M Akinkunmi, O Fadiran
appendiceal rupture, appendicitis, calcified appendicolith, computed tomography ct, ultrasonography uss.
M Akinkunmi, O Fadiran. Ruptured Acute Appendicitis With Calcified Appendicolith Mimicking Acute Gastroenteritis. The Internet Journal of Health. 2009 Volume 12 Number 1.
A rare case of a man who presented with clinical features suggestive of acute gastroenteritis after a meal, and was subsequently diagnosed with ruptured acute appendicitis (AA) and calcified appendicolith on account of radiological findings, is reported. The diagnosis of AA can be difficult in the atypical case, and radiological imaging plays a vital role. The finding of calcified appendicolith in a patient presenting with acute abdomen should raise the index of suspicion of AA, especially in a developing country.
Appendicitis is more common in developed than in developing countries and appendicoliths have an aetiologic role in the disease. The prevalence of appendicolith is higher in developed countries than in developing countries, and also higher in patients with than in those without appendicitis. This has been attributed to the low-fibre diets consumed in developed countries which lead to appendicolith formation1. Calcified appendicoliths are found in 10% of patients with acute appendicitis, but they are seen more frequently in perforated appendicitis and in abscess formation2. The clinical diagnosis of acute appendicitis (AA) is based primarily on patient history and on physical examination findings. The classic presentation of AA is seen in only 50% - 60% of patients, and the diagnosis may be missed or delayed in atypical presentations. The differential diagnosis of AA are abdominal pain of unknown cause, pelvic inflammatory disease and other gynaecologic disorders, mesenteric lymphadenitis, acute gastroenteritis and other gastrointestinal tract diseases, and urinary tract infection and obstruction3. This case is reported because firstly, it is uncommon for AA to mimic acute gastroenteritis in clinical presentation, secondly the calcified appendicolith was quite large, measuring 19 x 18mm, and thirdly to highlight the importance of radiological imaging in the diagnosis of acute abdominal pain.
AA is a 45 year old man who presented with the history of abdominal pain of sudden onset, diarrhoea, fever, headache, and vomiting. His last meal (which he ate with other members of his family) was eight hours before presentation. No other member of the family had any of these symptoms. The past medical and surgical history and the drug history were not contributory. On examination, he was ill-looking, febrile (temperature of 37.6 degrees centigrade), and dehydrated. The pulse rate was 78/minute; regular and the blood pressure was 140/90 mmHg. The chest was clinically clear. The abdomen was full and mildly tender generally. The clinical impression was ?malaria, ?gastroenteritis secondary to food poisoning. He was commenced on intravenous (IV) fluids, IV hyoscine butylbromide, IV Maxolone, and intramuscular diclofenac. A plain abdominal radiograph was requested on account of increasing abdominal distension.
Abdominal ultrasonography revealed free extraluminal intraperitoneal fluid as evidenced by fluid in the hepatorenal recess. There was an aperistaltic, non-compressible, blind-ended, tubular structure in the right iliac fossa, measuring 13.9 mm in diameter, representing an inflamed appendix . There was periappendiceal inflammatory fluid and pericecal inflammation. The sonographic diagnosis was perforated AA with peritonitis, with perforated typhoid Ileitis as a differential diagnosis. Abdominal radiograph showed splaying of the properitoneal fat lines in keeping with abdominal distension, and a rounded, laminated, calcified mass (about 2 cm in diameter) in the right iliac fossa, representing a calcified appendicolith (Figure 1). Abdominopelvic computed tomography (CT) scan showed a rounded, high attenuation mass measuring 19 x 18 mm in diameter in the lumen of the distended appendix, indicating a calcified appendicolith (Figure 2). Minimal, free, extraluminal, intraperitoneal fluid was observed. The gall bladder, spleen, pancreas, and both kidneys were normal. Minimal, bilateral pleural effusion and mild consolidative changes of the basal segments of the lower lobes of both lungs were noted. The CT findings were conclusive of calcified appendicolith and perforated AA with peritonitis.
The stool, electrolytes and urea, and creatinine, and urinalysis were normal. Malarial parasites was negative; serum
Histopathology confirmed a vermiform appendix about 7 cm long and 2.5 cm in diameter, with a rough and slightly hyperemic serosa. The cut section revealed lumen containing fecal matter and a calcified appendicolith measuring 1.5 x 1.6 x 1.4 cm. Microscopically, the histological section of the appendix showed hyperplasia of the mucosal lymphoid follicles and mucosal infiltrate of eosinophils and mononuclear cells extending into the submucosa. There were areas of necrosis of the entire wall thickening. There were fibrinopurulent inflammatory exudates covering the serosal layer. The pathologic diagnosis was acute necrotizing appendicitis with peritonitis.
The anatomy, pathophysiology, and clinical diagnosis of AA, the role of CT and ultrasonography, and the effect of imaging on clinical outcomes, have been well described3. The surgical diagnosis of AA is customarily made on clinical grounds alone using history, physical examination, and white blood cell count in the typical presentation4. However in atypical presentations such as presented in this case, diagnostic imaging with CT and ultrasonography is usually required. The diagnosis of perforated AA was facilitated in the case presented by the radiological investigations. The clinical history and physical examination findings were not sufficient to clinch the diagnosis of AA. If anything, the diagnosis of acute gastroenteritis featured prominently in this case before the outcome of the ultrasound, plain abdominal x-ray, and CT examinations. In 1995, Ohmann
AA may masquerade as acute gastroenteritis in its clinical presentation. Whenever there is an atypical presentation of suspected AA, radiological imaging will be useful in further evaluation of such patients, as exemplified in the case presented. Calcified appendicolith may be seen in association with AA; and in a developing country this relationship appears to be more striking.