Dilemma of mucosal appendicitis: a clinico-pathological entity? A retrospective cohort study.

BACKGROUND: The presence of mucosal inflammation within appendicectomy specimens is poorly described in the literature, and there is debate regarding the clinical significance of this histological finding. The aim of this study is to correlate clinical and radiological data with histologically confirmed acute mucosal appendicitis (MA). METHODS: A retrospective cohort study was performed to identify all patients who underwent appendicectomy over 5 years at Caboolture Hospital. Data were collected in regards to clinical Alvarado score, pathological specimen findings, radiological findings and coincidental conditions, and comparison made between MA and negative appendicectomy groups. RESULTS: A total of 1347 appendicectomy specimens and data were reviewed. Of these, 219 (16%) specimens were microscopically confirmed to have acute mucosal inflammation, 150 (68%) were females. Median age was 19 ± 14 years. A total of 243 (18%) were histologically negative. There was a statistically significant difference in mean Alvarado score in the MA group (5.0 ± 1.9 versus 4.3 ± 1.8, P = 0.0002). Patients with MA are more likely to report migratory pain (48.4 versus 31.4%, P = 0.0001) and rebound tenderness (24.9 versus 14.6%, P = 0.002). Computed tomography and ultrasound scans were negative in 74.1 and 72.6%, respectively, in patients with MA. More MA patients benefited from appendicectomy compared with the negative appendicectomy group (82 versus 63%, P = <0.0001). CONCLUSION: There is a subgroup of patients with MA who are young females with have low Alvarado scores, have non-diagnostic imaging, and may represent almost one-fifth of appendicectomy specimens. This study supports the probability that MA is a pathological entity.

Cytomegalovirus enteritis with ischemia in an immunocompetent patient: A rare case report.

INTRODUCTION: Cytomegalovirus (CMV) is predominantly an opportunistic infection in the immunocompromised patients. Though, there are few cases of CMV colitis being reported in the immunocompetent individuals, CMV enteritis is exceedingly rare and enteritis leading into small bowel ischemia has never been reported yet. PRESENTATION OF CASE: A-78-year-old male patient presented with distal small obstruction for 4 days duration. Clinical examination revealed a distended abdomen and localised peritonism in right iliac fossa. An initial computed tomography (CT) scan revealed distended small bowel loops up to the thickened inflammed terminal illeum with no free fluid or gas and a normal appendix. No immunosuppressive risk factors such as human immunodeficiency virus, transplant procedures, or steroid therapy were present. Hematologic investigations showed leucocytosis with neutrophilia. Diagnostic laparoscopy confirmed a thickened terminal ileum causing small bowel obstruction. Laparoscopy converted to laparotomy and right hemicolectomy was performed. Histology showed isolated small bowel ischemia with ulcerative changes and cytomegalovirus inclusions. The patient was started on ganciclovir therapy and subsequently had an uneventful recovery and discharged after 16 days. DISCUSSION: Cytomegalovirus enteritis was initially not suspected in our patient. In this case CMV caused ischemia of the small bowel without evidence of colonic involvement. Even in elderly patients, the small bowel remains resilient to the ischemic changes because of the copious blood supply. CONCLUSION: We report possibly the first case of isolated small bowel ischaemia caused by cytomegalovirus in immunocompetent individuals, needed surgical resection.

A diagnostic dilemma: Left-sided appendicitis in a 10 year old boy with previously undiagnosed intestinal malrotation. A case report.

INTRODUCTION: Intestinal malrotation is a congenital rotational anomaly that occurs as a result of an arrest of normal rotation of the embryonic gut, said to occur in 1 in 6000 live births. Due to the abnormal caecal and appendix position, diagnosis of acute appendicitis becomes more challenging, thus leading to diagnostic and operative intervention delays. Our aim is to highlight the diagnostic challenges in this clinical scenario. PRESENTATION OF CASE: We present a case of a 10 year old boy with previously undiagnosed intestinal malrotation with a left sided acute appendicitis. Initial symptoms lead to a treatment for gastroenteritis, however, due to ongoing pain a CT abdomen was done which showed the malrotation and appendicitis. He required a laparoscopy converted to open appendicectomy due to an appendicecal mass. DISCUSSION: Historically, intestinal malrotation was thought to be a disease of infancy with infrequent occurrence after the age of one year. However, recent analysis has shown an increase in presentations after one year of life into adulthood. Thus, the prevalence of malrotation in children and adults over the age of one year appear to be higher than initially presumed. CONCLUSION: Left sided acute appendicitis is a diagnostic dilemma, thus often leading to management delays. It is pertinent to remember that malrotation of the gut is more common than previously thought, and not just a disease of infancy. It is advisable to consider imaging studies while balancing the risk-benefit-ratio of radiation exposure, especially in paediatric cases to cinch the diagnosis.

"Less is more": Non operative management of short term superior mesenteric artery syndrome.

INTRODUCTION: Superior mesenteric artery (SMA) syndrome is a relatively rare aetiology of proximal intestinal obstruction. This is caused by narrowing of vascular angle of SMA and aorta compressing the third part of the duodenum (D3). Predisposing factors may include precipitous weight loss, corrective spinal surgery or repair of an aortic aneurysm. PRESENTATION OF CASE: A 53 year old male presented to our department with worsening post-prandial vomiting and epigastric pain for last three months. One examination, epigastric region was distended with succussion splash on abdominal auscultation. History did not include any predisposing factor. CT scan showed narrow angle of 12.77° between SMA and aorta owing to the compression of D3. Since onset of vomiting and resultant poor oral intake, he had lost 11 kg of his usual body weight. After gastric decompression, nasojejunal enteral feeding was started. Diet was progressed to oral feedings gradually and following return to his baseline weight, he continued to be free of symptoms in follow-up visits. DISCUSSION: Although there are recognised predisposing factors but sometimes aetiology remains idiopathic. SMA syndrome should initially be managed non-operatively with gastric decompression, correction of water and electrolyte imbalance, and hemodynamic instability. Regaining weight helps increasing vascular space between SMA and D3 thus relieving obstruction. Persistence of symptoms beyond 3-4 weeks warrants surgical intervention. CONCLUSION: Non operative management with nutritional supplementation remains the first line of therapy.