Appendicitis in the Neutropenic Child


With advancement in chemotherapy many children now survived to leukemia, lymphoma and other malignancies. The use of chemotherapeutic agents is associated with bone marrow toxicity and development of neutropenia along with infectious complications in the gastrointestinal tract. Right quadrant pain in the neutropenic child can be the direct consequence of acute appendicitis, neutropenic typhlitis, pseudomembranous colitis or obstructive ileus. Both appendicitis and neutropenic colitis are the most common surgical complications in children with leukemia. The use of steroids in these patients can masquerade acute appendicitis since the blunt the classic signs of appendicitis such as abdominal tenderness, rebound tenderness, involuntary guarding and abdominal wall rigidity. This causes confusion in the clinician trying to determine of the child has an acute abdominal condition or his symptoms are the result of side effects of chemotherapy. The incidence of appendicitis in the population of chemotherapy-induced neutropenia children is the same to the general pediatric population (2% - 4%). The clinical presentation and findings on physical exam of neutropenic children diagnosed with appendicitis are often vague and atypical. Since the most important decision is to differentiate acute appendicitis from neutropenic colitis children with right lower abdominal pain, fever and CT Scan findings of cecal wall thickness carries a presumptive diagnosis of typhlitis. In the absence of these findings acute appendicitis should be suspected and managed accordingly. Limited operative morbidity in neutropenic children with appendicitis leads to favor surgery over medical antibiotic therapy with delayed intervention. Medical management of appendicitis in the child with neutropenia increase hospital stay and use of pain medication. The majority of the children managed nonoperatively had recurrence of their RLQ pain on subsequent rounds of chemotherapy. Early appendectomy once the diagnosis is confirmed is safe and eliminates the course of the disease in addition to avoiding the concern for uncontrolled intraperitoneal contamination in the immunosuppressed child.

References:
1- Hobson MJ, Carney DE, Molik KA, Vik T, Scherer LR 3rd, Rouse TM, West KW, Grosfeld JL, Billmire DF: Appendicitis in childhood hematologic malignancies: analysis and comparison with
typhilitis.  J Pediatr Surg. 40(1):214-9, 2005
2- Mortellaro VE, Juang D, Fike FB, Saites CG, Potter DD Jr, Iqbal CW, Snyder CL, St Peter S: Treatment of appendicitis in neutropenic children. J Surg Res. 170(1):14-6, 2011
3- Tierney JS, Novotny NM: Appendectomy in neutropenic children: a safe and expedient solution to a challenging problem.  J Surg Res. 178(1):110-2, 2012
4- Scarpa AA, Hery G, Petit A, Brethon B, Jimenez I, Gandemer V, Abbou S, Haouy S, Breaud J, Poiree M: Appendicitis in a Neutropenic Patient: A Multicentric Retrospective Study. J Pediatr Hematol Oncol. 39(5):365-369, 2017
5- Ozyurek E, Arda S, Ozkiraz S, Alioglu B, Arikan U, Ozbek N: Febrile neutropenia as the presenting sign of appendicitis in an adolescent with acute myelogenous leukemia. Pediatr Hematol Oncol. 23(3):269-73, 2006
6- Angel CA, Rao BN, Wrenn E Jr, Lobe TE, Kumar AP: Acute appendicitis in children with leukemia and other malignancies: still a diagnostic dilemma. J Pediatr Surg. 27(4):476-9, 1992


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