Presentation
One-week history of generalized abdominal pain and distension with obstructive bowel symptoms.
Patient Data
AP supine abdominal radiograph showed marked dilatation of small bowel loops without radiographic evidence of pneumoperitoneum. Gas can be seen in colon.
Erect chest radiograph showed absence of free air under diaphragm.
Dilated proximal small bowel loops, predominantly affecting jejunum with largest diameter measuring up to 6.3cm in diameter. The transition point is at the mid jejunum, which is located at the left lumbar region (lower border of L2 vertebral level). The abrupt change of distended jejunum at the transition point (sagittal), only occurs at one point, suggestive of single point obstruction. No appreciable bowel related mass or external compression at transition point.
No thickened bowel wall or intramural gas. No portal venous gas. The small bowel loops and whole large bowel loops are mostly collapsed distal to the aforementioned transition point.
Mild stranding and free fluid at small bowel mesentery.
Slightly high attenuating collection at the pelvis with pneumoperitoneum at the right side of this collection.
Increased fat stranding and thickened peritoneum at the right paracolic gutter are suggestive of active inflammatory/infective process at right iliac fossa. Normal appendix is not visualized. Normal ileo-cecal valve and terminal ileum are seen without abnormal wall thickening. Abnormally thickened blind ending tubular structure seen inferior to ileo-cecal valve, posterior to the cecum with intraluminal high attenuating content which can represent appendicolith.
Case Discussion
CT features are in keeping with acute appendicitis complicated with perforation (pneumoperitoneum) and intra-abdominal collection. Small bowel obstruction (distal jejunum), which is likely secondary to infectious process of acute perforated appendicitis.
Patient proceeded with emergency laparotomy, appendectomy and small bowel serosal repair, where intra-operative findings noted as followings:
pus 200cc in the abdomen
small bowel about 200cm from terminal ileum was collapsed
gangrenous appendix at retrocecal till right lumbar near transaction at the base
proximal part of the small bowel from duodeno-jejunal junction down to distal jejunum appears very dilated after release from upper abdominal wall due to soft adhesion at the area
multiple serosal tear repaired
This case nicely showed the importance of assessing the more common causes of acute abdominal pain in adult which is acute appendicitis and to have proper review system whenever reviewing radiological studies in order to avoid the satisfaction of search. As in this case, after finding the single point small bowel obstruction, the search should not stop at that point which would lead to miss the more urgent diagnosis of perforated appendicitis.
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