Presentation
Severe lower abdominal pain
Patient Data
Findings: Marked inflammatory changes are present in the pelvis with acute appendicitis.
There are stones at the base causing obstruction and also the tip with no
perforation at this stage but would be concerning for impending changes. No
free gas is seen.
Normal assessment of the large bowel. Small volume free fluid in the pelvis.
There is also a gastric band in situ with mild thickening of the distal esophagus and a small proximal pouch consistent with a gastric slip.
Conclusion: Fairly marked acute appendicitis with an obstructive calculus at the
base and prominent phlegmonous change surrounding but no drainable collection or
perforation.
Case Discussion
This patient presented with three days of right iliac fossa pain with nausea and vomiting. She had a white cell count (leukocytosis) of 38.5 with a CT showing appendicitis with fecolith/appendicolith at its base. The patient became suddenly peritonitic and septic (HR 110, T 38.2) in the emergency department so the decision was made to operate overnight.
Previous history of open cholecystectomy and laparoscopic gastric band.
Procedure: Laparoscopic staple cecectomy and appendectomy.
Findings:
- acute gangrenous appendicitis with perforation close to base of appendix
- abscess cavity involving appendix, loops of small bowel, mesentery and cecum
- cecum pole quite friable with some denuding of serosa during mobilization
- four quadrant purulent peritonitis
- localized fecal spillage from perforation
- due to inflammation, difficult dissection to allow mobilization of cecum
- decision made to perform staple cecectomy
Histopathology:
Macroscopic: An elongated appendix 95 mm in length x 12 mm diameter with mesoappendix attached to a depth of 18 mm. At the base of the appendix there is a full thickness defect involving 80% of the circumference of the appendix. There is fecolith obstructing the lumen. No tumor seen.
Microscopic: Severe necrotizing appendicitis. Extensive mucosal ulceration and a transmural neutrophilic infiltrate with serositis and peri-appendicitis. No dysplasia or carcinoma is identified.
Summary: Acute necrotizing appendicitis with perforation.