Acute appendicitis - large appendicoliths

Case contributed by Dr Michael P Hartung


Lower abdominal and back pain.

Patient Data

Age: 60 years
Gender: Male

Dilated, fluid filled appendix with periappendiceal inflammation. Several dense filling defects are consistent with fecaliths. A few small locules of air are present within the lumen. The appearance mimics that of a small bowel loop.


"The appendix was identified at the base of the cecum. It was greatly distended, injected, erythematous with some filling attachments to the surrounding fatty tissue and sidewall of the abdomen. These were broken and taken down bluntly. The base of the appendix was soft and the remainder of the appendix was distended and firm. A window was made at the base of the appendix and a blue load EndoGIA stapler was then used to divide the appendix from the cecum. Two fires of a white load were then used to divide the mesoappendix. There was some bleeding from the appendiceal artery which was controlled with 5 mm clips and cautery. Once hemostasis was confirmed, the area was irrigated, suctioned dry both in the pelvis, right pericolic gutter and over the liver."

Gross: The specimen, received fresh, is a 15.1 cm in length x 1.7 cm in diameter appendix with attached mesoappendix, 5.0 x 4.1 x 2.7 cm. There are no perforations identified. The serosal surface is fibrous and gray. The mesoappendix is yellow-tan and unremarkable. The mucosal surface is white-pink and smooth. The lumen contains multiple fecaliths and fecal material.

Case Discussion

Acute appendicitis with multiple fecaliths. The degree of distention of the appendix with air, fluid, and intraluminal material makes it somewhat difficult to distinguish from adjacent loops of small bowel in the right lower quadrant. 

Careful inspection in three planes increases diagnostic confidence that this structure arises from the base of the cecum and is blind-ending, and therefore represents acute appendicitis rather than terminal ileitis, enteritis, or Meckel's diverticulitis.

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Case information

rID: 61805
Published: 20th Jul 2018
Last edited: 4th Aug 2020
Inclusion in quiz mode: Included

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