causing perforation of the appendix in an African boy
General Hospital, Moorside Road, England
General Hospital, Moorside Road, Davyhulme, Manchester, England, M41 5SL.
bodies in the appendix are well recognised but rarely found. The author is not
aware of any other reported cases of a foreign body causing perforation of the
appendix in a child in Africa. Presented here is the case of a 13yr old Ugandan
boy with abdominal pain who was found to have a perforated appendix with a seed
sitting in the perforation.
13 years old male presented to hospital with intermittent abdominal pains for one
month associated with watery diarrhoea and mild fever. He had recently taken a
course of albendazole. Examination revealed mild tenderness in the right iliac
fossa (RIF) and right upper abdomen. A stool sample was negative for parasites
and oocysts. It was thought that he was having acute appendicitis and was
admitted to the surgical ward. He was treated with oral metronidazole and
ciprofloxacin but after two days his symptoms improved and he was discharged
days later he re-attended surgical clinic complaining of right sided abdominal
pain. Again he was tender in the RIF but there was no guarding or signs of
peritonism. He was readmitted to the surgical ward and again put on oral
metronidazole and ciprofloxacin. His Hb was 8.6g/dl.
days after admission the patient was sent for appendicectomy. On the day of the
operation his abdomen was soft with mild RIF tenderness and active bowel
sounds. There were no features of peritonism. The appendix was located via a
grid iron incision and was found to be laying retrocaecally. It was inflamed
with a distal perforation and an oval shaped, 13x8 mm seed was seen to be
partially protruding from the perforation (Figure 1). No pus was seen in
the abdomen. Peritoneal lavage was performed with warmed 0.9% saline. The
patient was put on X-Pen and gentamicin 160 mg with IV fluids. The patient made
an uneventful recovery and was discharged home three days post-op in a stable
condition. The patient didn’t recognise the seed nor could he recall eating it.
The seed was sent to Makerere University and the photograph showed to local
people but it was not able to be identified.
Abdominal pain in children
is a common problem seen by doctors all over the world. Pain in the abdomen has
a broad differential diagnosis encompassing relatively benign conditions such
as urinary tract infection or constipation to life threatening emergencies such
abdominal perforation . Appendicitis is the most
commonly performed emergency abdominal surgery and the leading cause of acute
paediatric surgical admission yet determining which patients have appendicitis
is difficult [2,3]. Various scoring
systems based on clinical signs have been shown to be of use in identifying
patients at high risk of appendicitis .
Foreign bodies in the
appendix are very uncommon with one study showing a frequency of 0.005% in
13,228 patients . The literature has described many
causes of foreign bodies in the appendix such as seeds, needles, tongue studs,
parasitic worms, bullets and dental drill pieces [5,6]. Long, thin, sharp and pointed items are thought to be most
likely to cause perforation after ingestion whilst seeds are thought to present
a medium risk of perforation . Appendicitis can even
occur after appendicectomy, a phenomenon known as ‘stump appendicitis’ so
surgeons still need to consider a diagnosis of appendicitis in patients who
have had their appendix removed .
appendicitis is a surgical emergency and delay in performing appendicectomy
increases the risk of perforation. Perforation of the appendix due to a foreign
body can occur without classical signs and symptoms of perforation. Surgeons
all over the world should be aware of the potential operative findings of a
foreign body and be able to deal with them appropriately.
Figure 1: The perforated
appendix and seed
patient and his family gave consent for the article to be written.
author declared they have no competing interests.
DG, Byerley JS, Liles EA, Perrin EM, Katznelson J, Rice HE. Does this child
have appendicitis?. JAMA. 2007 Jul 25;298(4):438-51. This article on
R, Williams GT, Rees BI. Review of the pathological results of 2660
appendicectomy specimens. Journal of Gastroenterology. 2006; 41 (8):
article on PubMed
M, Mathur A, Singh S, Morris C, Green G, Kulkarni M. Home next day: early
discharge of children following appendicectomy. Journal of Child Health
Care. 2007; (3): 208-20. This article on
MW. The Paediatric Appendicitis Score (PAS) was useful in children with
acute abdominal pain. Evidence Based Medicine. 2009;14(1):26. This article on
PJ, Seelig MH, DeVault KR, Wetscher GJ, Floch NR, Branton SA, Hinder RA.
Ingested foreign bodies within the appendix: A 100-year review of the
literature. Dig Dis. 1998 Sep-Oct;16(5):308-14. This article on
CD, Mukherjee A. Appendicitis due to tongue stud ingestion: a case study
and review of management plans. South Dakota Journal of Medicine.
article on PubMed
M, Devas G. A child with appendicitis after appendectomy. Journal of
Emergency Medicine. 2008;34(1):59-61. This article on