Acute peritonitis secondary to post-traumatic appendicitis: A case report and literature review

BACKGROUND

Blunt abdominal trauma has rarely been reported as a cause of acute appendicitis in the literature. However, the coexistence of the two conditions can cause issues for the patient. We present here a systematic review of cases of traumatic appendicitis as well as our own experience with a 12-year-old male patient.

CASE SUMMARY

A 12-year-old male was admitted 3 d after abdominal trauma, experiencing peritoneal syndrome. A pelvic formation was discovered during abdominal ultrasound, and surgical exploration revealed a perforated appendix. A literature review was conducted applying the keywords "appendicitis," "abdominal," and "trauma" to the PubMed, Embase, and Medline databases. Our initial search included 529 papers published between 1991 and 2022, of which 33 papers were finally included. They revealed 51 reported cases. The trauma mechanisms included road traffic accidents, falls, assaults, ball accidents, a horse kick, and a colonoscopy. Eight patients underwent surgical exploration with no prior radiological investigation, and twenty-six patients underwent an initial radiological examination. All reports indicated a perforated appendix.

CONCLUSION

Acute traumatic appendicitis represents a diagnostic quandary that can be misdiagnosed resulting in significant morbidity and potential mortality. A high level of suspicion combined with radiological examination may aid in the diagnosis and treatment of this condition.

Splenogonadal fusion misdiagnosed as spermatic cord cyst: a case report

INTRODUCTION

Splenogonadal fusion is a rare congenital anomaly. The aim of this study was to report a case of splenogonadal fusion mimicking a spermatic cord cyst, and discuss therapeutic management of this rare congenital malformation.

OBSERVATION

An eight-years old patient was presented with an asymptomatic three-centimeter oval scrotal mass mistaken for a spermatic cord cyst. Surgical exploration has revealed tow purple-red, firm encapsulated masses. The first mass was two cm long and adherent to the upper pole of the left testis with a cleavage plane. The second mass was four cm long, attached to the first by a fibrous cord and drawn on its superior pole by a serpiginous vascular structure that extended inside the abdomen. The spermatic cord was individualized. Extemporaneous anatomopathological examination of the first mass, totally excised, has concluded to benign lesion. Therefore, the peritoneum was opened, and the superior mass was excised as high as it could be reached without orchiectomy. Definitive Anatomopathological examination concluded to an ectopic splenic tissue. The final diagnosis was a continuous splenogonadal fusion.

CONCLUSION

This case highlights the clinical characteristics of this condition, with a special focus on the signs and findings that might help prevent unnecessary orchiectomy. Consequently, it is essential to include this malformation in the differential diagnosis of scrotal masses in children.

Rhabdoid renal tumor: an aggressive embryonal tumor in an infant — a case report

Background

Malignant rhabdoid tumor of the kidney is the most aggressive childhood renal tumor. A preoperative diagnosis is critical in order to correctly establish a therapeutic strategy and a full metastatic workup.

Case presentation

We report on a 3-month-old case with fever, diarrhea, and abdominal distension treated surgically with adjuvant chemotherapy. The diagnosis was confirmed postoperatively. Relapse was quick, and the child died 5 months after surgical resection.

Conclusions

Rhabdoid renal tumor in young age is associated with a high mortality rate even with invasive strategies. Case reports and research are critical for evaluating existing protocols and improving prognosis. Diverse clinical trials are being conducted in the hopes of improving the prognosis of rhabdoid renal tumors.

Urachal rhabdomyosarcoma: A case report of an extremely rare localisation

Urachus is a tubular structure connecting the allatois to the bladder's apex, in the embryonic development. We report a rare case of a 5-year-old boy, with no past medical history, complaining of secondary enuresis, pollakiuria and urgent incontinence. Physical exam revealed a hypogastric mass. Echo guided percutaneous biopsy followed by a histological analysis showed embryonal RMS. The remainder of the staging ruled out metastasis. The patient received neoadjuvant chemotherapy before proceeding to complete tumor excision. Surgical exploration revealed that the tumor was primitively related to the urachus. Total resection was performed. The one year follow-up was uneventful.

Treatment-resistant schizophrenia : the relationship between clozapine plasma concentration and clinical outcome

Introduction

Clozapine is highly effective in patients with treatment-resistant schizophrenia but, to ensure optimal clinical response it is important to optimize its use and this depends on adequate pharmacological monitoring.

Objectives

Evaluate the therapeutic response rate according to clozapine plasma concentration.

Methods

It was a cross-sectional, retrospective and analytical study, carried out over a period of six months, in the F and A psychiatry departments of the Razi hospital in Tunis, including patients followed for treatment-resistant schizophrenia and receiving clozapine. We evaluated the response to clozapine using the Brief Psychiatric Rating Scale (BPRS).

Results

The average age was 37.7 ± 9.4. The mean age of introduction of clozapine was 31 years and the mean time to its introduction was 9.3 years. Clozapine was administered as a single drug in 85% of cases. The mean dose of clozapine was 373 mg/day. The mean of clozapine plasma concentration was 386.5 ng/ml with a minimum of 89 ng/ml and a maximum of 913 ng/ml. The clinical response rate to clozapine was 25% with a BPRS good response threshold value of less than 35. Patients with clozapine levels above the conventional cut-off of 350 ng/ml (n=34) had a response rate of 34.6%. A response rate of 37% was observed in the group of patients with a clozapine plasma concentration interval of 200-350 ng/ml. There was no statistically significant difference in therapeutic response (p=0186)

Conclusions

Our study revealed a therapeutic response variation according to plasma clozapine concentration and showed the existence of a non-negligible and effective response rate.

Disclosure

No significant relationships.

Secondary closure of large omphalocele using component separation technique: A pediatric case report

Introduction and importance

Component separation technique is utilized in adults to repair large abdominal wall defects but rarely used in children. We report a successfully performed component separation technique in a child after neonatal Gross closure for large omphalocele without biologic mesh placement.

Case presentation

A 6-year-old girl was treated at the age of 4 days for omphalocele type 2 according to Gross technique. She reconsulted six years later. Clinical examination showed a large eventration measuring 150 ∗ 100 mm. CT scan revealed a broad collar of 150 mm and a large pocket containing liver, transverse colon, stomach and part of the small intestine. The child was proposed for a cure of the eventration using synthetic mesh type GORTEX. Intraoperatively, releasing bowel adhesions with abdominal wall resulted in perforation of the small intestine. Faced with the inability to use the mesh we resorted to abdominal closure with component separation technique. The postoperative was simple without complications or recurrence of the eventration. Follow up was of 4 years.

Clinical discussion

Staged surgical closure and non-operative delayed closure are the two distinct strategies for managing giant omphaloceles. By providing closure with less intra-abdominal pressure, the Component separation technique is a procedure which can be used in the two strategies. It may minimize the complications associated with large omphalocele management.

Conclusion

Faced with the impossibility of using a mesh, the component separation technique must be recognized as part of the therapeutic arsenal for secondary closure in children with a giant omphalocele.

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We report a case of a secondary closure of large omphalocele using component separation technique in 12 years-old girl.

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Our pediatric patient illustrates the safety and feasibility of this technique in children without any complication.

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Component separation technique must be recognized in the therapeutic arsenal closure of large abdominal wall defect in children

Is pneumoperitoneum specific of post-traumatic appendicitis? Case report and literature review

Introduction

Acute appendicitis and blunt abdominal trauma may co-exist, imposing a dilemma of whether there is only coincidence or there is a cause to effect relationship. The etiopathogenesis of this rare association remains obscure. Pneumoperitoneum has rarely been described in patients with acute perforative appendicitis following abdominal trauma.

Case presentation

We report a rare case of acute perforated appendicitis after blunt abdominal trauma in an 8-year-old boy revealed by a pneumoperitoneum. We also reviewed the literature on this rare condition to assess the specificity of pneumoperitoneum in the diagnosis and to understand its etiopathogenesis.

Conclusion

Abdominal pain and fever several days after an abdominal trauma may be a sign of post-traumatic appendicitis in the pediatric population. Pneumoperitoneum is not specific of post-traumatic appendicitis but it can be a protective sign, since it will lead to immediate laparotomy in patients with an unrecognized surgical abdomen.

Spontaneous perforation of common hepatic duct: an intraoperative surprise

Background

Pediatric spontaneous bile duct perforation is one of the rare causes of acute abdomen in infants. With a highly variable presentation, diagnosis and treatment can prove challenging. We report a case of spontaneous common hepatic duct perforation mistaken for appendicular peritonitis.

Case presentation

An otherwise healthy 3-year-old boy presented to the emergency department with complaints of abdominal pain, distention, bilious vomiting, and fever evolving for 4 days. Preoperative ultrasound was suggestive of appendicular peritonitis. Laparotomy revealed abundant biliary fluid, a distended gallbladder with thickened and inflammatory wall, and a macroscopically normal appendix. Intraoperative cholangiography showed a leak of contrast from the anterior wall of the common hepatic duct, 2–3 mm below the upper biliary confluence and 2 cm above the junction of the cystic duct to the common hepatic duct. A cholecystostomy was performed, and two external intraabdominal drains were placed. A retrograde cholangiogram was performed on postoperative day 21 showing no extravasation of contrast product. The patient was discharged on postoperative day 25.

Conclusion

Spontaneous perforation of the common hepatic duct is a rare phenomenon. It should be considered as a differential diagnosis in pediatric patients that present with unexplained peritonitis. The optimal method of diagnosis and management remains controversial.

Thoraco-abdominal duplications in children: Two case reports

Introduction

Thoraco-abdominal duplication is rare congenital malformations of the notochord that occurs in only 2% of cases of alimentary tract duplications.

We report two rare cases of thoraco-abdominal duplication, emphasizing the value of radiological assessment and discussing the place of diagnostic and therapeutic laparoscopy.

Presentation of case

It was a 12-year-old girl and an 8-month-old boy, admitted for epigastralgia and dysphagia with respiratory distress respectively. Imaging was in favor of pancreatic duplication with intra-thoracic extension for the first patient and gastro-esophageal duplication for the second. A mass excision was done laparoscopically for the first and by a thoracotomy for the second. The aftermath of the surgery was simple in both cases.

Clinical discussion

Thoraco-abdominal duplications are rare congenital malformations that account for only 2% of cases of gastrointestinal duplications. Their diagnosis is difficult since the revealing symptomatology is not common. The treatment is only surgical is facilitated by the laparoscopy which has a diagnostic and therapeutic interest.

Conclusion

Our case reports focused on the difficulty of the diagnosis that is done by imaging and is confirmed by surgery with anatomopathological examination of the excised mass. Diagnostic and therapeutic minimally invasive approach should be used whenever possible.

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Thoraco-abdominal duplications account for only 2% of cases of gastrointestinal duplications.

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Their diagnosis is difficult since the revealing symptomatology is not common.

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The treatment depends on the type of duplication.

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This management is facilitated by the laparoscopy.

Idiopathic urolithiasis in Tunisian children: a report of 134 cases

We evaluated the metabolic and the nutritional aspects of 134 urolithiasis children in order to outline the characteristics of idiopathic urolithiasis in children. This prospective study group of 134 children (56 females, 78 males) with renal calculi was evaluated. The age range of the patients was six months to 16 years. A dietary survey was performed on every child. All patients were investigated with respect to stone localization and serum and urine risk factors. Statistical analysis of data was carried out using software SPSS 11.0 for Windows. Hypercalciuria was the most common risk factor detected in this group (28.3%). A decrease of water intake was noted in all age groups, especially in the rural area (549.6 mL/day vs. 1150.6 mL/day), and there was an increase in animal protein intake in 17 cases (mean: 1.9 g/kg). In addition, increased intake of starchy foods and food with high oxalate content (sorgum) were detected in the ten to 16 years age group (51%) of our study. Calcium oxalate monohydrate represents the principal component of idiopathic stone (58.2%), which is more frequent in children (68%) than in infants (51.7%) (P <0.02). The major etiology of idiopathic urolithiasis highlights the influence of dietary habit in stone formers in our country. The increased occurrence of calcium oxalate stones in school age children confirms the change in the etiology of urolithiasis according to age.

Changes in urinary stone composition in the Tunisian population: a retrospective study of 1,301 cases

BACKGROUND

Studies that evaluate the effect of age on stone composition are scarce. The aim of this study was to highlight the changes in epidemiological characteristics (stone composition and location) of urolithiasis according to patients' age.

METHODS

We studied 1,301 urolithiasis patients with age ranging from 6 months to 92 yr (781 males and 520 females). Stone analysis was performed using a stereomicroscope and infrared spectroscopy to determine the morphological type and molecular composition of each stone.

RESULTS

The annual average incidence of new stone formation was 31.7 per 100,000 persons. In 71.8% of cases, calculi were located in the upper urinary tract. Compared to other age groups, children and old men were more affected by bladder stones. Calcium oxalate monohydrate was the most frequent stone component, even though its frequency decreased with age (59.5% in young adults and 43.7% in the elderly, P<0.05) in favor of an increase in uric acid stones (11.5% in young adults and 36.4% in the elderly, P<0.05). Struvite stones were rare (3.8%) and more frequent in children than in adults.

CONCLUSIONS

The analysis of these data showed that urinary stones in Tunisian patients are tending to evolve in the same direction as the stones in patients from industrialized countries.

[Changes in kidney stones type according to sex and age in Tunisian patients]

BACKGROUND

Studies that evaluate the effect of age and gender on the stone composition are scarce. The aim of this study is to highlight the modification of epidemiological characteristics of this pathology according to patients' sex and age.

PATIENTS AND METHODS

We studied 1269 urolithiasic patients ranging from 6 months to 92 years old and known as having urinary stones (752 males and 517 females). Stone analysis was performed respectively using a stereomicroscope and infrared spectroscopy to determine, respectively, the morphological type and molecular composition of each.

RESULTS

The annual average incidence of new stone formation was 30.25 per 100,000 inhabitants. In 1041 patients (81%), calculi were located in the upper urinary tract. Children and old man were more affected by bladder stone. Calcium oxalate monohydrate remains the most frequent stone component even if its frequency fell according to age (63.2% in teenagers and 40.6% in elderly [p<0.05]) in favour of the increase of uric acid stones (3,5% in teenagers and 41.5% in elderly [p<0.05]). Struvite stones were rare (3.5%) and more frequent in children.

CONCLUSION

The analysis of these data shows that urinary stones in Tunisia are tending to evolve in the same direction as in industrialized countries.

Benign intrascrotal lipoblastoma in a 4-month-old infant: a case report and review of literature

Lipoblastomas are rare benign soft tissue tumors that occur primarily in young children. Most lipoblastomas occur in the extremities, trunk, head, and neck. An intrascrotal location is unusual. We describe a case of a 4-month-old infant with an intrascrotal lipoblastoma and discuss the differential diagnosis and review the literature.

Urinary lithiasis and urinary tract malformations in children: a retrospective study of 34 cases

BACKGROUND

Although the association of urinary lithiasis and urinary tract malformation is not rare, their management poses challenges. The aim of this study was to evaluate the relationship between urolithiasis and malformations of the urinary system. There were 34 patients (19 males and 15 females) with a mean age of 4.8 years (range, 2 months to 14 years). All patients had urinary lithiasis with a urinary tract malformation. Abdominal pain was the most frequent clinical symptom (38%). Urinary infection was found in 7 patients (21%) and macroscopic haematuria was present in 10 patients (29%). The most frequent urinary tract malformations were megaureter (8 cases), uretero-pelvic junction obstruction (7 cases) and vesico-ureteric reflux (8 cases), but its malformative origin could not be confirmed. Treatment consisted of lithiasis extraction in 32 cases associated with specific treatment of the uropathy in 27 cases. Postoperative outcome was uneventful in all cases. In fact, urinary lithiasis and urinary tract malformation association is not rare. Indeed, 9-34% of urinary lithiasis are noted to be associated with urinary tract malformation. Positive diagnosis relies specifically on kidney ultrasound, intravenous urography, and urethrocystography. Treatment depends on the type of urinary tract malformation, localisation and size of the urinary lithiasis.

CONCLUSION

In conclusion, urinary lithiasis and urinary tract malformation association is a frequent eventuality. Surgical intervention is the usual mode of treatment.

Congenital bilobar emphysema

Congenital bilobar emphysema is reported to be extremely rare. We describe 3 cases, and we review the diagnosis problems and treatment methods of this childhood respiratory tract pathologic condition.

Transverse testicular ectopia: a three-case report and review of the literature

OBJECTIVES

To describe the embryologic, clinical, and therapeutic features of transverse testicular ectopia (TTE) and to review the literature on similar cases.

METHODS

Three cases of TTE were discovered accidentally during surgery for inguinal hernia and undescended testes; a persistent Müllerian duct syndrome (PMDS) was associated in 1 case. We also performed a literature search for other reports of TTE.

RESULTS

A conservative surgical approach was chosen: transseptal orchiopexy was preferred in 2 cases and the Müllerian remnant was preserved in the first case.

CONCLUSIONS

TTE is a rare anomaly that usually presents as a unilateral cryptorchidism and a contralateral descendent testis with an associated hernia. In suspected cases, laparoscopy and ultrasonographic evaluation may be helpful in diagnosing this condition before surgery. Surgery, transseptal orchiopexy, is highly recommended to manage TTE especially when vasa deferentia are fused. In case of PMDS, the authors preferred preserving Müllerian remnants because of the risk of vas deferens and testicular blood supply damage. Recently, laparoscopy is useful for both diagnosing and management of TTE and associated anomalies.

Ovarian inflammatory myofibroblastic tumor in children

Inflammatory myofibroblastic tumors or inflammatory pseudotumors are uncommon solid tumors that are highly vascularized, have an intermediate prognosis, and are associated with local recurrence, and rare metastasis. Inflammatory myofibroblastic tumors (IMT) most often are seen in the lung of young adults, but there have been reports of these tumors occurring in children, in various sites. The authors report a case of an ovarian IMT arising in a six-year-old girl (third case reported in the literature), treated by a right adnexectomy with uneventful postoperative course, and discuss recent reports.

Laparoscopic treatment of hydatid cyst of the liver in children. A report on 34 cases

PURPOSE

This study evaluated the safety and efficiency of laparoscopically treated liver cysts in children.

METHODS

From September 2001 to July 2004, 34 patients underwent laparoscopic treatment of hydatid cysts of the liver. All patients had chest x-ray, abdominal sonography, and hydatid serology. The different stages of the procedure were the same as in open surgery: puncture, aspiration, injection of scolicidal agent, reaspiration, removal of proligerous membrane, and resection of the dome.

RESULTS

The patients' mean average age was 7 years and 7 months (range, 3-14 years). The number of cysts ranged from 1 to 10 with a diameter of 40 to 150 mm (mean diameter, 65.5 mm). One case had a mesenteric associated hydatid cyst, another splenic hydatid cyst. The average length of hospital stay was 5 days (range, 4-14 days). No per- or postoperative complications were reported. At 12 to 45 months follow-up, no recurrence has been reported.

CONCLUSION

Laparoscopy represents an excellent approach for the treatment of hydatid cyst of the liver in children.

Spontaneous perforation of the extrahepatic bile duct in infancy: report of two cases and literature review

BACKGROUND

Spontaneous perforation of the bile duct (SPBD) is a rare disease in infancy. The pathogenesis, diagnostic modalities and treatment options for this condition are reviewed and discussed.

METHODS

The authors report 2 new observations of SPBD in 2 male newborns aged respectively 27 and 21 days.

RESULTS

The 2 newborns presented with cholestatic jaundice. Abdominal sonography showed an extrahepatic mass. Exploratory laparotomy revealed that the perforation was located in the cystic duct in the first case and in the common bile duct (CBD) in the second. The site of perforation was repaired and both patients underwent simple external biliary drainage. The postoperative course was uneventful for both patients with follow-up ranging from 2 to 4 years.

CONCLUSIONS

SPBD is a rare, but important cause of surgical jaundice in infants. The pathogenesis of SPBD is unknown and multifactorial and diagnosis is often problematic. Surgical management is always required and a conservative approach is usually recommended. The prognosis is good with early surgical management.

Pediatric urolithiasis in Tunisia: a multi-centric study of 525 patients

PURPOSE

To investigate retrospectively the clinical and epidemiological characteristics, and method of treatment of childhood urolithiasis, a major urological problem in Tunisia.

MATERIALS AND METHODS

The records of 525 children with urolithiasis treated in Tunisia between 1990 and 2004 were reviewed in a multi-centric study with regard to age at diagnosis, sex, history, and physical, laboratory, and radiologic findings. Metabolic evaluation when performed included serum electrolytes, calcium, phosphorus, uric acid, 24-h urine collection for calcium and creatinine, and a sodium nitroprusside test for cystine. In all cases urine specimens were sent for culture.

RESULTS

The stone was located in the upper tract in 420 (80%) and lower tract in 105 children. Of the urine cultures, 40% were positive. Metabolic investigation was performed in 201 patients and was normal in 170 (84%). Urinary stasis secondary to a urinary tract anomaly that led to the formation of stones was found in 77 patients. Stones were treated by surgery (80%), extracorporeal shock wave lithotripsy (ESWL) (5%) and ureteroscopic extraction (4%), and percutaneous nephrolithotomy was performed in 10 patients (2%). The stone passed spontaneously in 9% of cases.

CONCLUSION

The use of ESWL and endourological methods of treatment for childhood urolithiasis must be generalized, with open surgery being reserved for particular and complex cases.

[Intussusception owing to pathologic lead points in children: report of 27 cases]

OBJECTIVE

Intussusception owing to pathologic lead points is a challenging condition for pediatric surgeons. The aim of this study was to review the particularities of clinical presentation, the place of morphologic investigation in depicting the presence of an organic lesion and the management of secondary intussusception.

PATIENTS AND METHODS

The authors report a series of 27 patients treated from 1986 to 2004, for secondary intussusception.

RESULTS

Nineteen boys and 8 girls, aged from 45 days to 11 years (mean age: 40 months) presented with secondary intussusception: Meckel's diverticulum (13 cases); lymphoma (8 cases); intestinal duplication (3 cases); heterotopic pancreas (2 cases); intestinal polyp (1 case). All patients were operated upon after failure of hydrostatic reduction. An intestinal resection with an end to end anastomosis was done for 26 patients. The biopsy of a large abdominal mass after an easy reduction of the intussusception was performed in 1 case. Chemotherapy was started at the sixth postoperative day for the 8 children having lymphoma. Two of them died during therapy. For the 25 others, the postoperative course was uneventful with a mean follow-up of 4 years.

COMMENTARY

The improvement of the management and the prognosis of secondary intussusception requires an early diagnosis. Morphologic examination must not be limited to the diagnostic of intussusception but must aim at searching a lead point. The reduction of this particular form is based exclusively on surgery.