Neonatal Perforated Appendicitis Masquerading as Necrotizing Enterocolitis

Abstract

A preterm neonate underwent emergent laparotomy for presumed necrotizing enterocolitis (NEC). Intraoperatively, neonatal perforated appendicitis (NPA) was encountered. This may represent a form of NEC localized to the appendix. A high index of clinical suspicion and early laparotomy are recommended.Key words: Neonatal perforated appendicitis; Neonatal appendicitis; Necrotizing enterocolitis; Localized NEC CASE REPORTAn 1890-g male product of a dichorionic-diamniotic twin intrauterine pregnancy was born at 36 0/7 weeks' gestation to a 27-year-old G2P3 mother who had received regular antenatal care. The prenatal labs and habit history were unremarkable; prenatal ultrasound demonstrated intrauterine growth restriction (IUGR). Following spontaneous onset of labor, twin-A was delivered vaginally, and our patient was then delivered by cesarean section for footling breech presentation. Apgar scores at 5 and 10 minutes were 8 and 10, respectively, with initial heart rate between 100-120 beats per minute and oxygen saturation <70% responsive to brief positive pressure ventilation. The patient was admitted to the Neonatal Intensive Care Unit (NICU) for further management and care. His initial NICU stay was uneventful aside from physiologic hyperbilirubinemia requiring phototherapy and recalcitrant hypoglycemia requiring parenteral alimentation and glucose infusion. He remained hemodynamically normal on room air through the first nine days of life.He was tolerating oral feeds on fortified breast milk and appropriately gained weight to 1960-grams. On the tenth day of his NICU stay he developed feeding intolerance and mild fever to 38 °C. The abdomen was moderately distended with mild diffuse tenderness to palpation and hypoactive bowel sounds in all 4 quadrants. Minimal abdominal wall erythema was noted but no overt signs of peritonitis, palpable hernias, or masses were appreciated. Abdominal radiograph demonstrated gaseous distension and pneumatosis intestinalis of bowel loops in the right lower and upper quadrants (Fig.1A). The white blood cell count was 6,000 cells/mm3 with 8% bands. C-reactive protein was 168mg/dL. Comprehensive metabolic panel was within normal range. He was made nil per oral, a nasogastric tube was placed, blood cultures were drawn, and he was started on intravenous vancomycin (15mg/kg), amikacin (15mg/kg), and a loading dose of metronidazole (15mg/kg). Repeat abdominal radiograph three hours later revealed intraperitoneal free air (Fig.1B). Patient was emergently brought to the operating room for exploratory laparotomy, washout and possible bowel resection, for a CASE REPORT

An Experience with 31 Cases of Neonatal Appendicitis: A Retrospective Study

“…NA is usually reported in associated with Hirschsprung's Disease or NEC, and rarely as isolated or as an Amyand hernia. [1,9,11,15,18] Some authors believe that NA may be associated with cystic fibrosis [5]. In this study, 10 patients had NA secondary to NEC; none of our patients had Hirschsprung's Disease (HD) or Cystic Fibrosis (CF).…”

“…Most studies have not shown reliable investigations/biomarkers in the diagnosis of NA. [7,10,11,15,18] Plain radiographs, although not diagnostic of appendicitis, are helpful in detecting complications such as perforation. [1]Spiral computed tomography can also be a very useful diagnostic tool; [15][16][17] however, is less frequently used, which may be due to avoidance of radiation, higher cost, and development of early peritonitis also directs for early surgical intervention.…”

Apendicitis aguda perforada con diagnóstico prequirúrgico y hernia inguinal bilateral en recién nacido de pretérmino

“…Diversos reportes han destacado la similitud clínica con enterocolitis necrosante, por lo que se ha plantea-do tanto una posible asociación entre ambas condiciones, como que la apendicitis en el recién nacido podría estar en el contexto de la ella 2,5,6,8 . Otras condiciones asociadas que se han observado son la enfermedad de Hirschsprung, fibrosis quística, íleo meconial, hernia inguinal uni o bilateral, o infección por citomegalovirus 3,4 , aunque en algunas series reportadas no se ha demostrado la asociación con enfermedad de Hirschprung ni fibrosis quística 9 .…”

“…En la actualidad el manejo quirúrgico es mayoritariamente laparoscópico 14 y tiene objetivos tanto diagnóstico como terapéutico. La precocidad del diagnóstico tiene gran importancia en el pronóstico, tanto en las complicaciones sépticas como en la sobrevida, considerando que por las características clínicas el diagnóstico suele ser tardío 1,4,5,6,14,15 . Algunas propuestas de tratamiento conservador, con antibióticos y sin cirugía, hasta hoy, no cuentan con evidencia en recién nacidos 16 .…”

“…Otros desafíos en el diagnóstico radiológico es sospechar la inflamación apendicular cuando se encuentra dentro del conducto inguinal (Hernia de Amyand) 20 , así como otras complicaciones, como es el caso de la apendicitis en el contexto de una enterocolitis necrotizante 5,6,21 , hernias atascadas bajo las cuales subyace una apendicitis complicada 10 , cuadros que se presentan como torsión testicular u ovárica, en las cuales hay un apéndice inflamado y perforado 22,23 . Hacer el diagnóstico en forma oportuna permite orientar de mejor manera las estrategias quirúrgicas.…”