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Joana Patena Forte1; Sara Vaz Rodrigues1; Joana Henriques1; Aline Vaz Silva1; Dinorah Cardoso1; Rui Alves1

1 - Cirurgia Pediátrica, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central

- Poster, IX congresso Iberoamericano de Cirurgia Pediátrica

Introduction: Acute appendicitis is a common diagnosis in pediatric patients, but there are few reports in children younger than one year old. In young children appendicitis usually presents with vague or atypical symptoms, such as irritability, fever, and vomiting. The inability to communicate symptoms along with the difficulty of the abdominal examination in this age group concurs to a delayed diagnosis and complications. The rate of perforation on presentation is inversely related with age.
Cases report: Two 4-month-old male patients were diagnosed with acute appendicitis in our hospital in the last 6 years. The first presented with 48 hours of fever, irritability and episodes suggestive of abdominal pain. He had previously been treated for a presumable urinary tract infection. He developed a distended abdomen, with diminished peristaltic sounds and tenderness. The second patient presented with eight-days of fever, irritability, and anorexia. He had been previously treated with amoxicillin for otitis. There was no response to treatment, he became pale, septic, and with a distended abdomen, with diffuse tenderness most pronounced in the right quadrants. With a diagnosis of sepsis of unknow origin, he was transferred to our intensive care unit. In both cases laboratory tests only showed elevated C-reactive protein levels, and diagnosis was made after abdominal ultrasound. They underwent open appendectomy, the former patient for perforated appendicitis with a circumscribed abscess on the right lower quadrant, and the latter for a retrocecal gangrenous appendicitis. They restarted oral intake on the second and fourth day after surgery, respectively, and were discharged after one week of intravenous antibiotic therapy with cefuroxime, gentamicin and metronidazole. No intraperitoneal abscess or other complications reported in either case.
Discussion: Despite being the most common surgical diagnosis in pediatrics, acute appendicitis still poses a challenge. In the differential diagnosis of abdominal pain in infants, appendicitis is seldom considered, as intussusception, gastrointestinal viral diseases or respiratory and urinary infections are much more common causes. Imaging exams, as the abdominal ultrasound, are very important tools in the diagnosis of acute appendicitis in infants. The history and physical examination can be difficult to interpret, as demonstrated in these two cases. In this age group the rate of misdiagnosing acute appendicitis is high, often leading to a more severe disease with perforation and peritonitis. Despite this, the reported rate of postoperative complications in infants, as demonstrated in these cases. Although rare in infants, acute appendicitis should be excluded when infants present with irritability, fever and vague abdominal symptoms, as an early diagnosis and treatment can reduce the morbidity associated with complicated appendicitis.

Palavras Chave: apendicite aguda, 1ª infância