[Appendix constrictor ring: a rare cause of intestinal obstruction]

Death caused by appendicular knotting and small-bowel strangulation in a child: A case report and review

Acute appendicitis is one of the most common surgical emergencies in paediatrics. However, acute appendicitis in early infancy is an uncommon condition. Furthermore, strangulation of the small intestine through appendicular knotting is described as very unusual in the literature and is generally not well-diagnosed in the clinical context. This article reports the case of a 23-month-old girl who entered the emergency department with a three-day history of abdominal symptoms and who died in less than 24 hours without receiving surgical intervention. The case turned judicial at the request of the parents who claimed lack of clarity in the diagnosis. A medico-legal autopsy was ordered to clarify the cause and manner of death. The autopsy documented herniation, strangulation and torsion of a 70 cm segment of the jejunum/ileum through an appendicular knot caused by the attachment of the distal end of the inflamed appendage to the ileum. The case is relevant because it is the first case of death by appendicular knot and strangulation of small bowel in an infant reported in the literature. The importance of autopsy to clarify the clinical diagnosis is noted.

Appendicitis as a rare cause of mechanical small-bowel obstruction: A literature review of case reports

•

Appendicitis as a cause of small-bowel obstruction is an extremely rare.

•

Our study confirmed that this complication is difficult to diagnose preoperatively.

•

A conclusive diagnosis typically has to wait until visualization during the surgery.

•

Surgical management varies from appendectomy up to right-sided hemicolectomy.

Introduction

Although bowel paralysis accompanying acute appendicitis is well known, mechanical bowel obstruction as a direct consequence of appendicitis remains a rare, but potentially life-threatening, acute abdomen. The aim of our literature review was to find all documented cases of this particular complication and compare them with our own case study.

Methods

We searched the PubMed database for relevant articles published from 1963 to 2015. The study included patients for whom direct links between appendicitis and strangulation of the terminal ileum were found, and for which the disease course had been documented in detail. The study also included our own case report since it met the inclusion criteria. A total of 190 articles were examined with a final yield of 17 case reports from 13 articles.

Results

17 patients (11 men and 6 women), with a mean age of 48 ± 23.9 years, met the inclusion criteria. The average period between symptom onset and surgery was 3.4 ± 3.7 days. Symptoms of the disease were consistent with small-bowel obstruction. Treatment included simple appendectomy (n = 7), possibly supplemented by segmental resection (n = 5), followed by ileocecal resection (n = 4), and one case that required a right-sided hemicolectomy (n = 1).

Conclusion

We found mechanical bowel obstruction directly related to appendiceal inflammation to be extremely rare, and relatively few individual cases involving this potentially life-threatening complication have been documented in the literature. Clinical signs of the disease are variable, non-uniform, and consistent with symptoms of small-bowel obstruction during their progression.