Presentation
Initial periumbilical and right iliac fossa pain, persisting for 4 days, associated with fever, vomiting and localized tenderness. Now presenting with diffuse generalized abdominal pain, distension and worsening vomiting. Full blood count revealed marked leukocytosis.
Patient Data
Multiple dilated small bowel loops on CT topogram.
Findings consistent with small-bowel obstruction.
No signs of pneumoperitoneum.
Inflamed and thickened appendix with a hyperenhancing appendiceal wall and a large proximal appendicolith.
Focal interruption in the midportion of the appendix is evident with a relatively large rounded lesion of internal fluid attenuation measuring 3.5 x 3.5 cm, associated with extensive periappendicular fat stranding, pelvic free fluid and reactive regional lymphadenopathy.
Reactive wall thickening and edema of an adjacent ileal loop is demonstrated, along with multiple dilated ileal loops with air-fluid levels, consistent with small-bowel obstruction.
Patent mesenteric vessels. No signs of bowel ischemia. No pneumoperitoneum.
Incidental bridging osteophytes at the superior portions of both sacroiliac joints.
Red circle: Inflammatory appendicular mass/phlegmon
Green circle: Mesenteric fat stranding and lymphadenopathy
Yellow rectangle: Reactive small bowel wall thickening and edema
Blue arrow: Appendicolith
Case Discussion
This is a case of acute appendicitis complicated by perforation, manifested by a large inflammatory appendicular mass/phlegmon in the right iliac fossa, adherent to an adjacent ileal loop, resulting in reactive ileal wall thickening and edema with secondary small-bowel obstruction due to ileus.
Acute appendicitis may result in small bowel obstruction, which may be mechanical SBO due to localized periappendiceal inflammation resulting in adhesions, or as a result of ileus secondary to localized peritonitis with reactive bowel wall inflammation due to a perforated appendix.
If acute appendicitis and small bowel obstruction coexist, symptoms of SBO may mask those of acute appendicitis.
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