Bratisl Lek Listy 2005; 106 (6–7): 201 – 202 201

CLINICAL STUDY

Infectious ileocecitis – appendicitis mimicking syndrome

Zganjer M, Roic G, Cizmic A, Pajic A

Department of Pediatric Surgery, Children’s Hospital Zagreb, Croatia.mirko.zganjer@zg.htnet.hr

Abstract

The purpose of our study is to emphasize the central role of ultrasound (US) in finding the cause of
abdominal pain in children. Ultrasound of the lower abdomen quadrant should be considered in all
cases in which the clinical signs and symptoms are not diagnostic of appendicitis. There is a wide range
of clinical syndromes and diseases which can easily be diagnosed using a high resolution ultrasound
with adjunct of color and power Doppler. The spectrum of abnormalities includes appendicitis, mesen-
teric lymphadenitis, infectious ileocecitis, Crohn’s disease, intussusception, ovarian cysts, and encysted
cerebrospinal fluid. One of the most common causes of acute abdominal pain in children is acute ter-
minal ileitis (infectious ileocecitis) with mesenteric lymphadenitis. Ultrasound is the best tool to rapidly
differentiate this disease from acute appendicitis, and prevent unnecessary laparotomy (Ref. 12).
Key words: infectious ileocecitis, ultrasound, children.

It is well known that the bacteria Yersinia enterocolitica (1,
2), Campylobacter jejuni (3), Salmonella enteritidis (4, 5) and
Shigellae species are responsible for most cases of acute food
poisoning and are important causes of diarrhea in humans. It is
less known that the same microorganisms can also cause right
lower abdominal pain with appendicitis-mimicking syndrome.
In these patients pain is the predominant symptom, and diarrhea
is absent or only mild. We usually perform ultrasound in every
patient with abdominal pain except when the clinical signs and
symptoms, and laboratory test results clearly show that immedi-
ate exploratory laparotomy is necessary.
This study reflects three years of our experience with infec-
tious ileocecitis and describes its clinical, microbiological, ra-
diological and sonographic findings (6).
Materials and methods
It is well known that acute abdominal pain in the lower ab-
dominal quadrants is a common problem in pediatric surgery
because it may be a symptom of acute abdomen. The aim of our
study was to describe and establish ultrasound as a method of
diagnosing acute appendicitis.
We analyzed 2000 patients that presented with lower abdomi-
nal pain, in the last three years. Physical examination, standard
laboratory tests were done in all cases, and stools were collected
for microbiological analysis in the patients with accompanying
diarrhea. Ultrasound was performed in all patients with an agenda
to prevent unnecessary laparotomy.
Results
Medical history, physical examination and laboratory tests
in infectious ileocolitis are generally the same as in acute appen-
dicitis. The predominant symptom is acute or subacute pain in
the lower right part of the abdomen. Some clinical clues may
suggest the correct diagnosis and, with experience, mistakes were
made very rarely.
In this group of patients, we performed 1208 (60.4 %) appen-
dectomies over a period of 3 years. In the same period 792 (39.6 %)
patients were not operated on and were treated conservatively. 296
patients, 37.3 % of the ones treated conservatively, had infectious
ileocecitis. There were 165 female and 131 male patients. The
children were between 3 years and 15 years old (9.8 years old on
average). 497 patients, 62.7 % of the ones with conservative treat-
ment, had pneumonia, ovarian cysts, mesenteric adenitis, lower
urinary tract infections, unrecognized trauma and etc.
Department of Pediatric Surgery, Children’s Hospital Zagreb, Croatia,
and Department of Radiology, Children’s Hospital Zagreb, Croatia
Address for correspondence: M. Zganjer, MD, Dept of Pediatric Sur-
gery, Children’s Hospital Zagreb, Klaiceva 16, 10000 Zagreb, Croatia.
Phone: +385.1.4600227
202 Bratisl Lek Listy 2005; 106 (6–7): 201 – 202
The sonographic hallmark of infectious ileocecitis is symmetri-
cal mural thickening of terminal ileum and cecum (7, 8, 9). Cen-
tral echogenicity of the inflamed mucosa or air within the lumen is
present. The sonographic thickening of terminal ileum and cecum
is confined to mucosa and submucosa without the involvement of
tunica muscularis, serosa or the surrounding fatty tissue. Enlarged
mesenteric lymph nodes are usually present. Most of the mesen-
teric lymph nodes were found in the region right to the umbilicus,
both cranially and caudally. Peristalsis was weakened, but not ab-
sent. Diameter of the appendix was 5 mm or less.
In patients with infectious ileocecitis in whom severe diarrhea
was present, colonic wall thickening extended more distally in the
colon. In infectious ileocecitis ileum and cecum were never sur-
rounded by inflamed, hyperechogenic noncompressible fat. We
had approximately 2 patients every week with infectious ileocecitis.
In the specimens of the stools collected for microbiological analy-
sis, within a period of 3 years, there were 87 positive cultures. We
found that only Salmonella enteritidis is a likely cause of ileocecitis.
There are a couple of reasons for this:
1) Since diarrhea was usually absent or mild, stool cultures
were not always requested.
2) Campylobacter and Yersinia require special culture tech-
niques and must be specifically searched for in the stool - this is
not a part of our everyday procedures.
3) Sometimes diarrhea occurred when children were already
at home and treated symptomatically and so the stool cultures
were not done.
Discussion
Infectious ileocecitis is a common problem in pediatric sur-
gery because it mimics acute abdomen. Sonography is currently
the best tool to rapidly differentiate this disease from acute ap-
pendicitis and prevent unnecessary laparotomy.
In the period of three years, we have performed 115 unnec-
essary laparotomies (9.51 % of the total number of surgical in-
terventions), when the sonographic diagnosis was appendicitis,
but laparotomy revealed only mesenteric adenitis.
It is unnecessary to say that if other signs of acute abdomen are
clear and it is not possible to perform an ultrasound at that moment,
for any reason, laparotomy is absolutely indicated. In our opinion,
it is not necessary to peform CT examinations or barium studies
because ultrasound is sufficient for establishing the diagnosis (only
9.51 % false positive results). Ultrasound is a method of choice
in detection of inflammatory diseases in lower abdomen. Ac-
cording to our experience ultrasound should be routinely used in
every abdominal pain before indicating operative treatment (12).
1) Pain in infectious ileocecitis is in most cases intermittent
and colicky in nature.
2) Diarrhea is usually mild or absent.
3) During physical examination local tenderness on pressure
is often less prominent than in appendicitis.
4) In infectious ileocecitis white cell count is elevated slightly,
just as in appendicitis. White cell counts were between 5.4—
14.8 (average 8.6).
5) Clinical signs in patients with infectious ileocecitis are
not so alarming that immediate explorative laparotomy is neces-
sary. In approximately half of the patients symptoms are rela-
tively mild, and it is possible to wait for the further course of
development of the disease.
6) The erythrocyte sedimentation rate (ESR) was consider-
ably higher in infectious ileocecitis than in acute appendicitis.
In a couple of cases where the symptoms were more acute
and alarming we proceeded with surgical treatment immediately.
When laparotomy was done, we found normal appendix with
enlarged mesenteric lymph nodes, torsion of ovary, torsion
of ovarian cyst, or intussusception. In the cases of non-operative
treatment, antibiotic therapy was usually not necessary (antibi-
otics were administered only to patients with additional diseases).
In 24 cases we had sonographic diagnosis of infectious ileo-
cecitis, but decided to perform an appendectomy anyway, be-
cause the patients had very strong pain in the right lower abdo-
men, tenderness at Mc Burney’s point and leukocytosis. In 9
cases acute appendicitis was present, and in 15 cases infectious
ileitis with mesenterial adenitis was found.
In only 32 patients with infectious ileocecitis we used antibi-
otics because these children had additional disease (pneumonia,
low urinary infection, upper respiratory infection etc.) (10, 11.)
In 115 patients we had sonographic diagnosis as appendici-
tis and mesenteric adenitis, without elevated white cell count
and with only slight abdominal pain. We performed laparotomy,
on the basis of because we trusted the ultrasound, however, only
mesenteric adenitis was detected.
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Received February 15, 2004.
Accepted May 20, 2005.