A CASE OF PERFORATIVE APPENDICITIS WITH BILATERAL SUBDIAPHRAGMATIC PNEUMOPERITONEUM

Abstract

A 12-year-old girl was admitted to the hospital with an 8-day history of abdominal pain, nausea and fever. High fever (40°C), marked leukocytosis (12, 700/mm³), and positive CRP (38.1mg/dl) were noted. On physical examination, the abdomen was distended with diffuse tenderness, rebound tenderness and muscle guarding. The maximal tenderness was elicitted in the right lower quadrant. An upright chest X-ray film revealed free air under bilateral diaphragms. Distended small bowel loops were seen on the abdominal X-ray films. There were no leakages of gastrografin on upper GI study. A diagnosis of perforated appendicitis with generalized peritonitis was made. An emergency operation was scheduled. Through a right lower paramedian incision the peritoneum was opened, revealing a considerable amount of purulent exudate which grew out E. coli on culture. Exploration revealed gangrenous appendix with perforation and abscess in the iliocecal area. Appendectomy and drainage of the peritoneal cavity was performed. The postoperative course was uneventful except for the wound abscess. The patient was discharged on the 32th post operative day.
It is extremely rare that perforative appendicitis is associated with peritoneal free air, and only 39 cases (35 cases in the world and four cases in Japan) have been reported since 1960. Some bibliographical comments are also presented.