Presentation
Abdominal pain, fever and raised white cell count. Very tender left iliac fossa and sigmoid colon. ?Diverticulitis
Patient Data
The appendix is markedly distended in the right side of the pelvis and there is surrounding inflammatory stranding and fluid within the rectovesical pouch. Appearance is in keeping with acute appendicitis. There is fecal loading of the large bowel. No diverticulitis.
Appendectomy has been performed. Oral contrast has not passed beyond the stomach and there is distension of small bowel loops with fluid consistent with ileus. In the right iliac fossa, medial to the ileocecal junction and directly anterior to the appendectomy clips, there is a rounded fluid collection containing some antedependent gas with maximal dimensions of 4.5 x 5.7 x 4.5 cm (ML by AP by SI). There is the impression of collapsed bowel surrounding the anterior aspect of the fluid collection. A small volume of free fluid is seen within the pelvis.
Case Discussion
This case of acute appendicitis was missed on initial CT interpretation perhaps because the reader did not consider differential diagnoses beyond the clinical impression of acute diverticulitis. Looking in the pelvis for free fluid (any free fluid in a male patient is abnormal) and attempting to identify the appendix are two essential tasks to perform when assessing a CT in the setting of acute abdominal pain. Surgery was unfortunately delayed in this patient and his post-operative course was complicated by a fluid collection at the surgical site that required drainage.
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