One day history of RIF pain associated with nausea and vomiting.
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The appendix is prominently distended with a large fecolith located at the base and several more located at the tip. While there is mild inflammatory change at the base, rest of the fat surrounding the appendix is within normal limits. There is no evidence of perforation.
There is also small hiatus hernia and previous gastric sleeve surgery.
Interestingly, the patient felt a 'pop' following transfer to the ward and the pain was uncontrollable since. This was associated with rebound tenderness on palpation which was different from original examination findings. This raised the suspicion of a ruptured appendix and the patient was shortly taken to theater.
Laparoscopic appendectomy showed perforated appendix adjacent to a large fecolith at the base. This was associated with four quadrant pus which required a large washout to reduce the risk of postoperative abscess formation. Histology confirmed acute appendicitis.