Presentation
Right lower quadrant pain and tenderness, positive Rovsing and psoas signs. Appendicitis?
Patient Data
Thin-walled mediocecal appendix fills up with gas and contrast material. No periappendiceal fat stranding.
Distended gallbladder with a thickened wall that shows interrupted mucosal enhancement, highly suspicious for necrosis. Pericholecystic fat stranding and free fluid. Free fluid also anterior to the liver and below it, in the paracolic gutters and in the pelvis.
Moderate intrahepatic bile duct dilatation. The common bile duct is dilated up to 10 mm and ends in an abrupt cutoff which probably represents a non-calcified gallstone.
The cecum measures 7.5 cm across. Dolichotransverse colon. Transition point to a collapsed distal colon in the descending colon at the level of the inferior splenic margin. Immediately proximal to this point, there is focal concentric wall thickening concerning for neoplasia.
Mini gastric bypass.
Impression:
- normal-appearing appendix
- gangrenous cholecystitis, most probably with perforation and free intraperitoneal bile
- focal wall thickening in proximal descending colon with distal bowel collapse - carcinoma? peristalsis?
The pale blotches on the surface of the hyperemic gallbladder represent foci of wall necrosis.
Case Discussion
The patient underwent laparoscopic cholecystectomy, where a gangrenous gallbladder was carefully removed. Free bile in the right lower quadrant had caused chemical peritoneal irritation and was thus responsible for eliciting clinical signs of appendicitis.
No neoplasm palpated in the colon.
Colonoscopy performed several weeks after surgery demonstrated a normal colon without any wall irregularity, meaning that the focal thickening was probably just peristalsis.
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