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Joana Patena Forte1; Ema Santos1; Maria Luís Sacras1; Aline Vaz Silva1; Rui Alves1; Marisa Inácio Oliveira2; Raquel Maia2; Paula Kjollerstrom2

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

- Poster, IX congresso Iberoamericano de Cirurgia Pediátrica

Introduction: Aplastic anemia in children is an uncommon but life-threating disorder. Its hallmark is an hypocellular bone marrow with severe pancytopenia, therefore, patients suffering from this condition have an increased risk of bleeding, infectious complications and delayed wound healing after surgery. Acute appendicitis has a 7% life-long risk and a pick incidence in the second decade of life. Appendectomy is one of the most common urgent surgical procedures. It is considered safe, but can have short and long-term complications in up to 30% of cases.
Objective: Discuss treatment options of acute appendicitis in patients with aplastic anemia.
Case report: We present three cases of acute appendicitis in children with aplastic anemia, successfully managed with antibiotics, without the need for rescue surgery. At our institution, from 2013 to 2019, 3 patients with acquired aplastic anemia, waiting for bone marrow transplants (2 male and 1 female, aged between 9 and 16 years old), were diagnosed with acute appendicitis. They presented with right lower quadrant abdominal pain, and two of them with fever. None had nausea, vomiting or diarrhea complaints. Laboratory analysis revealed pancytopenia and elevated C-reactive protein levels (73.8 - 146.8 mg/L). Ultrasound examination revealed in all three cases a distended and non-compressible appendix, with hyper-echogenicity of the mesentery, and no signs of perforation or abscess formation. These findings were compatible with non-complicated appendicitis. All patients were treated with intravenous broad-spectrum antibiotics, one with piperacillin/tazobactam and metronidazole and the others with meropenem and metronidazole, until resolution of symptoms and normalization of ultrasound findings and CRP levels. There were no complications reported, and on follow-up of at least 3 months there were no recurrences or complications. No patient underwent interval appendectomy.
Discussion: Acute appendicitis is a frequent diagnosis in children, and although appendectomy is considered safe, effective and the treatment of choice, the non-operative treatment with antibiotics has growing evidence of efficacy in the treatment of uncomplicated appendicitis. Although there are still few randomized trials in a pediatric setting this treatment option has shown a low complication and recurrence rates. The treatment of appendicitis in patients with aplastic anemia is controversial and scarcely reported, but surgical procedures raise concerns in complications rate increment. The short duration of symptoms, without signs of complication on abdominal examination and ultrasound, in these clinically stable patients, allowed for a non-operative management, without complications on follow-up.
Conclusion: Abdominal pain in severe neutropenic patients should prompt an immediate diagnosis and treatment. A non-surgical approach can be an option in the treatment of uncomplicated acute appendicitis in some selected and clinically stable patients with other co-morbidities, such as aplastic anemia, without a rise in complications or recurrence rate.

Palavras Chave: aplasia medular, apendicite aguda, tratamento conservador