Pneumoperitoneum in Perforated Appendicitis in the COVID Pandemic:A Case Report

ABSTRACT

Introduction and Importance Pneumoperitoneum, presenting as air under the diaphragm on a plain erect chest X-ray, is most often an indication of perforation of a hollow viscus, however it is a rare consequence of acute appendicitis. Case Presentation We report a case of a 54-year-old man who presented with severe epigastric pain and an acute abdomen. The presumptive diagnosis of perforated viscus could not be confirmed with computed tomography, which led to a misdiagnosis. Diagnostic laparoscopy revealed perforated gangrenous appendicitis. Clinical Discussion The current COVID pandemic has resulted in delayed and severe presentations of acute pathologies, in terms of appendicitis, with perforation. The appendix, albeit being a hollow viscus, rarely presents with pneumoperitoneum when perforated, this can be explained by the pathogenesis of appendicitis. However, two mechanisms have been propounded to explain the relationship between pneumoperitoneum and perforated appendicitis;the absence of a fecalith or lymphoid hyperplasia or the presence of gas forming bacteria. In attempts to comply with COVID recommendations in the operation theatre, diagnostic laparoscopy was carried out, however the patient was already prepped, positioned and ports were in place for omental patch repair and abdominal lavage. This proved to be futile and additional measures were taken lengthening operation time, such as additional port introduction and repositioning to facilitate the appendectomy. Conclusion The purpose of reporting this case is to highlight that pneumoperitoneum can be rarely associated with gangrenous appendicitis and timely diagnosis is important for the emergency management of this condition during the COVID pandemic.