Coincidental or Causative?: Post-Traumatic Appendicular Mass
I Wani, I Mir, G Naikoo, M Ahmed
appendicular mass, blunt trauma, ultrasonography
I Wani, I Mir, G Naikoo, M Ahmed. Coincidental or Causative?: Post-Traumatic Appendicular Mass. The Internet Journal of Surgery. 2006 Volume 11 Number 1.
We present a case report of an appendicular mass following blunt abdominal trauma with emphasis on clinical assessment in blunt abdominal trauma. This appears to be the first case report of this type with blunt abdominal trauma presenting with an appendicular mass.
Blunt abdominal trauma is a routine surgical emergency and affects almost all organs. It continues to cause morbidity and mortality. Causative relationship between blunt abdominal trauma and appendicitis is still under speculation. Appendicitis has variable clinical course and outcome, sometimes it may be complicated by an appendicular mass.
A 35-year-old female reported to our casualty services with a 36 hours' history of persistent abdominal pain and nausea after suffering a kick on her right lower abdomen. She already had consulted a local physician who prescribed her painkillers, antispasmodics and muscle relaxants. She was admitted for observational care. No history of migration of pain and anorexia was given by patient. Low grade fever was present. Mild tachycardia was noted attributed to antispasmodics, with normal blood pressure. Past history revealed similar attacks, but never diagnosed with appendicitis. Positive findings were pallor and mild soft tissue tenderness and rigidity in the right lower abdominal quadrant. Blood counts showed a white blood cell count of 15.500/mm3 with neutrophilic leucotoysis. Bruise or any other mark of trauma was absent on abdominal examination. No gas under the diaphragm was seen on upright X-ray of the abdomen and probe tenderness was seen on abdominal sonography. During the observational period, the patient had rising pulse rate, a fall in blood pressure and increased temperature. On ultrasonographical re-scan of the abdomen, increased probe tenderness was recorded and a small hypoechoic lesion measuring 2.4×2×1.8cm was seen in the right illiac fossa with a volume of 12.1ml in cross-section, suggestive of an appendicular lump as shown in Fig.1. The patient underwent exploratory laparotomy and a small appendicular mass was found. Appendectomy was done. Histopathology of the specimen showed features of appendicitis.
Frequent re-evaluation is an essential component in the management of patients with blunt abdominal trauma. Clinical accuracy increases with repeated assessment of the patients. To be diagnosed with traumatic appendicitis, a patient should have suffered a severe blunt traumatic insult directly on the abdomen with an interval of less than 6-8 hours until the emergence of symptoms following the trauma and with no abdominal pain prior to the trauma1. Controversy still exists whether appendicitis is a true complication of blunt abdominal trauma or just coincidence2. There is also lack of definitive evidence to support traumatic genesis of appendicitis3. Despite the selective approach and the adjunctive diagnostic methods, exploratory laparotomy continues to be the most accurate method to diagnose the presence of intrabdominal injury, where there is limited approach to modern diagnostic tools.
There is still more to be done to solve the myth of blunt abdominal trauma leading to an appendicular mass with emphasis on keen clinical assessment and observation in blunt abdominal trauma, to look for the development of appendicitis and its complications.
Imtiaz Ahmed Wani Post Graduate Scholar, Amira Kadal, Srinagar Kashmir, India ,190009 Cell Phone No. 9419904864 E-mail: firstname.lastname@example.org