Acute Appendicitis in Infants

Abstract

The reduction in mortality in acute appendicitis during the past 40 years constitutes a remarkable achievement. Unfortunately, there remains a comparatively high death rate in this disease in small infants.Evidence exists that this is due, in part, to a lack of progress in the early diagnosis of this disorder. It appears that the great advances in technical and therapeutic procedures have obscured the importance of early diagnosis. For this reason it seems worth while to review the factors responsible for delay in diagnosis and to discuss some of the associated problems.This study concerns itself with (a) a report of acute appendicitis with perforation in a 15-day-old infant with survival; (b) an analysis of acute appendicitis in infants 36 months of age or younger, from 1942 to 1952, at the Los Angeles County Hospital, and (c) a survey of the literature. Acute Appendicitis in aFifteen-Day-Old Boy A full-term boy was born on Jan. 27, 1950. During the week preceding his normal delivery, the infant's mother and sister had been ill with moderately severe viral infections. At the age of 15 days, the infant was seen in the office of one of us (M. J. N.) with a history of episodes of restlessness and crying of two days' duration. During the first 36 hours the discomfort was apparently mild and occurred mainly at the time of feedings. At the end of this time, he became increasingly irritable, slept poorly, refused feed¬ ings, and for the first time appeared ill. No vomiting had occurred, and the infant had not appeared to be feverish.Initial examination revealed an acutely ill in¬ fant with slightly sunken eyes and a depressed anterior fontanel. The abdomen was markedly distended and generally rigid and tender. No masses were palpable. Peristalsis was diminished.The rectal temperature was 101.8 F. ; the white blood count was 7400, with 58% polymorphonu¬ clear cells (30% nonsegmented cells). The infant was admitted to Cedars of Lebanon Hospital the same afternoon. The repeat white blood count was 6100, with 65% polymorphonuclear cells (42% nonsegmented cells), red blood count 5,620,000, and hemoglobin 17 gm. The urine showed no abnormalities. A preoperative diagnosis of peri¬ tonitis probably secondary to a perforated ap¬ pendix was made. Eight hours were required for preoperative preparation, i. e., correction of fluid and electrolyte imbalance, antibiotic therapy, nasogastric suction, and additional consultation.At surgery (approximately 60 hours after onset), the peritoneal cavity contained a grayishyellow, cloudy fluid. There was a thick fibrinopurulent exúdate in the ileocecal area. The appendix lay free in the right iliac fossa, was acutely inflamed and showed a 2-ram. perforation near its midpoint. An appendectomy was per¬ formed and the wound closed without drainage. Culture of the peritoneal exúdate grew Escherichia coli and nonhemolytic streptococci. Penicillin was administered for seven days and streptomycin for three days. The infant made an uneventful recovery and was discharged on the eighth post¬ operati...

The Continuing Challenge of Acute Appendicitis

“…Later the introduction of an tibiotics prompted Fields et al [81] to rec ommend immediate operation in all cases. The debate continues, with comparisons of the two methods being published [82][83][84].…”

“…91], In babies the problem is particularly acute. 75% being perforated on admission [81,94], Fields et al [81] and Fields and Cole [94] reviewed their experi ence in 68 infants under 36 months of age. The perforation rate remained unchanged over a 20-year-old period (ending in 1963), but the mortality rate decreased from 13 to 7%, still by no means acceptable.…”

Focal Bacterial Infections

“…Acute appendicitis is extremely rare in infants younger than 4 weeks of age. Reviews of more than 25,000 cases of appendicitis in infants and children in Great Britain [155], Ireland [156], Norway [157], Germany [158], and the United States [159][160][161][162][163][164] revealed only 8 infants who presented during the neonatal period. Pediatric surgery centers in Germany [165], Boston [166], Cleveland [167], Chicago [168], and Detroit [169] found only four cases of neonatal appendicitis.…”

The North looks ahead.

“…Indeed it has been recorded in a baby 9 days old' and in another 15 days old. 2 Though deaths from acute appendicitis are now uncommon they still occur, particularly in children in the first few years of life. The mortality rate is closely related to the severity of the disease and depends on whether the appendix is merely inflamed, gangrenous, or perforated.3 The acutely inflamed appendix in an infant is frequently gangrenous and perforated, usually because of late diagnosis.…”