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Ann Saudi MedAnn Saudi MedAnnals of Saudi Medicine0256-49470975-4466King Faisal Specialist Hospital and Research Centre 10.5144/0256-4947.2006.249asm-3-249What’s Your Diagnosis?Diagnosis: Ruptured Neonatal Appendicitis Mounla Nabil May-Jun 2006 26 3 249 249 Copyright © 2006, Annals of Saudi Medicine2006This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
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The plain radiograph demonstrates the falsiform ligament (Figure 1) which is not normally seen. However, when there is gas in the abdomen, the liver is pushed back from both sides of the ligament. The resulting contrast makes the ligament evident.1 To confirm the impression of pneumoperitoneum, a second plain film of the abdomen was taken while the infant was held in an upright position. It clearly showed the accumulation of gas under the diaphragm (Figure 2). Had the baby been very sick and if she could not be held upright, a cross-table or lateral decubitus x-ray film should have been taken. It would have shown a bubble of gas in the abdomen just under the umbilical stump. This approach is presently recommended so as not to disturb the patient.

Discussion
The infant underwent a laparotomy one hour after noticing the abdominal distension. At the site of the appendix there was foam and bubbles. She underwent appendectomy. Breast milk was withheld and total parenteral nutrition and antibiotics restarted. She had an uneventful postoperative course, gained weight and was discharged 1 month later with a weight of 2 kilograms. Frequently, when abdominal radiographs are taken, the infant is sleeping on his/her back and signs of pneumoperitoneum may not be evident. Focusing on the falsiform ligament could give a clue to the diagnosis. Our differential diagnosis included necrotizing enterocolitis (NEC), ruptured viscus, perforated diverticulosis, accidental entry of a thermometer or catheter into the genital tract.2 NEC was ruled out because of the clinical course and negative laboratory tests. Rectal or vaginal perforations were considered unlikely as we do not use a rectal thermometer or probe in our nursery and as the bladder of the infant was not catheterized. Appendicitis is the most common abdominal condition requiring surgery in children.3 However, a ruptured appendicitis is rare and a ruptured neonatal appendicitis is even more rare. Finally, we would like to alert the reader that the falsiform ligament on the plain X-ray film is a positive sign for the diagnosis of perforation. However, one has to be aware that its absence does not rule out perforation. An acute sense of suspicion will ensure a quick intervention and a happy ending.

Figure 1 Falsiform ligament (arrow) on plain abdominal radiograph.

Figure 2 Pneumo-peritoneum.
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References
1 Field S  Morrison I   The acute abdomen Sutton David   Textbook of Radiology and Imaging 7th Edition Edinburgh Churchill Livingston 2003 663 689 
2 Berseth CL  Poenaru D   Necrotizing Enterocolitis and Short Bowel Syndrome Taeusch  Ballard  Gleason   Avery’s diseases of the Newborn 8th Edition Philadelphia Elsevier Saunders 2005 1123 1133 
3 Muehlstedt SG  Pharm TQ  Schmeling DJ   The Management of Pediatric Appendicitis: A Survey of North American Pediatric Surgeons J Pediatr Surg 2004 39 6 875 879 15185217