Perforated acute appendicitis

Case contributed by Dr Kenny Sim

Presentation

84 year old female with vomiting and abdominal pain. Raised WCC and inflammatory markers.

Patient Data

Age: 84
Gender: Female
Modality: CT

Extensive inflammatory change in the right iliac fossa is present involving the caecum, terminal ileum and appendix. The appending is dilated (9mm) and hyperemic. The mucosa near the tip of the appendix is not visualised with apparent defect of the mucosa as it enters a poorly circumscribed non-walled-off fluid collection measuring ~3cm in diameter.

There is a moderate length segment of terminal ileum just upstream of the ileo-caecal valve that demonstrates wall thickening, mural stratification and surrounding stranding. There is also free fluid tracking within the adjacent mesentery as well as subcentimetre mesenteric lymph nodes more centrally. No free intraperitoneal gas. Small volume free fluid also tracks inferiorly into the pouch of Douglas.

No upstream small bowel dilatation. No focal hepatic lesion identified. No portal venous gas identified. The kidneys, gallbladder, adrenals, pancreas and spleen are unremarkable. Circumaortic left renal vein noted.

Conclusion:

Extensive right iliac fossa inflammation, with close relationship to an abnormal appendix suggesting that appendicitis, despite age of the patient, is the likely diagnosis. Defect of the mucosa at the tip of the appendix adjacent to a fluid collection is suspicious for perforation.

Case Discussion

The patient proceeded to theatre and subsequent appendicectomy. 

Pathology confirmed the pre-operative imaging diagnosis:

MACROSCOPIC DESCRIPTION: "Appendix": Appendix 40x10x10mm with brown ragged mesoappendix showing full thickness perforation.

MICROSCOPIC DESCRIPTION: Sections of the appendix show mucosal ulceration, associated with transmural acute inflammatory cell infiltrate. Part of the wall is disrupted, consistent with a perforation. The serosa is covered by heavy inflammatory exudate. There is no evidence of malignancy. 

DIAGNOSIS: Acute appendicitis with perforation

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Case Information

rID: 43965
Case created: 31st Mar 2016
Last edited: 6th Dec 2016
Inclusion in quiz mode: Included

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