosing appendicitis in children can also
be challenging because eliciting the symptoms and
significant physical findings can be difficult in an
apprehensive and uncomfortable young child. In
addition, symptoms such as vomiting and irritability
are nonspecific and also occur in disorders more
common in young children than appendicitis.
Among adults, a history of migration of
periumbilical pain into the RLQ is one of the most
predictive clinical features of appendicitis. Pain
typically develops before vomiting[14]. In children,
this pattern might not occur, perhaps because of
differences in the pathophysiology of the disease
or in the child's ability to relate information regarding
signs and symptoms. Indeed, historical features
vary with age[7]. In neonates (birth to 30 days old),
abdominal distention and vomiting are frequently
noted, often with irritability and lethargy. In most
infants (< 2 years old), vomiting, pain, and fever
are present, and diarrhea is not uncommon[9].
Irritability, grunting respiration, and right hip
complaints were also described. Vomiting is often
the first symptom noted in preschool children (2~5
years old), frequently followed by abdominal pain
. Fever is also present in most, but not all, patients.
Anorexia frequently occurs. Most children have
symptoms for at least 2 days prior to a diagnosis
. In school-aged children (6~12 years), abdominal
pain and vomiting are present, but often without
the typical migration of periumbilical pain to the
RLQ. Other prominent symptoms include fever,
anorexia, and pain with movement[15]. Diarrhea,
constipation, and dysuria are less frequent, but
occur often enough to potentially confuse the
diagnosis. In adolescents (13 years and older), the
clinical features of appendicitis are similar to those
in adults and include anorexia, RLQ abdominal
第 8 卷 第 2 期 2010
pain, and vomiting[14]. The onset of pain typically
occurs before vomiting and is a sensitive indicator
of appendicitis.
Althoughthe traditional signs of RLQ tenderness,
guarding, and rebound tenderness are noted less
frequently in young children, an abdominal
examination is the key to diagnosing appendicitis.
Again, findings vary in children by age[7]. In neonates,
abdominal distension is frequently seen. A palpable
abdominal mass and abdominal wall cellulitis were
noted. Hypothermia, hypotension, and respiratory
distress may also occur. In infants, fever and diffuse
abdominal tenderness, due to rupture, are the
predominant physical findings. Localized RLQ
tenderness occurs in < 50% of patients. In preschool
children, fever and RLQ tenderness are frequently
reported. Most school-aged children report fever
and RLQ tenderness. Involuntary guarding and
For children without a typical presentation
of appendicitis, imaging can be helpful to establish
or exclude the diagnosis. Ultrasonography and CT,
separately or in combination, are the most frequently
used modalities. Unfortunately, increased utilization
of CT and improved accuracy of imaging for acute
appendicitis have not contributed to lower rates
of unnecessary appendectomies, and the perforation
rate remains as high as 33%[16,17].
A prospective study of children presenting to
an emergency department with suspected appendicitis
sought to develop and validate low-risk criteria to
identify those who could be observed or discharged
safely without imaging studies[18]. Together, 3
features had a sensitivity of 98% (95% confidence
interval (CI) 90.1%~99.9%) and negative predictive
value of 98% (95% CI 86.6%~99.9%) in identifying
children who could safely be observed or discharged
without imaging: the absence of nausea, emesis, or
anorexia; the absence of maximal tenderness in the
RLQ; and an absolute neutrophil count of < 6750/
Ching-De Cheng
Lung-Huang Lin
De-Fang Chen
mm3. While awaiting further studies, such children
might not need immediate CT, decreasing exposure
to ionizing radiation, healthcare costs, and delays
in surgical treatment. Close follow-up should be
maintained for these patients until the symptoms
have resolved.
Older children and adolescents develop
appendicitis more often than younger children and
have clinical features similar to those seen in adults.
Younger children can be especially difficult to
diagnose because the presentation may be nonspecific,
and apprehension and discomfort may make them
uncooperative. Laboratory testing and imaging
studies, such as ultrasound and CT, are helpful in
evaluating appendicitis in children, but these tools
cannot replace a thorough history taking and
physical examination. Evaluation of appendicitis
continues to require both clinical and image findings.
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2. Flum DR, Koepsell T. The clinical and economic
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bacteriology of gangrenous and perforated
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outcomes of children with acute abdominal pain.
Pediatrics 1996;98:680-685.
5. Ohmann C, Franke C, Kraemer M, et al. [Status
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appendicitis in preschool age children. Am J Surg
Rothrock SG, Pagane J. Acute appendicitis in
children: emergency department diagnosis and
management. Ann Emerg Med 2000;36:39-51.
Rothrock SG, Skeoch G, Rush JJ, et al. Clinical
features of misdiagnosed appendicitis in children.
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Horwitz JR, Gursoy M, Jaksic T, et al. Importance
of diarrhea as a presenting symptom of appendicitis
in very young children. Am J Surg 1997;173:80-82.
Alloo J, Gerstle T, Shilyansky J, et al. Appendicitis
in children less than 3 years of age: a 28-year
review. Pediatr Surg Int 2004;19:777-779.
Nance ML, Adamson WT, Hedrick HL. Appendicitis
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Bundy DG, Byerley JS, Liles EA, et al. Does this
child have appendicitis? JAMA 2007;298:438-451.
Becker T, Kharbanda A, Bachur R. Atypical clinical
features of pediatric appendicitis. Acad Emerg
Med 2007;14:124-129.
Paulson EK, Kalady MF, Pappas TN. Clinical
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Kwok MY, Kim MK, Gorelick MH. Evidencebased approach to the diagnosis of appendicitis
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Martin AE, Vollman D, Adler B, et al. CT scans
may not reduce the negative appendectomy rate
in children. J Pediatr Surg 2004;39:886-890.
Partrick DA, Janik JE, Janik JS, et al. Increased
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Fu-Jen Journal of Medicine Vol.8 No.2 2010
Ruptured Appendicitis: A Case Report
病例報告:2 歲幼童之破裂性闌尾炎
鄭清德 1
林隆煌 1,2,* 陳德芳 3
兒童之急性闌尾炎常在後期才被診斷出來。而檢驗數據及影像檢查 (例如超音波或電腦
斷層) 對兒童闌尾炎之診斷也有相當幫助。本病例為 2 歲男孩,入院時診斷為急性腸胃
術清除後發燒及腹痛狀況方才改善。(輔仁醫學期刊 2010;8 (2):97-103)
國泰綜合醫院小兒科 1 輔仁大學醫學系 2 國泰綜合醫院一般外科 3
投搞日期:2010 年 04 月 14 日;接受日期:2010 年 06 月 15 日
*通訊作者:電子信箱:[email protected]
第 8 卷 第 2 期 2010