Presentation
Lower abdominal pain for 3 days associated with nausea and constipation.
Patient Data
Dilated pelvic appendix with a maximum diameter of 12 mm containing a large appendicolith at its base and few others distally. Intraluminal and intramural gas and patchy enhancement of the appendix wall. Marked adjacent fat stranding, reactive thickening of the nearby terminal ileum, sigmoid colon, urinary bladder wall and pelvic right ureter and minor pelvic free fluid. Suspected adhesions between the appendix and the described structures. Considerable thickening of cecal pole, measures about 12 mm.
Diagnosis was made as acute obstructed pelvic appendicitis with suspected adhesions to the nearby structures.
No lymphadenopathy. Otherwise normal.
Operative notes:
Grid iron incision was done.
Appendix is pelvic in position completely gangrenous till the base and perforated forming an early mass with the surroundings and moderately thick wall of the cecum.
Pus swap was taken.
Appendix was released from the surroundings, mesoappendix was ligated and separated, base was ligated twice, and appendectomy was completed.
Two fecoliths were removed from the right iliac fossa.
Irrigation was done.
Big drain was inserted in the pelvis.
Intra-operative photo of the inflamed gangrenous appendix.
Case Discussion
Delayed presentation of a 70 year old man with lower abdominal pain, not shifting, mainly supra-pubic, associated with nausea but no vomiting, constipation for 3 days and elevated inflammatory markers. The patient was initially suspected to have diverticulitis and was referred to ultrasound which showed minimal pelvic free fluid. CT scan revealed a long inflamed pelvic appendix with a proximal obstructing appendicolith.
This case illustrates some important features suggesting gangrenous appendicitis: proximal obstruction, intraluminal and intramural gas and marked periappendiceal inflammation.
A normal appendix can contain gas and/or feces, however when the lumen is obstructed, continued mucus secretion distends the upstream appendix and this appears on CT as a distended fluid-filled appendix. Progressively increasing wall tension causes ischemia and intraluminal stasis leads to gas-forming bacterial overgrowth. Bacteria then invade the wall and perforation ensues.
I would like to express my gratitude to Dr. Hassan Mohammed Ismail and Dr. El Sadiq Elmukashfi Ahmed, SQH Surgery Department, for their assistance in this case study, providing informative picture and operative notes.
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