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CASE REPORT Table of Contents   
Year : 2009  |  Volume : 6  |  Issue : 2  |  Page : 114-115
An unusual cause of caecal perforation in a child


Department of Paediatric Surgery, University of Oxford and John Radcliffe Hospital, Oxford, United Kingdom

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Date of Web Publication29-Jul-2009
 

   Abstract 

Faecolith impaction leading to caecal perforation is a rare cause of acute abdominal pain in children. We present a case of an 11-year-old boy who was admitted to our department with a perforated caecum caused by faecolith impaction. Histology demonstrated a normal appendix with ganglion cells present. No mechanism of action could be detected for the faecolith impaction. This is a previously unreported cause of caecal perforation in children.

Keywords: Caecal perforation, faecolith, paediatric

How to cite this article:
Simpkin V L, Lakhoo K. An unusual cause of caecal perforation in a child. Afr J Paediatr Surg 2009;6:114-5

How to cite this URL:
Simpkin V L, Lakhoo K. An unusual cause of caecal perforation in a child. Afr J Paediatr Surg [serial online] 2009 [cited 2019 Nov 22];6:114-5. Available from: http://www.afrjpaedsurg.org/text.asp?2009/6/2/114/54777

   Introduction Top


Faecolith impaction leading to caecal perforation is a rare cause of acute abdominal pain in children. Caecal perforation is more common in the adult population following, trauma (for example, colonoscopy), inflammatory bowel disease, malignancy, or diverticular disease. [1],[2],[3],[4] In the younger age group, it is most likely caused by acute appendicitis, nonHodgkin's lymphoma, Meckel's diverticulum, or Hirschsprung's disease. [5],[6],[7] It may pose a diagnostic challenge as it closely mimics the pain of acute appendicitis. The diagnosis is usually made at surgical exploration. [8] We describe a case of an otherwise well 11-year-old boy with caecal perforation, clinically diagnosed as acute appendicitis, caused by an impacted faecolith with a normal appendix.


   Case Report Top


An 11-year-old boy was admitted to our hospital via accident and emergency unit with a history of right iliac fossa pain of five hours duration, which was intermittent in character. There was no history suggestive of vomiting or diarrhoea, and no urinary symptoms were observed. Also, no history of constipation was reported. He had a recent upper respiratory tract infection (URTI) with a cough for the past week. He was mildly pyrexial (37.8) and tachycardic with a heart rate of 107 beats per minute. On examination, the right iliac fossa was tender with guarding but no abdominal distension. Laboratory results only revealed leucocytosis with no other abnormalities detected. Urinalysis showed no abnormalities. A clinical diagnosis of acute appendicitis was made.

Laparascopic appendicectomy was performed which was converted to an open laparotomy following the finding of omental cake, and a perforated mass on the caecum. The appendix appeared normal. Intraoperatively, the caecal mass was suggestive of a malignancy. The caecal mass was excised and a right hemicolectomy with primary ileocolic anastomosis was performed [Figure 1]. He was commenced on IV antibiotics for five days. His postoperative course was uneventful and he was well at 12 months follow-up.

Pathology

Microscopically, no transmural inflammation of the appendix was seen. Acute transmural inflammation with abscess formation in the caecum was seen where the faecolith was identified macroscopically [Figure 2]. Acute inflammation extended through the muscle and onto the serosal surface, most probably, representing the site where the omentum was stuck onto the perforated bowel wall. Ganglion cells were present in the appendix and in the specimen.


   Discussion Top


We describe an unusual cause of caecal perforation, not previously reported. At histological examination no mechanism was reported other than faecolith impaction. No diverticulae were identified and the appendix was normal, with ganglion cells present. While there are several causes of caecal perforation in children including acute appendicitis, trauma, and Meckel's diverticulum, none were identified in this case. [5],[6],[7] After evaluation of the clinical picture, investigations and intraoperative and histological findings, we classify this as a caecal perforation caused by faecal impaction. Laplace's law of physics states that the pressure required to stretch the walls of a hollow viscus, decreases in inverse proportion to its radius of curvature. [9] The caecum has the largest diametre of the colon and, therefore, requires the least amount of pressure to distend and perforate. [9] However, there is no mechanism identified, as to why the faecolith impacted at this point. One case report of idiopathic perforation of the bowel was found but this was in a neonate. [10]


   Conclusion Top


Histology confirmed the finding of an impacted faecolith, leading to acute inflammation and perforation of the caecum with no other underlying pathology. Faecolith impaction leading to caecal perforation was found in this child. The aetiology is unknown and is currently not reported in children.


   Acknowledgement Top


We are grateful to Dr. Gould for kindly supplying the pathology images.

 
   References Top

1.Luning TH, Keemers-Gels ME, Barendregt WB, Tan AC, Rosman C. Colonoscopic perforations: A review of 30,336 patients. Surg Endosc 2007;21:994-7.   Back to cited text no. 1    
2.Greenstein AJ, Sachar DB, Mann D, Lachman P, Heimann T, Aufses AH Jr. Spontaneous free perforation and perforated abscess in 30 patients with Crohn's disease. Ann Surg 1987;205:72-6.  Back to cited text no. 2    
3.Tiwary SK, Singh MK, Khanna R, Khanna AK. Case Report Colonic carcinoma with multiple small bowel perforations mimicking intestinal obstruction. World J Surg Oncol 2006;4:63.   Back to cited text no. 3    
4.Hildebrand P, Kropp M, Stellmacher F, Roblick UJ, Bruch HP, Schwandner O. Surgery for right-sided colonic diverticulitis: Results of a 10-year-observation period. Langenbecks Arch Surg 2007;392:143-7.  Back to cited text no. 4    
5.Sai Prasad TR, Chui CH, Jacobsen AS. Laparoscopic appendicentomy in children: A trainee's prospective. Ann Acad Med Singapore 2006;35:694-7.  Back to cited text no. 5    
6.Yanchar NL, Bass J. Poor outcome of gastrointestinal perforations associated with childhood abdominal non-Hodgkin's lymphoma. J Pediatr Surg 1999;34:1169-74.   Back to cited text no. 6    
7.Sai Prasad TR, Chui CH, Singaporewalla FR, Ong CP, Low Y, Yap TL, et al . Meckel's diverticular complications in children: Is laparoscopy the order of the day? Paediatr Surg Int 2007;23:141-7.  Back to cited text no. 7    
8.Griffiths EA, Date RS. Acute presentation of a solitary caecal diverticulum: A case report. J Med Case Reports 2007;1:129.  Back to cited text no. 8    
9.Saegesser F, Chapuis G, Rausis C, Tabrizian M, Sandblom P. Intestinal distension and colonic ischemia: Occlusive complications and perforations of colo-rectal cancers. A clinical application of Laplace's Law. Chirurgie 1974;100:502-16.  Back to cited text no. 9    
10.Yadav SK, Helmi S, Al-Ramadan S. Idiopathic Perforation of Caecum in a Neonate: Case Report. Kuwait Medical Journal 2005;37:47-9.  Back to cited text no. 10    

Top
Correspondence Address:
K Lakhoo
University of Oxford and John Radcliffe Hospital, Headley Way, Oxford OX3 9DU.
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0189-6725.54777

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    Figures

  [Figure 1], [Figure 2]

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    Abstract
    Introduction
    Case Report
    Discussion
    Conclusion
    Acknowledgement
    References
    Article Figures

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