Upon preoperative diagnosis of acute small bowel obstruction, without an obvious cause, acute perforative appendicitis must be considered. Reevaluation of the history and careful reexamination of the physical findings with that diagnosis in mind should be carried out. If appendiceal disease is likely, maximum antibiotic therapy must be begun immediately along with the administration of fluids, electrolytes and other corrective therapy. A mercury-weighted small bowel tube should be inserted and every effort made to advance it into the small bowel before operation. Operative treatment should be restricted to the least possible. A McBurney incision is best unless wider operation is indicated. If an abscess is present, drainage alone may be the procedure of choice. Severely distended and decompensated small bowel must be decompressed, for if not relieved it can be the cause of death in acute perforative appendicitis. Decompression may be accomplished either by small bowel intubation with continuous suction or by enterotomy and aspiration. If not relieved, small bowel distention will be the mechanism responsible for death in a large percentage of patients with acute perforative appendicitis.
Acute appendicitis, as well as intestinal obstruction, is a common surgical emergencies. Both the conditions can present as an acute abdomen, however the diagnosis of acute appendicitis can be overlooked when it presents as a small bowel obstruction. Difficulties in correctly identifying the cause of pain can be hazardous to the patient and care needs to be taken in obtaining a prompt and accurate diagnosis enabling the most appropriate management. Appendiceal duplication although rare and difficult to diagnose preoperatively, should be checked while operating for appendicular pathology in order to avoid serious clinical and medicolegal implications.
We hereby report a case of appendiceal duplication presenting as small bowel obstruction with one appendix having acute appendicitis and the other one perforated in the middle third.
Meckel's diverticulum is a rare congenital abnormality arising due to the persistence of the vitelline duct in 1–3% of the population. Clinical presentation is varied and includes rectal bleeding, intestinal obstruction, diverticulitis and ulceration; therefore diagnosis can be difficult.
PRESENTATION OF CASE
We report a case of acute appendicitis complicated by persistent post operative small bowel obstruction. Further surgical examination of the bowel revealed an non-inflamed, inverted Meckel's diverticulum causing intussusception.
Intestinal obstruction in patients with Meckel's diverticulum may be caused by volvulus, intussusception or incarceration of the diverticulum into a hernia. Obstruction secondary to intussusception is relatively uncommon and frequently leads to a confusing and complicated clinical picture.
Consideration of Meckel's diverticulum although a rare diagnosis is imperative and this case raises the question “should surgeons routinely examine the bowel for Meckel's diverticulum at laparoscopy?”
Meckel's diverticulum; Acute appendicitis; General surgery; Paediatric surgery
Rapunzel syndrome is a rare type of presentation of trichobezoar, an extension of hair fibers into the small bowel and rarely beyond the ileocecal valve. Its clinical presentation is deceptive ranging from abdominal mass to symptoms of obstruction. We report a 8-year-old girl admitted with a history of abdominal pain and vomiting off and on for a period of 1 year. Ultrasound findings were suggestive of subacute intestinal obstruction. On laparotomy, trichobezoar was found in the stomach extending into small bowel and was removed. Appendix was inflammed hence it was also resected. Microscopic evidence of a hair shaft was seen in the appendix indicating appendicitis was due to luminal obstruction by hair concretions.
Rapunzel syndrome; trichobezoar; appendicitis
Acute appendicitis is a common surgical problem however the diagnosis is often overlooked when it presents as a small bowel obstruction. In this report we present two cases of elderly patients who presented with small bowel obstruction and raised inflammatory markers. Both patients were successfully treated with a laparotomy, adhesiolysis and appendicectomy and went on to make a good recovery.
The authors suggest that the small bowel be assessed in all appendectomy cases for a pathological Meckel's diverticulum.
Meckel's diverticulum is a congenital anomaly resulting from incomplete obliteration of the omphalomesenteric duct. The incidence ranges from 0.3% to 2.5% with most patients being asymptomatic. In some cases, complications involving a Meckel's diverticulum may mimic other disease processes and obscure the clinical picture.
This case presents an 8-year-old male with abdominal pain, nausea, and vomiting and an examination resembling appendicitis.
A CT scan revealed findings consistent with appendicitis with dilated loops of small bowel. During laparoscopic appendectomy, the appendix appeared unimpressive, and an inflamed Meckel's diverticulum was found with an adhesive band creating an internal hernia with small bowel obstruction. The diverticulum was resected after the appendix was removed.
The incidence of an internal hernia with a Meckel's diverticulum is rare. A diseased Meckel's diverticulum can be overlooked in many cases, especially in those resembling appendicitis. It is recommended that the small bowel be assessed in all appendectomy cases for a pathological Meckel's diverticulum.
Meckel's diverticulum; Appendicitis; Laparoscopic; Internal hernia; Omphalomesenteric duct; Small bowel obstruction
Acute appendicitis is a rare complication of colonoscopy that has been reported only 12 times in the English-language literature and is usually associated with obstruction of the appendiceal lumen with fecal matter during colonoscopy. None of the previous reports have described findings of perforation of the appendix within 24 hours of colonoscopy.
We present the case report of a patient who underwent urgent laparotomy within 16 hours of colonos-copy for findings of free intraabdominal air and peritonitis from acute perforated appendicitis.
Laparoscopy confirmed 2 perforations of the appendix and diffuse peritonitis. Laparotomy was necessary to perform appendectomy, exclude a right colonic injury, and control intraabdominal sepsis.
In patients with abdominal pain who have had a recent colonoscopy, a high index of suspicion is necessary for accurate diagnosis of perforated appendicitis. Perforation can occur hours after colonoscopy even when a biopsy is not performed.
Perforated appendicitis; Colonoscopy
A villous adenoma is an extremely rare benign tumour in the appendix, in contrast to other benign appendiceal lesions. The clinical features are usually asymptomatic. Acute appendicitis is the most common complication with the lesion obstructing the orifice of the appendiceal lumen. Thus, a villous adenoma is usually found during surgical intervention for acute appendicitis. Mechanical obstruction induced by acute perforated appendicitis has been previously reported. Acute appendicitis caused by a villous adenoma presenting with acute intestinal obstruction has not been previously reported.
A 78-year-old woman presented to our Emergency Department with diffuse abdominal pain and tenderness. The abdominal plain film and computed tomography revealed an intestinal obstruction. After surgical intervention, the ruptured appendix was shown to be associated with intestinal obstruction. The post-operative pathologic diagnosis was an appendiceal villous adenoma.
This is the first report describing an appendiceal villous adenoma, which is an occasional cause of perforated acute appendicitis, presenting as a complete intestinal obstruction. We emphasize that in elderly patients without a surgical history, the occult cause of complete intestinal obstruction must be determined. If an appendiceal tumour is diagnosed, an intra-operative frozen section is suggested prior to selecting a suitable method of surgical intervention.
From an analysis of a recent series of 99 cases of acute perforated appendicitis in childhood several conclusions appeared valid.
1. The majority of infants and young children with acute perforated appendicitis do not exhibit the signs of localization of peritoneal irritation so characteristically seen in older children and adults. Hence if a history compatible with acute perforated appendicitis is present and there is evidence of peritoneal irritation on repeated examinations, patients of this age group may be assumed to have the disease and should be prepared and operated upon with minimal delay. Early operation after a maximum of several hours of preparation with parenteral hydration, nasogastric suction and antibiotics is the treatment of choice.
2. In nine patients in the present series with temperature and rapid pulse that did not fall to safe levels with the usual preoperative preparation, mild hypothermia appeared to reduce the risk of anesthesia and operation.
3. The use of intraperitoneal drains in children with acute perforated appendicitis is associated with a definite reduction in the incidence of postoperative intraperitoneal abscesses and with a probable reduction in the number of serious wound infections.
A 71-year-old man was diagnosed with an aggressive mantle cell lymphoma and was started on six cycles of R-CHOP chemotherapy. Approximately two weeks after starting his first cycle of chemotherapy, he complained of severe right lower quadrant abdominal pain, and an abdominal CT scan demonstrated an enlarged appendix with evidence of contained perforation. The man underwent open appendectomy for acute appendicitis and recovered. The appendectomy specimen was submitted for routine pathological analysis. There was histologic evidence of perforation in association with an inflammatory infiltrate with fibrin adhered to the serosal surface; scattered small lymphoid aggregates were present on the mucosal surface. Although the lymphoid aggregates in the submucosa and lamina propria were rather unremarkable by routine histologic examination, immunohistochemistry revealed the lymphocytes to be predominantly Cyclin D1-overexpressing B cells. To our knowledge, this is the first reported case of acute appendicitis in association with appendiceal involvement by mantle cell lymphoma.
Complications due to diagnostic colonoscopy are uncommon and acute appendicitis is a very rare complication of colonoscopy. This poses a diagnostic challenge as the presentation of appendicitis is similar to that of other complications of colonoscopy such as perforation or postpolypectomy syndrome. It is hypothesized that postcolonoscopy appendicitis might be associated with obstruction of the appendiceal lumen with fecal matter during colonoscopy. None of the previous reports in the literature have described findings of appendicitis after colonoscopy in a patient with active ulcerative colitis. We present a case of a 28 year-old man with active ulcerative colitis who underwent colonoscopy and subsequently developed acute appendicitis.
Postcolonoscopy appendicitis; Ulcerative colitis; Complications; Colonoscopy
Isolated superior mesentericveinous thrmbophlebitis is a rarely recognised condition associated with a high morbidity. It usually develops secondary to infection in the drainage area of the portal venous system, like appendix.
PRESENTATION OF CASE
We report a case of neglected perforated acute appendicitis complicated by superior mesenteric venous pyelephlebitis patiant represented with a vague pain to right of umlicus, which is atypical this why cat scan was done and showed obstructed superiormesentric vein, portal vein was free with acute appendicitis. Appendicectomy and treatment with broad-spectrum antibiotics, anticoagulation, and platelets led to a full recovery. Follow-up imaging after one month revealed complete canalization of superior mesentric vein.
Abdominal pain if atypical like our case report need imaging diagnosis. Modern diagnostic imaging techniques help the early diagnosis of acute phase pylephlebitis. CT can detect primary source of infection, extent of pylephlebitis, CT scan is the most reliable initially. Ultrasound scan with color flow Doppler is also a sensitive test for confirming partial patency of the portal vein and portal vein thrombosis accidentally discovered complete obliteration of superior mesenteric vein with thrombosis which remained not propagated by serial Doppler ultrasound of liver.
Appropriate treatment should be initiated as soon as possible. To avoid extension to portal vein. The principal treatment for pylephlebitis is to remove the source of infection as appendicectomy.
Anticoagulants must be used. Regarding the treatment of portal thrombosis, post operative use of heparin has been advocated.
Cat scan play an important role in case of atypical abdominal pain.
Thrombophlebitis; Thrombophlebosis; Portapyemia; Appendicitis
Intestinal obstruction is a common surgical emergency caused by varied conditions. Appendicitis as a cause is both uncommon and unsuspected. Strangulation of intestine caused by appendicitis is extremely rare with very few cases reported in literature. The diagnosis of such a condition is possible only on table, with CT having questionable value. This is a very rare and dangerous complication of a very common disease which can easily be overlooked. Every emergency surgeon needs to be aware of such a possibility.
We report a case of a 24 year old male presenting with classical features of intestinal obstruction. On laparotomy strangulated bowel was seen and appendix was found to be the cause. Although we obtained a history of appendicitis in this patient, it was not correlated to the present condition due to the rarity of such a scenario. We reviewed literature to find similar cases reported in the past.
A study has been made of the influence of age and sex on the incidence of cases of appendicitis and of fatal appendicitis in children and young adults. Appendicitis is uncommon in children under the age of 5, but the proportion of cases complicated by peritonitis is large, and the death rate in the population of this age is relatively high. Appendicitis is very common in adolescents, but here the proportion of cases complicated by peritonitis is small. However, because of the frequency of the condition, the death rate in the general population of this age is high, with a maximum at about the age of 15 years.
These findings are compatible with the suggestion that the appendix during the 'teens is particularly liable to obstruct and hence to become inflamed because of the large proportion of lymphoid tissue which it contains.
Inflammation of the appendix is more common in males than in females, and this male excess is greater in infants and pre-school children than it is in children of school age.
The general consensus is that appendicitis is basically provoked by fecaliths or lymphoid hyperplasic obstruction. Several studies based on histological diagnosis have not confirmed this hypothesis. On the contrary, obstruction has been proved in only a minority of cases. Diverse infections by parasites, bacteria, fungus, and noninfective agents have been associated with appendicitis in the medical literature. We describe a firefighter, who ingested a small quantity of leachate from decomposing corpses while working and developed enteritis a few hours later, which lasted several days and evolved to appendicitis. This case raises the possibility that the high quantity of bacteria concentration present in the leachate could have provoked enteritis and the subsequent appendicitis due to a direct effect of the bacteria on the appendix.
A case of carcinoma of the caecum is reported, which presented as acute appendicitis, although the carcinoma did not obstruct either the lumen of the appendix or the colon. The prognosis for caecal or proximal colonic neoplasm presenting as appendicitis is poor. This is in part due to the association being missed at the initial laparotomy. It is suggested that a more aggessive attitude should be taken in the pre- and post-operative management of any patient over 50 years of age who presents with appendicitis. The difficulties of identifying a small tumour at laparotomy even if the mucosa can be palpated are emphasized.
This study evaluated the feasibility of a laparoscopic approach in children with generalized peritonitis secondary to perforated appendicitis.
Materials and Methods
We retrospectively analyzed the medical records of patients who underwent laparoscopic appendectomy with drainage for generalized peritonitis secondary to perforated appendicitis at our hospital between September 2001 and April 2012. Laparoscopic outcomes were compared with outcomes of an open method for perforated appendicitis.
Ninety-nine patients underwent laparoscopic appendectomy (LA) for generalized peritonitis from perforated appendicitis, and 87 patients underwent open appendectomy (OA) for perforated appendicitis. Wound infection was more common in the OA group (12.6%) than in the LA group (4.0%; p=0.032). The incidence of intestinal obstruction during long-term follow-up was significantly higher in the OA group (4.6% vs. 0.0% in the LA group; p=0.046). LA was possible in most patients for whom LA was attempted, with a conversion rate of 10.8%. Conversion to OA was affected by the preoperative duration of symptoms and the occurrence of intraoperative complications.
LA is feasible for use in children with generalized peritonitis from perforated appendicitis, with reasonable open conversion and perioperative complication rates comparable to those of the OA group.
Appendicitis; peritonitis; laparoscopy; children
Perforation caused by capsule endoscopy impaction is extremely rare and, at present, only five cases of perforation from capsule endoscopy impaction are reported in the literature.
We report here two cases of patients with undiagnosed small bowel stenosis presenting with acute perforation after capsule endoscopy. Strictures in the small bowel were likely the inciting mechanism leading to acute small bowel obstruction and subsequent distension and perforation above the capsule in the area of maximal serosal tension.
Case 1 was a 55-year-old Italian woman who underwent capsule endoscopy because of recurrent postprandial cramping pain and iron deficiency anemia, in the setting of negative imaging studies including an abdominal ultrasound, upper endoscopy, colonoscopy and small bowel follow-through radiograph. She developed a symptomatic bowel obstruction approximately 36 hours after ingestion of the capsule. Emergent surgery was performed to remove the capsule, which was impacted at a stenosis due to a previously undiagnosed ileal adenocarcinoma, leading to perforation.
Case 2 was a 60-year-old Italian man with recurrent episodes of abdominal pain and diarrhea who underwent capsule endoscopy after conventional modalities, including comprehensive blood and stool studies, computed tomography, an abdominal ultrasound, upper endoscopy, colonoscopy, barium enema and small bowel follow-through, were not diagnostic. Our patient developed abdominal distension, acute periumbilical pain, fever and leukocytosis 20 hours after capsule ingestion. Emergent surgery was performed to remove the capsule, which was impacted at a previously undiagnosed ileal Crohn’s stricture, leading to perforation.
The present report shows that, although the risk of acute complication is very low, the patient should be informed of the risks involved in capsule endoscopy, including the need for emergency surgical exploration.
Gallstone ileus is an uncommon complication of cholelithiasis but an established cause of mechanical bowel obstruction in the elderly. Perforation of the small intestine proximal to the obstructing gallstone is rare, and only a handful of cases have been reported. We present two cases of perforation of the jejunum in gallstone ileus, and remarkably in one case, the gallstone ileus caused perforation of a jejunal diverticulum and is to the best of our knowledge the first such case to be described.
A 69 year old man presented with two days of vomiting and central abdominal pain. He underwent laparotomy for small bowel obstruction and was found to have a gallstone obstructing the mid-ileum. There was a 2 mm perforation in the anti-mesenteric border of the dilated proximal jejunum. The gallstone was removed and the perforated segment of jejunum was resected.
A 68 year old man presented with a four day history of vomiting and central abdominal pain. Chest and abdominal radiography were unremarkable however a subsequent CT scan of the abdomen showed aerobilia. At laparotomy his distal ileum was found to be obstructed by an impacted gallstone and there was a perforated diverticulum on the mesenteric surface of the mid-jejunum. An enterolithotomy and resection of the perforated small bowel was performed.
Gallstone ileus remains a diagnostic challenge despite advances in imaging techniques, and pre-operative diagnosis is often delayed. Partly due to the elderly population it affects, gallstone ileus continues to have both high morbidity and mortality rates. On reviewing the literature, the most appropriate surgical intervention remains unclear.
Jejunal perforation in gallstone ileus is extremely rare. The cases described illustrate two quite different causes of perforation complicating gallstone ileus. In the first case, perforation was probably due to pressure necrosis caused by the gallstone. The second case was complicated by the presence of a perforated jejunal diverticulum, which was likely to have been secondary to the increased intra-luminal pressure proximal to the obstructing gallstone.
These cases should raise awareness of the complications associated with both gallstone ileus, and small bowel diverticula.
Bacteria were isolated from 153 (47·5%) swabs of the appendix fossa in 322 patients undergoing appendicectomy. The commonest organism was Bacteroides species found in 78% of specimens. Other Gram-negative bacilli such as Klebsiella, or Enterobacter, and Esch. coli were present in 29 and 27% respectively. Gram-positive cocci were less frequently isolated.
A positive culture was obtained more commonly in perforated appendicitis (79%) than where chronic fibrosis, lymphoid hyperplasia, or acute appendicitis was present or when the appendix was normal. Bacteroides was isolated twice as often in perforated appendicitis.
The incidence of wound infection was 19% and varied according to the state of the appendix, being 63% in perforated appendicitis and 9·5% where lymphoid hyperplasia was present. Bacteroides was isolated from over 90% of the wound infections.
In the patients with perforated appendicitis where effective chemotherapy was given the incidence of wound infection was 15% whereas in untreated or inappropriately treated patients it was over 50%.
The isolation of bacteroides requires special precautions to be taken both in the collection of the specimen and laboratory culture. It is important that the chemotherapy of postappendicectomy infections include an antibiotic active against bacteroides.
Gastrointestinal perforation due to a foreign body is not unknown. The foreign body often mimics another cause of acute abdomen and requires emergency surgical intervention. The majority of patients do not recall ingesting the foreign body. Perforations have been reported to occur in a pathologically abnormal colon.
We report an interesting case of a 47-year-old Caucasian man who had a perforation of the sigmoid colon caused by an ingested chicken bone mimicking acute appendicitis. Our patient presented with right iliac fossa pain and local tenderness. When a laparotomy was performed, a chicken bone was found protruding through the sigmoid colon, which was found to lie in the right iliac fossa, thus mimicking acute appendicitis. Our case is different from previously reported cases in that perforation occurred in a non-pathological colon.
Our case emphasises the fact that the operating surgeon has to be aware of various differential diagnostic possibilities which mimic acute appendicitis. This has implications on the training of junior surgeons who are often involved in performing these procedures, and may do so out of hours. Care needs to be taken while obtaining consent for the necessary operation.
Colonoscopy is a widely used diagnostic and therapeutic modality with a relatively low morbidity. However, given the large volume of procedures performed, awareness of the infrequent complications is essential. Perforation is an established complication of colonoscopy, and can range from 0.2%-3% depending on the series, population and modality of colonoscopy. Acute appendicitis after colonoscopy is an extremely rare event, and a cause-effect relationship between the colonoscopy and the appendicitis is not well documented. In addition, awareness of this condition can aid in prompt diagnosis. Relatively mild symptoms and exclusion of bowel perforation by contrast studies do not exclude appendicitis from the differential diagnosis for post-colonoscopy pain. In addition to the difficult diagnosis inherent to postcolonoscopy appendicitis, treatment strategies have varied greatly. This paper reviews these approaches. We also expand upon prior articles by giving guidance for the role of nonoperative management in these patients. This case and review of the literature will help to create awareness about this complication, and guide optimal treatment of pericolonoscopy appendicitis.
Colonoscopy complications; Appendicitis
Common complications of Henoch-Schönlein purpura (HSP) that lead to surgical intervention include intussusception, perforation, necrosis, and massive gastrointestinal bleeding. Acute appendicitis is rarely seen as a complication of HSP. A seven-year-old boy was admitted for arthralgia, abdominal pain, hematochezia, melena, and purpuric rash on the lower extremities. On admission day abdominal ultrasonography was normal, but on day 5, he became pyrexial and developed right iliac fossa pain and tenderness with guarding. Ultrasonography showed distended appendix surrounded by hyperechoic inflamed fat. On exploration an acutely inflamed, necrotic appendix was removed and grossly there was an appendiceal perforation in the appendiceal tip. Microscopically some of the small blood vessels in the submucosa showed fibrinoid necrosis with neutrophilic infiltrations. The authors report the case of a child who developed acute perforative appendicitis requiring appendectomy while on treatment for HSP.
Purpura, Henoch-Schoenlein; Appendicitis; complications
The urachus is a vestigial structure between the dome of the bladder and the umbilicus. Tumors may develop from the remnants, most of which are well-differentiated, mucinous adenocarcinomas. Urachal adenocarcinoma is an exceedingly rare type of tumor.
We present a case of a 51-year-old female presenting to our institution with complaints of abdominal pain for 36 hours. The patient was taken to the operating room for an acute appendicitis. Laparoscopy was performed, and gross purulence and appendiceal perforation were noted as well as a mass on the anterior abdominal wall. Based on the location of the mass, we converted to an open midline laparotomy to treat both the perforated appendicitis and to remove the mass.
Pathology confirmed the diagnosis of perforated appendicitis and a mucinous-producing urachal adeno-carcinoma.
Data support both open and laparoscopic approaches for appendicitis. This case, although rare, highlights the importance of laparoscopy in a complete and thorough examination of the abdominal cavity. A standard right lower quadrant incision for an open technique would likely have resulted in omission of this lesion, and the patient would have presented at a more typical late stage of her cancer development with significantly more morbidity.
Urachal adenocarcinoma; Ruptured appendicitis; Laparoscopy
Acute appendicitis was once thought to be rare among rural blacks. It is now known that appendicitis is relatively common among Africans and in Africa. At the University College Hospital, Ibadan, Nigeria, appendicitis is the most common cause of acute abdomen on the surgical service.
One hundred and eighty-one cases of appendicitis were operated on in a two-year period from June 1975 to June 1977. A retrospective analysis of 47 fully documented cases showed that wrong diagnosis occurred more often in females than in males. There was a high incidence of perforation (31.9 percent) in this series. Deaths occurred in perforated cases and cases complicated by typhoid perforation of the terminal ileum. Parasites and their ova were often present in the lumen of some appendices.
The age group most affected was 16 to 20 years. This disease affected low, middle and upper income groups in our society. Chronic, recurrent appendicitis was frequently diagnosed (31.9 percent) and history of recurrent right lower quadrant pain as far back as three months was often elicited from these patients.