It’s Complicated: A Case Report of a Patient with Colo-cutaneous Fistula connected to the Appendiceal Stump

@#INTRODUCTION: Colo-cutaneous fistula is a very rare complication of colonic diverticular disease, occurring in approximately one percent of cases either spontaneously or after surgical or drainage procedure. Herein we describe a patient with a colo-cutaneous fistula from the sigmoid to the appendiceal stump in a post-appendectomy patient which also exits to the skin at the post-operative site. CASE PRESENTATION: The patient is a 76-year-old Filipino male who had appendectomy five months earlier and a history of diverticulitis, and presented with a subcutaneous abscess at the post-operative site. The abscess was drained, a colocutaneous fistula was radiographically established, and the surgical site was explored. Intraoperative findings showed the presence of multiple colonic diverticuli and a sigmoidcutaneous fistula on the right lower abdominal quadrant. Interestingly, an incidental descending colon mass was also noted at the splenic flexure measuring approximately 2x3 cm to which frozen section revealed adenocarcinoma which was not seen in pre-operative CT scans. An extended left hemicolectomy was performed, and no postoperative complications were noted. At present three years later, he fares well without any signs and symptoms of the disease. CONCLUSION: Diverticulitis is a common condition in the older age group that needs to be considered in patient management. Colo-cutaneous fistula may be a rare complication of the disease but should be part of our differentials as internists in working up patients presenting with persistently draining superficial wound that either occurs spontaneously or post-operatively. Patients with diverticulitis also have increased risk of colorectal cancer and diagnostic imaging may not always differentiate the two entities, thus colonoscopy should be done if possible.

Apendicitis del muñón apendicular: Reporte de caso y revisión de literatura / Appendicitis of the appendicular stump: Case report and review of the literature

Objetivo: Describir el caso de un paciente con apendicitis del muñón apendicular y realizar una revisión de la literatura. Sede: Hospital Médica Sur. Diseño: Caso clínico. Descripción del caso: Masculino de 38 años de edad con antecedente de apendicitis complicada manejada quirúrgicamente hace 15 años. Cursa 48 horas con dolor abdominal tipo cólico, mal localizado, orientado hacia la mitad inferior del abdomen, durante las primeras 24 horas afebril, no náusea ni vómito; durante las siguientes 12 horas, el dolor se intensifica hasta llegar a ser 10 de 10, en hemiabdomen inferior, con fiebre de 38.5°C, con náusea sin vómito. Se encuentran datos de irritación peritoneal, leucocitosis con neutrofilia, estudios paraclínicos de imagen sugerentes de apendicitis aguda, por lo que se decide laparotomía exploradora. Durante la misma se evidencia, a nivel de ciego, remanente apendicular de aproximadamente 1 cm, con cambios isquémicos y perforación a nivel de la base del ciego. Se realiza hemicolectomía derecha con ileo-transverso anastomosis latero-lateral. El estudio histopatológico confirma apendicitis del muñón. Conclusión: Una complicación rara de la apendicectomía es la apendicitis del muñón apendicular, que se presenta cuando no se realiza una resección apendicular adecuada. Esto se debe a mala identificación de la base apendicular, por diversos motivos, lo que condiciona a dejar un muñón apendicular de más de 5 mm.

Objective: To describe a case of appendiceal stump appendicitis and to perform a literature review. Setting: Hospital Médica Sur (Third level health care private hospital). Design: Case report. Description of the case: Man of 28 years of age, with an antecedent of complicated appendicitis managed surgically 15 years ago. The patient had coursed for the last 48 h with colic-type abdominal pain, not well localized, oriented towards the lower half of the abdomen, he was without fever the first 24 h, he presented no nausea nor vomiting; 12 h later the pain intensified until reaching 10 of 10, in the lower hemiabdomen, with fever of 38.5°C and nausea but no vomiting. Peritoneal irritation data were found, leukocytosis with neutrophilia, imaging studies were suggestive of acute appendicitis; hence, it was decided to perform an exploratory laparotomy. During this, an appendicular remnant of approximately 1 cm was evidenced at the base of the cecum. Right hemicolectomy was performed with ileo-transverse latero-lateral anastomosis. The histopathological study confirmed appendicitis of the stump. Conclusion: Appendicitis of the appendiceal stump is a rare complication of appendicectomy, which occurs when the appendicular resection is not performed adequately. This is due to a wrong identification of the appendicular base, for diverse reasons, which leads to leave an appendiceal stump of more than 5 mm.

Appendiceal Stump Bleeding That was Treated by Endoscopic Hemoclipping / 대한소화기내시경학회지

Appendiceal stump bleeding is a rare, but occasionally life-threatening complication. Significant lower gastrointestinal hemorrhage from an ulcerated appendiceal stump may occur after uncomplicated appendectomy. The common management includes ligation of the bleeding vessel or cecal resection by either emergency laparotomy or laparoscopy. Angiographic embolization of the bleeding vessel is an alternative therapeutic option. We report here on a case of gastrointestinal hemorrhage from an appendiceal stump, and this occurred six days after appendectomy. The bleeding was controlled endoscopically by placing hemoclips on the distinct vessel. The patient recovered thereafter without further intervention. Endoscopic hemoclipping is an effective and safe procedure, and it can replace emergency laparotomy, laparoscopy or angiographic embolization for treating appendiceal stump bleeding.

A Case of Appendiceal Stump Ulceration and Bleeding One Year after Appendectomy / 대한소화기내시경학회지

Postappendectomy bleeding is a rare and occasionally catastrophic phenomenon. Bleed-ing in the gastrointestinal tract may occur early or late. The cause of late bleeding included ulceration, vascular malformation or granuloma. We experienced a case of delayed appen-diceal stump ulceration and bleeding who underwent an appendectomy 1 year ago. The patient was admitted due to melena. A colonoscopy showed a well-circumscribed deep ulcer containing of silk suture material at the base of appendiceal stump. Biopsy revealed only granulation tissue with nonspecific inflammation. The silk was removed by biopsy forcep and sulfasalazine was tried. A repeat colonoscopy showed the complete ulcer heal-ing 3 months later. We report this case with a review of literatures.