Letter To The Editor: Post-Operative Intestinal Obstruction in Infants: Beware of Appendicitis

To the Editor:

Post-operative intestinal obstruction is a common complication of abdominal surgery in children and infants. This condition is uncommon after herniotomy and is usually associated with post-operative intestinal intussusception or the development of adhesions related to the manipulation of bowel loops.^1,2 Intestinal obstruction in infants could also be seen in the setting of acute appendicitis (AA). However, AA is very uncommon in the first year of life, usually presenting atypically with a high incidence of post-operative complications. ³

A two-month-old boy with no previous medical history underwent emergent repair of an incarcerated inguinal hernia. Surgery was quite challenging and lasted two h. Postoperatively, the infant developed severe bronchiolitis, which was managed successfully. The patient was discharged on the 15th post-operative day.

The infant returned after one month with a clinical picture of intestinal obstruction, including bilious vomiting and abdominal distension. The patient was febrile at 38.7°C with a heart rate of 180 bpm, a breathing rate of 45 breaths/min, and a blood pressure of 98/56. There was no stool passed in the past 24 h. Clinical findings included diffuse abdominal tenderness. Blood tests revealed anemia, leukocyte count of 18,590 × 10⁹/L and C-reactive protein (CRP) level of 66 mg/L. Abdominal CT revealed marked intestinal distension (Fig. 1A) with no evidence of pneumoperitoneum or intussusception. The appendix was not visualized. Following antibiotic therapy with cefotaxime and metronidazole, the infant underwent laparotomy with a pre-operative diagnosis of adhesive small bowel obstruction. Surgical exploration revealed a suppurative appendicitis with a perforation at the appendiceal base (Fig. 1B). An appendectomy was performed. Pathological evaluation confirmed the diagnosis of perforated appendicitis. Following surgery, the patient continued with 5 days of intravenous antibiotic therapy, with significant clinical improvement. On the 6th post-operative day, he was discharged home.

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FIG. 1.

(A): CT image showing significant intestinal distension. (B): Intra-operative photograph showing the perforation of the appendiceal base (black arrow).

Although AA is common in children, it is rarely considered in the differential diagnosis of acute abdomen in infants. In this age group, physicians tend to suspect more common diseases such as gastroenteritis, intestinal intussusception, intestinal obstruction, and necrotizing enterocolitis. The delay in diagnosing appendicitis in infants is due to the lack of specific clinical features commonly found in older patients. Thus, AA in young children may present as abdominal pain, diarrhea, fever, feeding intolerance, or marked irritability. Concomitant symptoms of the upper respiratory tract are frequent and can complicate the diagnostic process. ⁴

The usefulness of abdominal ultrasound in the diagnosis of AA in infants is much debated, with several authors pointing out the obvious limitations of ultrasound in this age group. While abdominal CT may be justified in the event of a non-diagnostic ultrasound in infants, this approach is not widely accepted, mainly because of the radiation exposure associated with this examination.^3–5

Although AA is very rare in infants, a high degree of suspicion of this condition is required. We believe that AA should be considered in infants and children presenting with acute abdominal symptoms, even in post-operative settings.