Форум РМС

Лечение в Москве - 8 (495) 506 61 01

Лечение за рубежом - 8 (925) 50 254 50

Differential diagnosis of acute appendicitis and acute intestinal infections in children

Differential diagnosis of acute appendicitis and acute intestinal infections in children

Iu.Iu. Sokolov, S.V. Stonogin, E.V. Stantso

Department of Pediatric Surgery, Russian Medical Academy of Continuing Professional Education,

Department of Pediatric Infectious Diseases, Russian Medical Academy of Continuing Professional Education,

Tushino Children’s City Hospital,

Moscow.

This article presents aspects of the differential diagnosis of acute appendicitis (AA) and acute intestinal infections (AII) in children of different ages, their general symptoms and syndromes, the main causes of diagnostic errors, the tactics of surgeons and pediatricians in difficult clinical situations.

The recommendations are intended for pediatricians and surgeons.

Almost in a quarter of pediatric patients the doctors have to differentiate OA and AEI (Iu.F. Isakov 1980). According to our data, 15-27% of admitted patients are consulted by the surgeon annually in the department of acute intestinal infection with abdominal pain (annually from 495 to 891 of 3300 patients admitted to the department of acute intestinal infections).

AA main clinical signs.

AA usually begins acutely but 25% of cases may have subacute condition first (S.Ya. Doletsky).

AA begins as a local inflammatory process, while in most AII pain syndrome is often preceded by toxicosis.

Acute appendicitis in children has a number of features compared to adults, and in some cases is extremely difficult to diagnose. This applies primarily to young children (up to 3 years old) (Iu.F. Isakov, A.F. Dronov, 1980) and children with atypical location of the appendix. The opinion that AA always begins acutely in children of the said age is untrue. The fact is AA can begin acutely, with the child’s anxiety, refusal to eat, whims, etc. Loose stools often accompany AA, especially its complicated forms (periappendicular infiltrates, abdominal abscesses), but they are usually infrequent and do not contain abnormal admixtures (such as blood, mucus, or spinach stool). Loose stools in appendicitis can be caused by a certain location of the inflamed appendix and periappendicular abscess: in the small pelvis on the wall of the sigmoid colon, medially in the abdominal cavity between the loops of the small intestine, retrocecal on the wall of the ascending colon. Loose stools in patients with appendicitis and its complications may also be due to intoxication caused by an inflammatory process in the appendix and surrounding tissues. Children with a hyperergic reaction may have more severe intoxication. In this case, AA proceeds as AII.

Acute appendicitis in older children is more similar to the clinical signs in adults. In most cases, the disease begins with abdominal pain. The pain is permanent, may subside, then intensify and tends to localize. A decrease in its severity in appendicitis may be associated with the burst of the appendix and its enveloping with a large omentum. The faster the appendix is wrapped in a large omentum, the faster the intensity of the abdominal pain syndrome decreases, or the pain can be completely stopped with the complete enveloping in a large omentum. The early disappearance of abdominal pain syndrome without drug therapy should alert surgeons as it may indicate appendicitis and omentitis. Here we report cases with destructive appendicitis, omentitis with no abdominal pain syndrome. Half of the cases have vomiting in AA accompanied by pain but it is not repeated (3-7 times a day). Fever in the range of 37.5-380C. The abdomen is more painless on palpation, develops muscle defense and symptoms of peritoneal irritation.

The role of abdominal ultrasound in the diagnosis of appendicitis in sick children with AII signs.

In our opinion, the ultrasound examination of the abdominal organs plays an important role in the timely diagnosis of AA in the presence of AII. Its role increases in difficult diagnostic cases, when it comes to the atypical location of the appendix, combined pathology and the absence of severe pain syndrome. Although not always the ultrasound results are reliable.

According to our data, the results of ultrasound of the abdominal organs and intraoperative findings in patients with abdominal pain syndrome in combination with acute infectious diseases coincided in 72.9% of cases, were different in 22.4% of cases and were doubtful in 4.7% of cases.

Here are the most interesting case reports. Patient I., 12 years old, was admitted to the department of infectious diseases on 03.10.2007. From 12.9.2007 throughout 03.10.2007 was staying in the Infectious Diseases Hospital No.1 due to acute right-sided pneumonia. The boy received combined antibacterial therapy (amikacin, cefazolin, lincomycin). At the same time, the child complained of non-intense abdominal pain. An ultrasound examination at Tushino Children’s Hospital confirmed signs of appendicitis and periappendicular abscess. Intraoperative findings showed retrocecal location of the appendix in the right lateral canal. The abdominal cavity contained a moderate amount of turbid effusion. The appendix was thickened, hyperemic, covered with fibrin. The postoperative course was uneventful.

Ultrasound examination plays an important role in the diagnosis of appendicitis and its complications in children with a combination of several chronic diseases, in patients with organic damages to the central nervous system, lack of speech contact with the patient, in combination with infectious diseases and long-term antibiotic therapy, atypical location of the appendix in patients with multiple developmental defects. Here is the following case report. Patient T., 4 years old. The girl was admitted to the department of infectious diseases on 11.03.2009 due to ARVI, contact with chickenpox from 28.02.2009, Down’s syndrome, severe mental retardation, hypothyroidism, 1st degree anemia, open foramen ovale. Due to the history, since 03.03.2009 she had received antibacterial therapy (flemoxin, cefazolin) for ARVI and urinary tract infection. On 11.03.2009, she became moody, and her belly increased in size. Stools were scanty. Abdominal ultrasound on 12.03.2009 found a mass lesion 4x5x5 cm in the right iliac region with an adjacent vermiform appendix and an omentum. The abdomen was distended, painful in the right part, where a dense round infiltrate with a diameter of 4 cm was palpable. Leukocytosis 13.9*109/l. Considering the history and the clinical signs, the patient most likely had an appendicular infiltrate, possibly with abscess formation against the background of chronic constipation, and long-term antibiotic therapy. Abdominal palpation under anesthesia led to the indications for surgical treatment. Palpation of the abdomen under anesthesia in the right half revealed a dense non-displaceable infiltrate 7x5 cm. The situation was regarded as abscess of the appendicular infiltrate. The indications for laparotomy had been substantiated. During the surgical procedure, the periappendicular abscess was drained. The appendix could not be visible. The postoperative course was uneventful.  

Laparoscopy in the diagnosis and treatment of AA.

Laparoscopy is currently the most accurate and minimally invasive method for the diagnosis and treatment of AA, especially in patients with acute infectious diseases. In 2005-2007, 70 patients from the department of infectious diseases of the Tushino Children’s Hospital with suspected acute surgical pathology underwent laparoscopy was. In 26 patients, the laparoscopic data coincided with the established clinical diagnosis of acute appendicitis. While 24 patients were found to have mesenteric adenitis, pelvioperitonitis, and other pathologies, which made it possible to avoid appendectomy.

Case report. Patient G., 14 years old, was admitted to Tushino Children’s Hospital on 16.06.2009. His first complaint of abdominal pain was on 15.06.2009, with repeated vomiting, fever 38.40C, multiple loose stools. The boy had pain in the right lower abdomen. The kid is under regular medical check-up with a neuropsychiatrist, immunologist (epilepsy), and also traumatologist for a closed fracture of the bones of the left forearm. During the observation period, the child had a constant abdominal pain syndrome, pain on palpation of the abdomen in the right iliac, with positive symptoms of peritoneal irritation. Abdominal palpation found no mass lesion. Blood test showed leukocytosis 18.8*109/l. Ultrasound findings confirmed the phenomenon of mesenteric adenitis. To exclude appendicitis, diagnostic laparoscopy was recommended. The appendix was not laparoscopically visible. An inflamed area of the omentum is visible in the right lateral canal. Conclusion: destructive appendicitis, omentitis. Indications for laparotomy. Incision was performed in the right iliac region. Moderate amount of purulent effusion was found in the pelvic cavity. The dome of the cecum was exteriorized into the wound. The appendix was not visible. The wound was enlarged laterally and medially. During revision, the appendix was located medially under the mesentery of the small intestine in multiple folds of the peritoneum. An abscess was drained with up to 10 ml of pus with a colibacillary odor in the area of the appendix, and the fecal stone was removed. Retrograde appendectomy was performed using a ligature technique. The length of the appendix was up to 5 cm, dark and perforated. The inflamed omentum was resected. A double-lumen drainage was installed in the small pelvis through the lateral angle of the wound. The postoperative course was uneventful. The patient was discharged after 21 days upon the surgical procedure. This case illustrates the role of laparoscopy in the diagnosis of appendicitis with an atypical location of the appendix (medially under the mesentery of the small intestine) in a patient with multiple concomitant pathology.

AII main clinical signs.

AIIs represent an extensive group of diseases with a large polymorphism of clinical signs: salmonellosis, dysentery, yersiniosis, escherichiosis, enterovirus infections, diseases caused by opportunistic flora, as well as diseases caused by an improper diet.

In AII diagnosis, the most important role belongs to the detailed collection of the epidemiological history, the examination of the patient, the stool characteristics, the type of skin rashes and feces culture data, as well as modern laboratory methods for identifying the causative agents of acute intestinal infections.

The differential diagnosis of AII and AA requires careful collection of history of the disease. First of all, this concerns the pain syndrome, i.e., the nature of pain at the onset and over time, its severity, localization, irradiation, the severity of intoxication (in AII, toxicosis often precedes the pain syndrome), fever, vomiting, the stool characteristics, and other signs of the disease, which will make it possible to diagnose either AA or AII.

Right iliac pain often occurs in typhoid-paratyphoid diseases. In these cases, the roseolous rash typical of typhoid fever and enlargement of the liver and spleen may develop.

Combination of AA and AII.

According to the information of Botkin City Clinical Hospital (1971), 8.6% out of 11,157 patients admitted with a diagnosis of acute intestinal infections were diagnosed with acute surgical pathology. The world literature reports 2.4% of appendectomies in children against the background of signs of acute infectious enteritis.

We managed 12 (0.07%) patients who developed acute destructive appendicitis against the background of acute intestinal infections, confirmed by bacterial tests (coliform stool culture, passive hemagglutination assay (PHAA)). Four patients were diagnosed with acute dysentery (1.7% of all patients with dysentery), 6 - salmonellosis (1% of all patients with salmonellosis), and 2 - yersiniosis (6.6% of all patients with yersiniosis). All 12 patients had invasive acute intestinal infections.

According to Rolshchikov, in abdominal yersiniosis, 27.8% of patients had lesions in their appendix. According to our observations, 3 patients had destructive appendicitis as one of the signs of yersiniosis.

In addition, 132 patients underwent surgery for suspected appendicitis, which found severe mesenteric adenitis against the background of an acute intestinal infection.

Here are the most interesting case reports.

Tania S., 14 years old. Developed an acute disease. The girl complained of abdominal pain. On the same day, she had fever 390C, chills, loose stools for 4 times, vomiting. Took Analgin. The next day, the temperature was 38.50C, loose stools for 8 times, the abdominal pain increased. The girl was referred to the hospital with a diagnosis of acute dysentery(?), acute appendicitis(?). Examined by a surgeon. Hospitalized to the department of infectious diseases. Blood test: Hb137g/l, Leukocytes 10.4*109/l, band neutrophils 30%, segmented neutrophils 58%, lymphocytes 13%, monocytes 4%, ESR 6mm/h. After 3 hours, she was again examined by a surgeon. Diagnostic laparoscopy was recommended. Surgery 48 hours after the onset of the disease. Diagnosis: phlegmonous appendicitis. Salmonella enteritidis, group D, was isolated from feces. The postoperative course was uneventful. The kid was discharged 9 days after surgery.

Katia K., 13 years old. Developed an acute disease. She had chills, fever 390C, abdominal pain, loose stools for 7 times with mucus. The next day, the abdominal pain increased, the temperature was 38.40C. The girl was referred to the hospital for acute gastroenteritis(?) acute appendicitis(?). On admission, the patient was in moderately severe condition. The abdomen was soft, painful on palpation in the lower parts. Examined by a surgeon. The doctor casted doubt upon the diagnosis of acute appendicitis. The kid was referred to the department of infectious diseases. Blood test: Hb139g/l, Leukocytes 17.9*109/l, band neutrophils 15%, segmented neutrophils 31%, lymphocytes 41%, monocytes 4%, ESR 7mm/h. Re-examined by the surgeon. Surgery 48 hours after the onset of the disease. Diagnosis: phlegmonous appendicitis. Shigella Sonne II was isolated from feces. The girl was discharged in satisfactory condition 8 days after the surgical procedure.

Sergei T., 14 years old. Developed an acute disease. The boy had severe abdominal pain, loose stools for 4 times with mucus, chills. Next two days, he had abdominal pain, loose stools, fever 39°C, and vomiting for three times. On the 3rd day of illness, he was hospitalized with a diagnosis of food poisoning. Examined by a surgeon. Referred to the department of infectious diseases. Blood test: Hb130g/l, Leukocytes 12*109/l, band neutrophils 10%, segmented neutrophils 78%, lymphocytes 2%, monocytes 7% PL cells 2, ESR 20mm/h. Re-examined by a surgeon 3 hours later, with suspected acute appendicitis. Ultrasound examination revealed no evidence of appendicitis. Re-examined by a surgeon. Surgery 72 hours after the onset of the disease. Diagnosis: phlegmonous appendicitis. Shigella Sonne II was isolated from feces. The boy was discharged on the 10th day of illness.

The presented case reports demonstrate the complexity of diagnosis in the combined course of AA and AII. In all cases, patients were admitted late, 2-4 days after the onset of the disease; however, all patients had the major symptom, i.e., abdominal pain, and dynamic management by surgeons and infectious disease specialists made it possible to choose the correct treatment tactics.

Causes of late diagnosis of appendicitis

According to the information of the Sklifosovsky Institute, the erroneous diagnosis of acute intestinal infection among patients with acute surgical pathology was observed in 12.7% of cases (E.P. Shuvalova, 1980). Among patients diagnosed with AII, the proportion of non-infectious patients was 40%.

The clinical signs of AII and AA have several common symptoms, such as abdominal pain, loose stools, intoxication, vomiting, fever, which can lead to erroneous diagnosis. The analysis of the cases shows that 25% of them had objective reasons for difficult diagnosis of AA, such as retrocecal, pelvic, subhepatic, intraomental, and medial location of the appendix, as well as the previous intake of broad-spectrum antibiotics (suprax, cedex, sumamed, amoxiclav, augmentin, zinnat, etc.) without preliminary examination of a sick child, analgesics, anti-inflammatory drugs for fever, leukocytosis, etc. The use of modern broad-spectrum antibacterial drugs makes the signs of appendicitis significantly less pronounced, significantly reduce the severity of or completely stop the pain syndrome and increases the timing of the diagnosis of AA and its complications. This is often facilitated by the atypical location of the appendix.

Often there is a careless, superficial examination and insufficient follow-up of the patient by surgeons and infectious disease specialists, an underestimation of the interpretation of laboratory research methods and the possibility of a combined pathology of AII and AA.

The latter may be due to objective reasons: 1) atypical location of the appendix (retrocecal, retroperitoneal, subhepatic, medial, pelvic, intraomental, submesenteric, intramesenteric), 2) abnormal development and position of organs, 3) accompanying diseases, on the other hand - insufficient knowledge of the features of the clinical course of AA in different age groups, underestimation and insufficient attention when collecting history and controlling the course of clinical signs in different periods of the disease, as well as the results of additional examination methods.

The most typical mistakes in the differential diagnosis of acute appendicitis and acute intestinal infections occur when underestimating the history, especially concerning the initial period of a certain disease with neglecting the symptoms characteristic of infectious pathology; when overestimating symptoms such as vomiting and loose stools, which are also possible in acute surgical pathology. The atypical location of the appendix must be considered too; broad-spectrum antibiotics and analgesics should not be taken without indications, otherwise they can change the severity of the initial period of the disease, and thus radically change the clinical signs of the disease.

Causes of late diagnosis of AA:

1. Superficial anamnesis.

2. Lack of observation over time.

3. Exclusion of appendicitis in the emergency department without examination by a senior surgeon.

4. Mild clinical signs with a certain location of the appendix (retrocecal, retroperitoneal, subhepatic, medial, intraomental, sub- or intramesenteric, pelvic).

5. Absence of pain syndrome at the stage of gangrenous changes in the appendix.

6. Overestimation of AII symptoms.

7. Intake of broad-spectrum antibiotics, analgesics, anti-inflammatory drugs without prior examination by surgeons and any additional examinations of patients.

8. Insufficient knowledge of the clinical course of AA by ambulance staff and pediatricians.

9. Underestimation of abdominal pain syndrome in combination with fever and leukocytosis.

10.  Parents’ refusal of surgical treatment with an established diagnosis of acute appendicitis.

AA is most difficult to diagnose when patients have several complicating risk factors: several infectious diseases, antibiotic therapy, the complete absence of pain syndrome, overweight (grade 3-4 obesity), atypical location of the appendix.  Here is a rare and complicated case report. Patient S., 11 years old. Admitted to the department of infectious diseases with abdominal pain, vomiting since 27.02.2009. According to the history, abdominal pain first appeared on 27.03.2009 at 05:00 a.m. Fever 38.30C. The day before he ate pancakes with meat, after which there was a single vomiting. The boy also had a sore throat, signs of lacunar sore throat. During the follow-up, abdominal pain disappeared; abdominal ultrasound was performed. The diagnosis of appendicitis was excluded during follow-up by on-duty surgeons. For lacunar sore throat, the patient was prescribed penicillin. On 02.03.2009, the patient had loose spinach stools. The boy was diagnosed with acute infectious enteritis. The therapy included a broad-spectrum antibiotic rifampicin, 1 capsule 2 times a day. 04.04.2009, re-examined by the surgeon: the abdomen was soft and painless on palpation, without infiltrates. Ultrasound reexamination of the abdominal cavity revealed no fluid or masses. There were no indications for emergency surgery. Treatment of acute intestinal infection was continued. Despite the ongoing antibiotic therapy, the child had a fever up to 37.70C, loose spinach stools with mucus up to 3-4 times a day. The kid had good appetite, no vomiting. The tongue was moist. The abdomen was soft and painless on palpation. Per rectum ampoule was filled with loose spinach feces. The blood test showed an increase in leukocytosis from 17.3 to 36,000/l, ESR from 24 to 40 mm/h, and band neutrophils up to 16%. The patient underwent repeated ultrasound of the abdominal cavity, which found a mass lesion 71x54x77mm at the entrance to the small pelvis, with a liquid component in the center (a festering urachal cyst? abscess? omentitis?). Considering this clinical picture, diagnostic laparoscopy, revision of the abdominal cavity after preparation in the general intensive care unit were recommended. After abdominal palpation under anesthesia, the child was operated on: the appendicular abscess of the third abdominal cavity was drained. The appendix was not visible. The postoperative course was uneventful. This case represents a difficult diagnostic situation when AA proceeds similar to an acute intestinal infection. The reasons for the diagnostic difficulties were the child’s overweight (70 kg), absence of pain syndrome, combined antibiotic therapy, and atypical location of the appendix.

Parents’ unjustified refusal of surgical treatment with an established diagnosis of acute appendicitis.

Case report. Case record No.14708. Patient: I.D. Startsev, 7 years old. Stayed 5 hours in TCCC from 04.05.2009 to 04.05.2009. Complaints of vomiting, loose stools, abdominal pain for 6 hours after diet violation. Fever 37.60С. Blood test on 04.05.2009: Hb 134, RBC 5.1, WBL 14.0, segmented neutrophils 85, lymphocytes 9, monocytes 6, ESR 19, abdominal ultrasound: the liver is not enlarged, the right lobe is 95mm, moderately echoic, homogeneous. Labile bend of the gallbladder. The pancreas is moderately heterogeneous, not enlarged. The spleen is normal. Multiple enlarged lymph nodes at the root of the mesentery. In the right iliac region, there is an aperistaltic tubular structure with a diameter of 13 mm. The bladder is intact. The patient is diagnosed with acute appendicitis, acute infectious gastroenteritis. The mother refused of the recommended surgical treatment, explaining by the desire to do surgical treatment in another medical institution with her doctor friend. 04.05.2009, the child was operated on in another medical institution. Diagnosis: gangrenous appendicitis, peritonitis 1, acute infectious gastroenteritis. This example demonstrates one of the reasons for the late terms of surgical procedures in patients with appendicitis and the development of complications of acute appendicitis (peritonitis).

Summary.

1. The main reason for ‘late’ surgical procedures is unclear clinical signs of AA (due to taking antibiotics, an atypical location of the appendix), leading to subsequent diagnostic and therapeutic defects at all stages of examination and treatment of the patient.

2. Identification of leukocytosis in a blood test over time is mandatory.

3. In case of abdominal pain syndrome, fever of unknown origin, palpable mass in the abdominal cavity, an emergency ultrasound of the abdominal organs must be performed.

4. Emergency laparoscopy is indicated in case of unknown cause of the abdominal pain syndrome and suspected AA.

5. As experience and analysis of case reports show, the optimal observation period for the differentiation of acute appendicitis and acute intestinal infections can be 4-8 hours. In difficult diagnostic cases, repeated ultrasound of the abdominal organs, blood test over time and diagnostic laparoscopy are necessary in case of any doubts of the surgeons.

Medical actions at admission.

1. In case of doubt, the surgeon should consult a senior surgeon, a leading specialist of the clinic.

2. Emergency ultrasound examination.

3. Hospitalization to the surgical department in any doubtful cases with the observance of anti-epidemic measures, follow-up by the surgeon and an infectious disease specialist.

4. In case of exclusion of appendicitis with the persisting abdominal pain syndrome, hospitalization to the department of infectious diseases with joint observation by an infectious disease specialist and a surgeon. Observation for 3-5 hours. If AA cannot be excluded, abdominal ultrasound and emergency laparoscopy should be performed.

5. Express differential diagnosis of acute bacterial intestinal infections (salmonellosis, shigellosis, yersiniosis) and AA is advisable to be performed using modern laboratory techniques (RHAA, LAA, ELISA, IFLA, AA, DFAT, O-aggregate hemagglutination assay, CAA, PCR, CBA, CAA, LAA). The methods are highly sensitive (89.7%) and specific (94.1%).

6. Additional non-invasive methods for the diagnosis of appendicitis and its complications suitable for children with overweight and lack of abdominal pain in the presence of leukocytosis, children under 3 years of age with difficult ultrasound imaging of the appendix are thermography, magnetic resonance imaging and spiral computed tomography of the abdominal cavities.

7. If non-invasive imaging of the appendix is impossible in patients with high risk factors (children under 3 years of age, children with obesity of II-III degree) and without abdominal pain syndrome in the presence of leukocytosis, abdominal palpation under endotracheal anesthesia must be performed.

Abbreviations

ELISA - enzyme-linked immunosorbent assay

IFLA - immunofluorescence assay

AA - acute appendicitis

AII - acute intestinal infection

ARVI - acute respiratory viral infection

PCR - polymerase chain reaction

DFAA - direct fluorescent antibody assay

AT - agglutination test (assay)

RHAA - reverse hemagglutination assay

CBA - complement-binding assay

CAA - coal agglutination assay

References

1. A.B. Baranov. Rational pharmacotherapy of pediatric diseases, Moscow, 2007, Lit-Terra, volume 15, p. 90, 106.

2. Iu.F. Isakov. Acute appendicitis in children, Moscow, Medicine, 1980.

3. S.Ya. Doletsky, V.E. Shchitinin, A.V. Arapova, Complicated appendicitis in children, L., Medicine, 1982.

4. N.D. Iushchuk, L.E. Brodov. Acute intestinal infections: diagnosis and treatment, M., Medicine, 2001.

5. I.M. Rolshchikov, V.I. Antonov. Surgery of abdominal yersiniosis, V., 1984.

6. Timchenko V.N. Infectious diseases in children. St. Petersburg, Spetslit, 2006, p. 268.

7. V.E. Shchitinin, E.V. Stantso, S.V. Stonogin. Differential diagnosis of acute intestinal infections and acute appendicitis, M., 2006.

8. Brockamp G., Peters H. Yersinia enterocolitica infection. On the differential diagnosis of acute lower right-sided abdominal pain. Zentralbl Chir, 1982; 107(18):1154-9.

9.  Hormann M., MR imaging of the gastro-intestinal tract in children. Eur J. Radiol., 2008, Nov; 68(2):271-7. Epub 2008 Aug 31.

10.  Iwanczak B., Stawarski A., Czernik J. Diagnostic difficulties in pediatric abdominal pain with potential appendicitis. Przeql Lek. 2007; 64 Suppl. 3:56-60.

11.  Kazlow P.G., Freed J., Rosh J.R. Salmonella typhimurium appendicitis. J Pediatr Gastroenterol Nutr, 1991 Jul;13(l):101-3.

12. Manganaro A., Impellizzeri P., Manganaro A. Acute abdomen caused by Salmonella typhi acute appendicitis. Minerva Pediatr., 2006 Apr;58(2):203-5.

13. Olinde A.J., Lucas J. F. Jr., Miller R.C. Acute yersiniosis and its surgical significance. South Med J., 1984, Dec;77(12):1539-40.

14. Perdikogjanni C., Galanakis E., Michalakis M. Yersinia enterocolitica infection mimicking surgical conditions. Pediatr. Surg. Int., 2006 Jul;22(7): 589-92. Epub 2006 Jun 13.

15.  Puylaert J.B., Van der Zant F.M., Eur Radiol. Infectious ileocecitis caused by Yersinia, Campylobacter, and Salmonella: clinical, radiological and US findings. 1997;7(l):3-9.

16.  Sybrandy R., Kluin-Nelemans J.C., Yersiniosis as a surgical disease. 1980;32(l):30-3.

  •  Tovar J.A., Trallero E.P., Garay J. Appendiceal perforation and shigellosis. Z Kinderchir, 1983, Dec;38(6):419.

18.  Trammer A., Hecker W.C., Appendicitis in enteritis. Monatsschr Kinderheilkd. 1989 Jul;137(7):422-4.

19. Yabunaka K., Katsuda T., Sanada S., Yatake H. Sonographic examination of the appendix in acute infectious enteritis and acute appendicitis. J. Clin. Ultrasound. 2008 Feb; 36(2):63-6.

20.  Zqanier M., Rote G., Cizmic A, Pajic A. Infectious ileocecitis-appendicitis mimicking syndrome. Bratisl Lek Listy 2005; 106(6-7):201-202.

Information about the authors:

1) Yuri Yurievich Sokolov - Head of S.Ya. Doletsky Department of Pediatric Surgery, Russian Medical Academy of Continuing Professional Education, Doctor of Medical Sciences, Professor. sokolov-surg@yandex.ru Address: department of surgery, 28, Geroev Panfilovtsev Str., Moscow, 125480.

2)  Sergei Vasilievich Stonogin - surgeon, Z.A. Bashlyaev Department of Surgery, Candidate of Medical Sciences. E-mail: svas70@mail.ru,   Address: department of surgery, 28, Geroev Panfilovtsev Str., Moscow, 125480.

3) Evgenia Vitalievna Stantso - Pediatrician, Board Certified, Candidate of Medical Sciences. Associate Professor, Department of Infectious Diseases, Russian Medical Academy of Continuing Professional Education