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Acute appendicitis and post-operative ileus

Case contributed by Vikas Shah
Diagnosis almost certain

Presentation

Abdominal pain, started off mid-abdomen and now localizing to right lower quadrant. Raised inflammatory markers.

Patient Data

Age: 35 years
Gender: Male

Appendix lies medial to cecum, is distended with wall thickening and with surrounding fat stranding. No fluid collections. No pneumoperitoenum. Findings consistent with uncomplicated acute appendicitis.

Appendectomy performed. Abdominal distension, vomiting and raised inflammatory markers on day 3 following surgery.

CT 3 days after surgery

ct

Inflammatory change in the right lower quadrant, with a small volume of free fluid. Much of the small bowel is distended and fluid-filled, with a soft transition to the collapsed terminal ileum. Differential is between ileus and early post-operative adhesions in the right lower quadrant.

Gastrografin challenge

x-ray

6 hours after Gastrografin administration, contrast fills dilated small bowel loops in the left side of the abdomen, but has also passed through into the large bowel, reaching the rectum. This indicates that there is no absolute small bowel obstruction. 

Case Discussion

The initial CT shows the typical findings of uncomplicated acute appendicitis, with thickening and distension of the inflamed appendix, but no perforation or abscess formation. A repeat study 3 days after an appendectomy shows inflammatory change within the right lower quadrant and a small volume of free peritoneal fluid, and fluid distension of much of the small bowel. In this context, the differential is between an ileus (due to slow recovery after surgery or peritoneal inflammation), or early post-operative adhesions causing a mechanical obstruction. 

A water-soluble contrast challenge was performed in order to determine whether surgical intervention would be required, and also as a therapeutic measure, and this is considered a soft indication for this test. The AXR findings indicate that there is no absolute mechanical obstruction, and likely an element of ileus given the persistently dilated small bowel loops. An uneventful recovery led to discharge soon after the final imaging study.

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