Recurrent Appendicular Abscess-An Interesting Case Report

Background: Anorectal abscess, a common surgical condition, can rarely spread upwards to involve complex anatomical compartments leading to sepsis. A 45-year-old diabetic male presented in the ER with complaints of recurrent Right Iliac Fossa (RIF) pain with local swelling and dysuria, along with high-grade fever with chills and rigour for the last few days. He had been diagnosed with a case of recurrent appendicular abscess and treated with repeated Incision & Drainage during three previous hospitalizations. He also complained of simultaneous painful swelling in the left gluteal region during every episode of RIF pain. Methods: On examination, there was a parietal fluctuant swelling and tenderness in RIF over the previous appendicectomy scar. On Digital Rectal Examination (DRE), there was left-sided fullness and a tender induration at the 6 o'clock position on the dentate line, indicating some crypto-glandular disease. At the bedside, incision and drainage at RIF were performed, and pus was sent for C/S which came positive for an ESBL-producing strain of Escherichia coli. He was provisionally diagnosed with a case of the parietal abscess. Results: CECT W/A showed features of necrotizing fasciitis involving the anterior abdominal wall, forming an abscess, which crossed the midline along the pre-vesical space, extending to the pelvis and left ischio-anal fossa. Thus, the primary source of sepsis was a complex Ano-Rectal Abscess. Appropriate surgical management was done for source control. Conclusion: Unusual sources of infection should be suspected in patients with persistent sepsis or recurrent abscess and appropriate imaging modalities should be utilized before surgical intervention.

Appendicular abscess: as a masquerader and pheochromocytoma as an incidentaloma in a 12 year old male child

A 12 year old boy presented initially with symptoms suggestive of urinary tract infection (UTI). Later, it turned out to be acute appendicitis with appendicular abscess. Pre-operative investigations revealed co-presentation of pheochromocytoma. Although this child was having no symptoms of pheochromocytoma, the presentation of phaechromocytoma with appendicular abscess needs to be dealt with extreme vigil as pheochromocytoma can result in severe sympathetic outburst storm. Laparoscopic appendicectomy was done and the child was discharged after complete recovery.

Jejunal gastrointestinal stromal tumors masquerading as an appendicular mass: an unusual presentation

Gastrointestinal stromal tumors (GISTs) are a rare variety of tumors of mesenchymal origin found in the gastrointestinal (GI) tract forming about 1% of all GI tumors. These originate from the interstitial cells of Cajal. Small bowel GISTs have been shown to present as obscure GI bleeding, obstruction and perforation in literature. We report a 57 years old female patient presenting with pain abdomen, fever and vomiting and palpable right iliac fossa (RIF) mass diagnosed as an appendicular mass and managed conservatively. She was planned interval appendicectomy and was discovered to have a jejunal GIST at laparotomy treated with resection and anastomosis. There are case reports of small bowel GISTs presenting as sources of obscure or overt GI bleeding and luminal or extra luminal mass causing small bowel obstruction. Surgery is mainstay of treatment with imatinib for adjuvant or neoadjuvant therapy. This case highlights an unusual presentation of a jejunal GIST with a sealed off perforation mimicking an appendicular mass in the RIF treated by surgical resection followed by adjuvant Imatinib therapy. GIST being an uncommon tumor with varied presentations can lead to misdiagnosis and delays in treatment. This differential should be kept in mind while evaluating small bowel pathologies to aid a timely diagnosis.

Primary appendectomy in appendicular masses of children: an institutional experience

Background: Early appendectomy (EA) for appendicular mass (AM) has been found to be a safer alternative in various studies in adults, while very few studies report such advantages in pediatric population. The purpose of this study was to assess the safety, efficacy and practical implications of EA in pediatric patients with AM.Methods: All patients with acute appendicitis or its complications that underwent EA between January 2016 and December 2018 were retrospectively reviewed. AM was defined if any or combination of the following criteria were satisfied with other signs of appendicitis: palpable mass in right iliac fossa (RIF), sonologically identified mass in RIF, per-operatively confirmed as a mass by surgeon.Results: 37 patients (among a total of 642 patients) were determined to have AM per-operatively and were included in the analysis. 29.7% (n=11) had a contained appendicular abscess. Age group ranged from 4-12 years (mean 7.8 years). The key per-operative findings were fecolith (21.6%), gangrenous appendix (56.8%), difficult adhesiolysis (48.6%), and full thickness bowel injury (2.7%). Postoperatively, wound infection in 9 (24.3%), intra-abdominal abscess in 1 (2.7%), prolonged ileus in 2 (5.4%) and sepsis in 2 (5.4%) were managed medically.Conclusions: EA approach in AM is a safe option in children as it avoids misdiagnosis, treats complicated appendicitis early, avoids second admission, and has shorter hospital stay with better compliance. Failures of non-operative management and potentially lethal complications of complicated appendicitis are also eliminated.

Apendicectomías negativas y su relación con los estudios de imagen / Negative appendectomies and their relation with imaging studies

Objetivo: Identificar si los estudios de gabinete, como la tomografía axial computada y ultrasonido, se asocian con la menor incidencia de apendicectomías negativas. Sede: Hospital Christus Muguerza del Parque, Hospital Privado de Tercer Nivel. Diseño: Estudio de prueba diagnóstica, retrospectivo, descriptivo, observacional, transversal. Análisis estadístico: Sensibilidad, especificidad, valores predictivos y prueba de Bayes. Pacientes y métodos: Se incluyeron a todos los pacientes que fueron sometidos a apendicectomía durante el periodo entre enero 2006 a diciembre 2008. Se correlacionó el reporte histopatológico, como estándar de oro diagnóstico, con los estudios de gabinete realizados que consistieron en tomografía axial computada (TAC) y ultrasonido (US) en pacientes con cuadro clínico sugestivo de apendicitis aguda. Resultados: Se incluyeron 207 pacientes, de los cuales 107 fueron hombres (52%) y 100 mujeres (48%). En 183 pacientes (88.4%) sometidos a apendicectomía se confirmó el diagnóstico histopatológico de apendicitis aguda, mientras que los 24 pacientes restantes (11.6%) tuvieron apendicectomía negativa, de los cuales fueron 10 hombres y 14 mujeres. Durante el periodo estudiado, la frecuencia de apendicectomías negativas disminuyó un 66% en el 2008 respecto al 2007, al mismo tiempo que la utilización de TAC para evaluar estos casos aumentó un 41%. La TAC presentó una sensibilidad de 89%, especificidad de 60%, valor predictivo positivo (VPP) 94.8% y valor predictivo negativo (VPN) de 40%, la posibilidad post-prueba negativa (PPPN) fue de 59.9%. El US tuvo una sensibilidad de 63%, especificidad de 40%, VPP de 85.5% y VPN de 15.8%, y la PPPN fue de 84.2%. Conclusiones: El mayor empleo de la TAC abdominal con contraste IV, ni el ultrasonido, se asoció con una menor incidencia de apendicectomías negativas. El criterio clínico sigue siendo vigente.

Objective: To identify whether diagnostic imaging, such as computed axial tomography (CAT) and ultrasonography (US) can be associated with a lower incidence of negative appendectomies. Setting: Hospital Christus Muguerza del Parque, private third level health care hospital. Design: Diagnostic test, retrospective, descriptive, observational, cross-sectional study. Statistical analysis: Sensitivity, specificity, predictive values, and Bayesian testing. Patients and methods: All patients subjected to appendectomy in the period from January 2006 to December 2008 were included in the study. The histopathological report, as diagnostic gold standard, was correlated with the imaging studies, CAT und US, in patients with clinical symptoms suggestive of acute appendicitis. Results: We included 207 patients, 107 were men (52%) and 100 women (48%). In 183 patients (88.4%) subjected to appendectomy, the histopathological diagnosis of acute appendicitis was confirmed, whereas the remainder 24 patients (11.6%) had negative appendectomies, these corresponded to 10 men and 14 women. During the study period, the frequency of negative appendectomies decreased 66% in 2008 with respect to 2007, concurrently the use of CAT to assess these cases increased 41%. CAT presented a sensitivity of 89%, specificity of 60%, positive predictive value (PPV) of 94.8% and negative predictive value (NPV) of 40%, the possibility of negative post-test (PNPT) was of 59.9%. US had a sensitivity of 63%, specificity of 40%, PPV of 85.5% and NPV of 15.8%, and PNPT of 84.2%. Conclusions: Neither the increase in the use of CAT with IV contrast medium nor of US was associated with a lower incidence of negative appendectomies. The clinical criterion remains being valid.

Observation of Operating and Traditional Chinese Drug in Appendicular Abscess:A Review of 235 Cases / 浙江中医药大学学报

[Objective] To analyze the effect of operating and traditional Chinese drugs in treating appendicular abscess.[Methods] A study was made on 235 cases of appendicular abscess in acute period;strengthen post-operation support therapy,use antibiotics,meanwhile apply Chinese medicines.[Results] No case had stump fistula or intestinal fistula,among which,227 cases went out hospital after 7 days after operation;only 8 cases had incision infection,who also went out of hospital after 11~15 days.All cases were cured.[Conclusion] Operating combined with TCM in acute stage after operation was feasible,with satisfying result.