Local peritonitis as the first manifestation of Crohn's disease in a child
An 11-year-old girl presented to our hospital with abdominal pain and vomiting lasting 3 days. Her past medical history was uneventful. At the time of presentation the patient was quite unwell and had fever (37.8°C). Clinical examination revealed abdominal tenderness with a positive McBurney sign. She had a white cell count of 15,000 K/ml (neutrophils, 86.2%; lymphocytes, 5.9%) and an erythrocyte sedimentation rate of 25 mm; all other hematological findings were within normal limits. An abdominal ultrasound investigation of the patient revealed the presence of free fluid in the right iliac fossa and an inflamed appendix. The preoperative diagnosis was acute appendicitis, and the child was immediately prepared for surgery. At the operation, pus was found in the right abdominal cavity and the appendix appeared to be swollen, thickened, and covered by inflamed omentum. The adjacent terminal ileum was reddened and edematous. An appendicectomy was performed and a drain was placed in the Douglas space following irrigation of the abdominal cavity. On the 7th postoperative day, the patient developed fever (39°C) and wound infection despite administration of antibiotics. The wound was drained and her clinical condition improved. Nevertheless, on the 11th postoperative day the patient again developed pyrexia (40°C) and enteric discharge from the wound. Histological evaluation of the resected appendix revealed only periappendicular inflammation containing prominent lymphoid follicles. The pus culture from the abdominal cavity revealed Escherichia coli.\nComputed tomography (CT) of the abdomen revealed a pericecal collection, two enterocutaneous fistulae, and two strictures in the ileum, suggesting CD [Figure and ]. A colonoscopy was also performed along with biopsy of the terminal ileum []. The histological findings were typical of those for CD. The patient was managed with total parenteral nutrition, antibiotics, and corticosteroids. Despite this conservative treatment, the child deteriorated and a reoperation was performed on the 45th postoperative day. A mass measuring 5 × 4 cm containing the cecum, terminal ileum, and part of the omentum were noted; probably resulting from postinfectional adhesions. A right limited hemicolectomy including the fistulae and strictures was performed using a stapler, with anastomosis of the macroscopically appearing healthy bowel of the ascending colon and ileum. Histological investigation of the resected specimen confirmed the presence of CD in the terminal ileum. The patient's postoperative recovery was uneventful. The child was followed-up for 1 year and remained asymptomatic thereafter, receiving long-term azathioprine to keep the disease inactive.