Downloaded from http://fn.bmj.com/ on August 19, 2015 - Published by group.bmj.com
Images in neonatal medicine
A gas-filled appendix on a plain X-ray of the abdomen in a preterm neonate A 72-day-old preterm baby girl, born at 27 weeks’ gestation, presented with abdominal distension, tachypnoea and desaturations. She was on 0.01 L/min of oxygen for her chronic lung disease (ventilated initially for 4 weeks and subsequently managed on continuous positive airway pressure and high-flow oxygen). She was receiving 200 mL/kg/day of mother’s breast milk via a nasogastric tube. Her oxygen requirement had increased to 0.1 L/min and her abdomen was distended, tense with palpable bowel loops. Blood gas, inflammatory markers and haemoglobin (9.4 g/dl) were within the normal range. She was initially managed conservatively for necrotising enterocolitis (NEC) with nil by mouth and triple antibiotics. An abdominal X-ray (AXR) showed dilated ascending colon, significantly prominent caecum and a gas-filled appendix (figure 1). There was no evidence of pneumatosis intestinalis. Clinically, she improved within 24 h and her abdomen was soft with no abdominal distension. She had subsequent X-rays including lateral decubitus view of the abdomen that were normal with no evidence of perforation or pneumatosis intestinalis. Her feeds were restarted after 48 h, and she established full enteral feeds in the next 24 h (150 mL/kg/day). Intraluminal air in the appendix is rarely seen on neonatal AXR and has not been previously described in the literature. In
this clinical context, NEC was one of the most important differential diagnoses and perforation could not be completely ruled out. Thus, a repeat X-ray with lateral decubitus view was done after starting conservative management for NEC. This showed no evidence of perforation and the abdominal gas pattern returned to normal, as well as the described clinical improvement. Intraluminal air in the appendix did raise the dilemma of acute appendicitis in the differential diagnosis when the baby became unwell. Acute appendicitis is not described in neonates in the literature; this diagnosis was unproven due to rapid clinical improvement and normal inflammatory markers with this baby. In adults, before the widespread use of CT, there are several reports of the usage of AXRs to look for signs suggesting appendicitis,1–5 which include, among others, a gas-filled appendix. Since CT has been used more extensively, intraluminal gas in the appendix is often felt to be a good sign to exclude appendicitis.6 However, intraluminal air can be seen in cases of appendicitis, although there will usually be other associated signs of the diagnosis. Overall the consensus in the literature is that plain radiography is insensitive and non-specific for appendicitis and should not be obtained routinely, except to evaluate for obstruction or free air. Plain X-rays are done routinely for investigation of abdominal pathology in preterm infants, and intraluminal air in the appendix could raise a dilemma in the diagnostic pathway. Thus, careful clinical evaluation and judicious use of repeat X-rays including lateral decubitus views will aid in the onward management. V B Anna Venugopalan, C Keaney Birmingham City Hospital, Birmingham, UK Correspondence to Dr V B Anna Venugopalan, Birmingham City Hospital, Dudley Road, Birmingham B18 7QH, UK; [email protected] Contributors VBAV had the idea for the article. VBAV and CK contributed to the conception and design of the article, data collection, manuscript writing and critical review about the intellectual content. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
To cite Anna Venugopalan VB, Keaney C. Arch Dis Child Fetal Neonatal Ed 2015;100:F432. Received 8 October 2014 Revised 10 January 2015 Accepted 28 January 2015 Published Online First 18 February 2015 Arch Dis Child Fetal Neonatal Ed 2015;100:F432. doi:10.1136/archdischild-2014-307342
REFERENCES 1 2 3 4 5
Figure 1 X-ray of the abdomen showing a gas-filled appendix (arrows) with a prominent caecum.
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Steinert R, Hareide I, Christiansen T. Roentgenolic examination of acute appendicitis. Acta Radiol 1943;24:13–27. Brooks DW, Killen DA. Roentgenographic findings in acute appendicitis. Surgery 1965;57:377–84. Shimkin PM. Radiology of acute appendicitis. Am J Roentgen 1978;130:1000–4. Rodrigues G, Kanniayan L, Gopashetty M, et al. Plain X-Ray in acute appendicitis. Internet J Radiol 2003;3:2. Thorpe JA. The plain abdominal radiograph in acute appendicitis. Ann R Coll Surg Engl 1979;61:45–7. Cabarrus M, Sun YL, Cortier JL, et al. The prevalence and patterns of intraluminal air in acute appendicitis at CT. Emerg Radiol 2013:20:51–6.
Anna Venugopalan VB, Keaney C. Arch Dis Child Fetal Neonatal Ed September 2015 Vol 100 No 5
Downloaded from http://fn.bmj.com/ on August 19, 2015 - Published by group.bmj.com
A gas-filled appendix on a plain X-ray of the abdomen in a preterm neonate V B Anna Venugopalan and C Keaney Arch Dis Child Fetal Neonatal Ed 2015 100: F432 originally published online February 18, 2015
doi: 10.1136/archdischild-2014-307342 Updated information and services can be found at: http://fn.bmj.com/content/100/5/F432
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Articles on similar topics can be found in the following collections Child health (1434) Immunology (including allergy) (385) Competing interests (ethics) (96) Clinical diagnostic tests (693) Drugs: infectious diseases (207) Infant health (801) Journalology (104) Neonatal health (866) Radiology (666) Radiology (diagnostics) (611)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Images in neonatal medicine
A gas-filled appendix on a plain X-ray of the abdomen in a preterm neonate A 72-day-old preterm baby girl, born at 27 weeks’ gestation, presented with abdominal distension, tachypnoea and desaturations. She was on 0.01 L/min of oxygen for her chronic lung disease (ventilated initially for 4 weeks and subsequently managed on continuous positive airway pressure and high-flow oxygen). She was receiving 200 mL/kg/day of mother’s breast milk via a nasogastric tube. Her oxygen requirement had increased to 0.1 L/min and her abdomen was distended, tense with palpable bowel loops. Blood gas, inflammatory markers and haemoglobin (9.4 g/dl) were within the normal range. She was initially managed conservatively for necrotising enterocolitis (NEC) with nil by mouth and triple antibiotics. An abdominal X-ray (AXR) showed dilated ascending colon, significantly prominent caecum and a gas-filled appendix (figure 1). There was no evidence of pneumatosis intestinalis. Clinically, she improved within 24 h and her abdomen was soft with no abdominal distension. She had subsequent X-rays including lateral decubitus view of the abdomen that were normal with no evidence of perforation or pneumatosis intestinalis. Her feeds were restarted after 48 h, and she established full enteral feeds in the next 24 h (150 mL/kg/day). Intraluminal air in the appendix is rarely seen on neonatal AXR and has not been previously described in the literature. In
this clinical context, NEC was one of the most important differential diagnoses and perforation could not be completely ruled out. Thus, a repeat X-ray with lateral decubitus view was done after starting conservative management for NEC. This showed no evidence of perforation and the abdominal gas pattern returned to normal, as well as the described clinical improvement. Intraluminal air in the appendix did raise the dilemma of acute appendicitis in the differential diagnosis when the baby became unwell. Acute appendicitis is not described in neonates in the literature; this diagnosis was unproven due to rapid clinical improvement and normal inflammatory markers with this baby. In adults, before the widespread use of CT, there are several reports of the usage of AXRs to look for signs suggesting appendicitis,1–5 which include, among others, a gas-filled appendix. Since CT has been used more extensively, intraluminal gas in the appendix is often felt to be a good sign to exclude appendicitis.6 However, intraluminal air can be seen in cases of appendicitis, although there will usually be other associated signs of the diagnosis. Overall the consensus in the literature is that plain radiography is insensitive and non-specific for appendicitis and should not be obtained routinely, except to evaluate for obstruction or free air. Plain X-rays are done routinely for investigation of abdominal pathology in preterm infants, and intraluminal air in the appendix could raise a dilemma in the diagnostic pathway. Thus, careful clinical evaluation and judicious use of repeat X-rays including lateral decubitus views will aid in the onward management. V B Anna Venugopalan, C Keaney Birmingham City Hospital, Birmingham, UK Correspondence to Dr V B Anna Venugopalan, Birmingham City Hospital, Dudley Road, Birmingham B18 7QH, UK; [email protected] Contributors VBAV had the idea for the article. VBAV and CK contributed to the conception and design of the article, data collection, manuscript writing and critical review about the intellectual content. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
To cite Anna Venugopalan VB, Keaney C. Arch Dis Child Fetal Neonatal Ed 2015;100:F432. Received 8 October 2014 Revised 10 January 2015 Accepted 28 January 2015 Published Online First 18 February 2015 Arch Dis Child Fetal Neonatal Ed 2015;100:F432. doi:10.1136/archdischild-2014-307342
REFERENCES 1 2 3 4 5
Figure 1 X-ray of the abdomen showing a gas-filled appendix (arrows) with a prominent caecum.
F432
6
Steinert R, Hareide I, Christiansen T. Roentgenolic examination of acute appendicitis. Acta Radiol 1943;24:13–27. Brooks DW, Killen DA. Roentgenographic findings in acute appendicitis. Surgery 1965;57:377–84. Shimkin PM. Radiology of acute appendicitis. Am J Roentgen 1978;130:1000–4. Rodrigues G, Kanniayan L, Gopashetty M, et al. Plain X-Ray in acute appendicitis. Internet J Radiol 2003;3:2. Thorpe JA. The plain abdominal radiograph in acute appendicitis. Ann R Coll Surg Engl 1979;61:45–7. Cabarrus M, Sun YL, Cortier JL, et al. The prevalence and patterns of intraluminal air in acute appendicitis at CT. Emerg Radiol 2013:20:51–6.
Anna Venugopalan VB, Keaney C. Arch Dis Child Fetal Neonatal Ed September 2015 Vol 100 No 5
Downloaded from http://fn.bmj.com/ on August 19, 2015 - Published by group.bmj.com
A gas-filled appendix on a plain X-ray of the abdomen in a preterm neonate V B Anna Venugopalan and C Keaney Arch Dis Child Fetal Neonatal Ed 2015 100: F432 originally published online February 18, 2015
doi: 10.1136/archdischild-2014-307342 Updated information and services can be found at: http://fn.bmj.com/content/100/5/F432
These include:
References Email alerting service
Topic Collections
This article cites 6 articles, 0 of which you can access for free at: http://fn.bmj.com/content/100/5/F432#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Child health (1434) Immunology (including allergy) (385) Competing interests (ethics) (96) Clinical diagnostic tests (693) Drugs: infectious diseases (207) Infant health (801) Journalology (104) Neonatal health (866) Radiology (666) Radiology (diagnostics) (611)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
