Presentation
Patient admitted with flank pain, worse in RIF. Raised inflammatory markers, intermittent pyrexia, previous proteinaceous urinary tract infection associated with stones. ?renal tract stones
Patient Data
No radiopaque calculus within the urinary tract. No collecting system dilatation. There is some perinephric stranding around the right kidney but there is also thickening of Gerota's fascia and inflammatory fat stranding in the pericolic fat anterior to this. This relates to a cavity containing fluid and gas behind the cecum and the ascending colon. It measures 30 x 35 mm in diameter and extends for 90 mm craniocaudal, most likely representing a periappendiceal abscess. A 12 x 6 mm calcified focus is seen within it medially
There are some prominent ileocolic lymph nodes medially.
The solid upper abdominal organs are unremarkable.
No other significant abdominal or pelvic finding. No bony abnormality.
Summary: Retrocecal/retrocolic appendix abscess.
Following the above CT and the diagnosis of appendicitis with abscess formation, the patient went to theater for a laparoscopic appendectomy with antibiotic cover. A drain was left at the abscess site and the patient returned to the ward for analgesia and observation. In the following 48 hours, the patient deteriorated clinically and inflammatory markers continued to rise.
A further CT abdomen and pelvis was requested;
"Abscess noted on previous CT, inflammatory markers still rising, drain in situ. pyrexial yesterday. ?collection remaining. on tazocin, but not improving"
Percutaneous drain within the right paracolic space; the bladder is catheterized.
Postsurgical changes with edema and some gas around the right flank. There is a tiny bubble of gas in the prehepatic subphrenic space, but no generalized pneumoperitoneum.
There remains a small collection only within the right flank, measuring approximately 3 x 1 x 3 cm but there is a slightly larger collection of fluid (3 x 6 x 6 cm) pooling in the pelvis. it has an enhancing wall. Interestingly, the previously seen appendicoliths are now within this collection.
There is very minor periportal edema through the liver, and nonspecific signs of abdominal sepsis. There are tiny bilateral pleural effusions.
Case Discussion
This is a rare case of a dropped appendicolith. After discussion with the surgical team, due the position of the appendicolith percutaneous drainage by interventional radiology was not felt to be the appropriate first-line treatment and the patient went to theater for an open laparotomy and wash out. The appendicolith was removed and the patient made a complete recovery and was discharged 7 days later on oral antibiotics.
Dropped appendicoliths are a rare finding with less than 30 cases reported within the past 40 years 1. The most common sites are the paracaecal region and Morrison's pouch 1. All modern (since 2004) reported cases have been following a laparoscopic technique. The limited available literature provides case report evidence to support a trial of image-guided intervention prior to open surgery 1.