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Clinical Infection & Immunity

Case Report

Volume 3, Number 1, March 2018, pages 29-31

Unusual Presentation of Appendicolithiasis With Pneumoperitoneum: A Rare Case Report

Fecaliths formed by mineral deposits layered with fecal debris and lodged in the appendix are called appendicoliths. The prevalence of fecaliths in the general population is 3% and appendicoliths are seen in 10% cases of acute appendicitis. And rarely its size exceeds more than 2 cm (giant appendicolith) [1-3]. Most of the patients with appendicoliths are asymptomatic. It is usually found accidentally in abdominal imaging studies. However, appendicoliths may cause serious appendicular inflammation and peritonitis [1]. We reported a case of large appendicolithiasis clinically resembling peptic ulcer perforation with pneumoperitoneum on imaging study.

A 22-years-old male admitted in the emergency department of EMCH (Enam Medical College Hospital) at night with the complaints of pain in right upper abdomen for 3 days with single episode of vomiting 2 days back and no defecation for the last 2 days. Clinically he was hemodynamically stable, non-toxic and oral temperature recorded as 37.8 °C. Abdomen was distended, rigid and tender over the right upper quadrant and right lower quadrant. Liver dullness was obliterated, no ascites was noted and no bowel sound detected. Digital rectal examination was normal. Intravenous crystalloid infusion with broad-spectrum antibiotic was started and high colored urine noted after urethral catheterization.

Hematological and biochemical reports revealed neutrophilic leukocytosis, high serum amylase but no electrolyte imbalance, and normal renal function (Table 1). Plain abdominal radiograph showed crescentic pneumoperitoneum under the right dome of the diaphragm and an unusual irregular radio opaque shadow in right iliac region about 1.8 cm in maximum diameter (Fig. 1). It was regarded as an intestinal foreign body or an art effect. Abdominal ultrasound could not correlate with that object and it also noted free fluid collection in the right hepato-renal pouch, little right sided pleural effusion (Fig. 2) and a vague bowel lump in the right iliac region.

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Table 1. : Hematological and Bio-Chemical Studies

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Figure 1. Plain abdominal radiograph showing pneumoperitoneum (single white arrow) and an unusual radio opaque shadow in right lower abdomen (double arrow).

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Figure 2. Sonographic impression of sub hepatic collection and pleural effusion.

Exploratory laparotomy was performed at night time on emergency basis with the diagnosis of peptic ulcer perforation and preceded with upper midline incision. Moderate amount of peritoneal collection was noted which was turbid, neither purulent nor bile stained. Stomach, duodenum and liver were found normal. So, incision was extended beyond the umbilicus and cecum was found thick walled and edematous and appendix could not be detected easily. After partial mobilization of cecum medially, it revealed thick, foul smelling and purulent collection behind the cecum. The fluid sample was sent for culture and sensitivity test. With meticulous handling of cecum and retrocecal approach, appendix was found severely inflamed, distended, and containing a large appendicolith near the base of the appendix and a large perforation near the base (Fig. 3). Up to the tip of the appendix could be reached with a great difficulty. Appendectomy was done and remnant of the base of the appendix was closed loosely with 1/0 Vicryl. Thorough peritoneal toileting was done with povidone-iodine and 3 L of normal saline. Ascending colon was checked submersing under normal saline for any leakage and there was no leak noted. Then abdomen was closed in layers with a silicone drain (18 FR) placing in pelvis. Total operation time was 90 min.

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Figure 3. A large appendicolith beside a no.4 BP knife.

Anesthetic recovery was uneventful. Bowel sound appeared on third postoperative day (POD). Liquid diet was resumed on fifth POD and drain tube was removed. Later on, he developed wound infection with 5 cm wound gap at the lower end of the incision. Specific oral antibiotic was started according to microbial sensitivity test. After regular dressing the wound, secondary closure was done on ninth POD and he was discharged on 10th POD with normal bowel and bladder function. Histopathology report revealed acute appendicitis with peritonitis and no malignancy (Fig. 4). Patient didn’t develop any further complications like recurrent abdominal pain, sepsis or subacute intestinal obstruction due to bands and adhesion within 6 months of post-operative follow-up.

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Figure 4. Histopathology showing the muscle layer of the appendix infiltrated with abundance of neutrophils.

Modern text book of surgery, clinical medicine and pathology still teach that obstruction is the main cause of appendicitis and fecaliths are the main cause of obstruction in adults [4-7]. The obstruction hypothesis has been challenged by some authors [8-10]. Aschoff proposed that bacterial infection and not obstruction of the appendix was the inciting event [8]. Arnbjornsson’s experimental work also challenges the obstruction hypothesis [9]. JP Sing et al also reported fecaliths prevalence is too low to consider the fecaliths the most common cause of non-perforated appendicitis [11].

Abdominal imaging study could detect appendicoliths accidentally and it remains mostly asymptomatic, moreover perforated appendicitis is also a rare presentation with pneumoperitoneum. In our case the presenting symptoms, signs and imaging studies were correlating more towards peptic ulcer perforation. Tenderness in right iliac region was thought due to Valentino’s syndrome. It is due to the spillage of gastric content in peptic ulcer perforation which may run down the right paracolic gutter leading to presentation with pain in right iliac fossa which is known as Valentino’s syndrome [12].

Appendicolithiasis may cause intermittent abdominal pain. It may mimic stone disease of the genitourinary tract. Sometimes it can be difficult to differentiate acute appendicitis from urolithiasis [1]. In this case it was also difficult for us to differentiate from peptic ulcer perforation.

It’s very important to note that the patients with appendicolithiasis are at increased risk of appendix perforation and abscess formation. In higher specialized center such cases could be managed with minimal access surgery to have improved diagnosis and early recovery with optimized surgical stress.

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