Pediatr Emerg Med J.  2022 Dec;9(2):108-112. 10.22470/pemj.2022.00605.

Intestinal obstruction caused by acute perforated appendicitis misdiagnosed as Hirschsprung’s disease in a 31-month-old boy

• Nam SH

• KMID: 2538072
• DOI: http://doi.org/10.22470/pemj.2022.00605

Abstract

Symptomatic abdominal distension in young children requires a differential diagnosis, such as overeating, constipation or surgical emergency. If the distension is associated with intestinal obstruction, clinicians should determine the cause, such as adhesion, hernia, tumor or inflammatory lesions. Herein, the author reports a case of intestinal obstruction caused by acute perforated appendicitis. A 31-month-old boy was referred with a 10-day history of abdominal distension and a presumptive diagnosis of Hirschsprung’s disease. He had undergone an unsuccessful enema. Initial plain radiography and computed tomography showed severely dilated bowel loops with the colon collapsed. During laparotomy, the perforated appendix was found attached to the retroperitoneum and mesentery, which resulted in ileal stenosis with ischemia. The author resected 10 cm of the ileum, and performed ileocecectomy. Postoperatively, the boy recovered uneventfully, except wound seroma. Due to the low incidence and vague symptoms, it is difficult to diagnose intestinal obstruction caused by appendicitis, particularly in young children. This case may serve as a reminder that acute perforated appendicitis can cause sudden onset of intestinal obstruction in young children without a history of surgery.

Keyword

Abdominal Pain; Appendicitis; Hirschsprung Disease; Ileus; Intestinal Obstruction

Figure

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  Fig. 1. Initial plain radiograph showing the multiple dilated bowel loops.

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  Fig. 2. Computed tomography scans, which was performed at an outside emergency department on the day of referral to the author’s hospital. The scans depict the dilated small bowel loops without an irregular bowel wall thickening. Inflammatory lesions, such as appendicitis, are invisible due to the dilated bowels and non-enhanced nature (A). Of note, fecal impaction (arrowheads) with the sigmoid colon non-collapsed (asterisk) (B). This finding suggests a short segment Hirschsprung’s disease. Abnormalities are not noted in the solid organs.

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  Fig. 3. Operative findings on day 4. The perforated appendix adheres to the retroperitoneum and posterior mesentery with the appendix crossing over the ileal mesentery, making stenosis (arrow, A). Surgical resection margins for ileocecectomy (lines, B) and necrotic segment of ileum (asterisk, B) are marked on the ileum.

Reference

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