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Przeslawski C, Iorio L, Gerken J. Aberrant Diagnostic Imaging Resulting in Misdiagnosed Acute Perforated Appendicitis: A Case Report. Cureus 2024; 16:e54304. [PMID: 38496122 PMCID: PMC10944640 DOI: 10.7759/cureus.54304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2024] [Indexed: 03/19/2024] Open
Abstract
A 31-year-old male with a history of diverticulitis presented for acute abdominal pain and was found to have several small areas of free air on computed tomography (CT) of the abdomen/pelvis. Due to inflammatory changes seen around the sigmoid colon and small bowel, he was diagnosed with perforated diverticulitis. The patient complained of significant right-sided abdominal pain with significant tenderness on abdominal examination. The patient was initially treated with diagnostic laparoscopy and was actually found to have acute perforated appendicitis with mild appendiceal adherence to the sigmoid colon. This case highlights the importance of careful history and physical examination in an era where imaging often precedes the surgeon's evaluation. The case also provides support for laparoscopy in select cases of pneumoperitoneum, sparing patients the morbidity of undergoing an open laparotomy.
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Affiliation(s)
- Christian Przeslawski
- General Surgery, Corewell Health Southeast - Farmington Hills Campus, Farmington Hills, USA
| | - Leanne Iorio
- General Surgery, Corewell Health Southeast - Farmington Hills Campus, Farmington Hills, USA
| | - Jeffrey Gerken
- General Surgery, Corewell Health Southeast - Farmington Hills Campus, Farmington Hills, USA
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Yun NR, Won YD, Lee SL. [Multi-Detector CT Findings of Typical and Atypical Appendicitis: A Pictorial Essay]. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2023; 84:1047-1065. [PMID: 37869118 PMCID: PMC10585090 DOI: 10.3348/jksr.2023.0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/03/2023] [Accepted: 05/28/2023] [Indexed: 10/24/2023]
Abstract
Multi-detector CT (MDCT) is a highly accurate diagnostic tool that is commonly used to evaluate appendicitis and its complications. The diagnosis of appendicitis based on MDCT findings can be difficult and challenging when the observed findings are inconsistent with the typical features. Atypical appendicitis includes a wide spectrum of features, such as variable positions of the appendix and cecum, complications, and unusual pathological findings of secondary appendicitis that mimic or induce appendicitis. Our pictorial essay describes the diverse spectrum of atypical appendicitis and appendicitis-like conditions in terms of location abnormalities, complications, and uncommon pathologies, including related tumors, reactive appendicitis, appendiceal diverticulitis, and IgG4-related disease. Through this essay, the readers can become more familiar with MDCT findings of atypical appendicitis.
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Teng TZJ, Thong XR, Lau KY, Balasubramaniam S, Shelat VG. Acute appendicitis–advances and controversies. World J Gastrointest Surg 2021; 13:1293-1314. [PMID: 34950421 PMCID: PMC8649565 DOI: 10.4240/wjgs.v13.i11.1293] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/24/2021] [Accepted: 09/29/2021] [Indexed: 02/06/2023] Open
Abstract
Being one of the most common causes of the acute abdomen, acute appendicitis (AA) forms the bread and butter of any general surgeon’s practice. With the recent advancements in AA’s management, much controversy in diagnostic algorithms, possible differential diagnoses, and weighing the management options has been generated, with no absolute consensus in the literature. Since Alvarado described his eponymous clinical scoring system in 1986 to stratify AA risk, there has been a burgeoning of additional scores for guiding downstream management and mortality assessment. Furthermore, advancing literature on the role of antibiotics, variations in appendicectomy, and its adjuncts have expanded the surgeon’s repertoire of management options. Owing to the varied presentation, diagnostic tools, and management of AA have also been proposed in special groups such as pregnant patients, the elderly, and the immunocompromised. This article seeks to raise the critical debates about what is currently known about the above aspects of AA and explore the latest controversies in the field. Considering the ever-evolving coronavirus disease 2019 situation worldwide, we also discuss the pandemic’s repercussions on patients and how surgeons’ practices have evolved in the context of AA.
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Affiliation(s)
- Thomas Zheng Jie Teng
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Department of Undergraduate Medicine, Lee Kong Chian School of Medicine, Singapore 308232, Singapore
| | - Xuan Rong Thong
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Department of Undergraduate Medicine, Lee Kong Chian School of Medicine, Singapore 308232, Singapore
| | - Kai Yuan Lau
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Department of Undergraduate Medicine, Lee Kong Chian School of Medicine, Singapore 308232, Singapore
| | | | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Department of Undergraduate Medicine, Lee Kong Chian School of Medicine, Singapore 308232, Singapore
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RAY K, SWAMINATHAN C. Two cases of atypical diverticular abscesses from sigmoid colon resulting from COVID-19 crisis-induced management delay. Chirurgia (Bucur) 2021. [DOI: 10.23736/s0394-9508.20.05150-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Yin JS, Govind S, Wiseman D, Inculet R, Kao R. Hepato-bronchial fistula secondary to perforated sigmoid diverticulitis: a case report. J Med Case Rep 2017; 11:106. [PMID: 28403899 PMCID: PMC5390442 DOI: 10.1186/s13256-017-1270-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 03/22/2017] [Indexed: 12/29/2022] Open
Abstract
Background Patients with diverticulitis are predisposed to hepatic abscesses via seeding through the portal circulation. Hepatic abscesses are well-documented sequelae of diverticulitis, however instances of progression to hepato-bronchial fistulization are rare. We present a case of diverticulitis associated with hepatic abscess leading to hepato-bronchial fistulization, which represents a novel disease course not yet reported in the literature. Case Presentation A 61-year-old Caucasian man presented with a history of unintentional weight loss and dyspnea both at rest and with exertion. He had a significant tobacco and alcohol misuse history. A massive right-sided pleural effusion was found on chest X-ray, which responded partially to chest tube insertion. A computed tomography scan of his thorax confirmed the presence of innumerable lung abscesses as well as a complex pleural effusion. An indeterminate tiny air pocket at the dome of the liver was also noted. A follow-up computed tomography scan of his abdomen revealed a decompressed hepatic abscess extending into the right pleural space and the right lower lobe. A sigmoid-rectal fistula was also revealed with focal colonic thickening, presumed to be the sequelae of remote or chronic diverticulitis. An interventional radiologist inserted a percutaneous drain into the decompressed hepatic abscess and the instillation of contrast revealed immediate filling of the right pleural space, lung parenchyma, and bronchial tree, confirming a hepato-bronchial fistula. After two concurrent chest tube insertions failed to drain the remaining pleural effusion completely, surgical lung decortication was conducted. Markedly thickened pleura were seen and a significant amount of gelatinous inflammatory material was debrided from the lower thoracic cavity. He recovered well and was discharged 10 days post-thoracotomy on oral antibiotics. The percutaneous liver abscess tube was removed 3 weeks post-discharge from hospital after the drain check revealed that the fistula and abscess had entirely resolved. Conclusions Refractory right-sided pleural effusion combined with constitutional symptoms should alert clinicians to search for possible hepatic abscess, especially in the context of diverticulitis. The rupture of an untreated hepatic abscess could lead to death from profound sepsis or rarely, as in this case, a hepato-bronchial fistula. Timely investigation and a multidisciplinary treatment approach can lead to improved patient outcomes.
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Affiliation(s)
- Jun Sunny Yin
- Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
| | - Shaylan Govind
- Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
| | - Daniele Wiseman
- Department of Medical Imaging, London Health Sciences Centre, University of Western Ontario, London, ON, Canada
| | - Richard Inculet
- Division of Thoracic Surgery, Department of Surgery, London Health Sciences Centre, University of Western Ontario, London, ON, Canada
| | - Raymond Kao
- Division of Critical Care, Department of Medicine, London Health Sciences Centre, Western University, London, ON, Canada.
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Kashiura M, Sugiyama K, Akashi A, Hamabe Y. Diverticulitis-induced pylephlebitis possibly misdiagnosed as biliary duct obstruction. Acute Med Surg 2016; 3:404-406. [PMID: 29123823 DOI: 10.1002/ams2.205] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 03/07/2016] [Indexed: 12/29/2022] Open
Abstract
Case A 59-year-old Asian man presented to our emergency department with hypogastrium pain, loss of appetite, and diarrhea. On admission, he was hypotensive and jaundiced. Laboratory test results revealed thrombocytopenia, hypercreatininemia, and hyperbilirubinemia. Color Doppler sonography showed no blood flow in the right and left branches of the portal vein, which seemed similar to biliary obstruction. Enhanced computed tomography showed portal vein thrombi, consistent with pylephlebitis; a broad-spectrum antibiotic and an anticoagulant were administered. Outcome The patient died of multiple organ failure 22 h post-admission. An autopsy revealed suppurative thrombi in the portal vein, multiple liver abscesses, and diverticulitis in the sigmoid colon. Conclusion Pylephlebitis, a rare complication of intra-abdominal infections, is associated with high rates of morbidity and mortality. Ultrasonography findings mimic those of biliary obstruction. Enhanced computed tomography is useful for diagnosing this condition.
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Affiliation(s)
- Masahiro Kashiura
- Tertiary Emergency Medical Center Tokyo Metropolitan Bokutoh Hospital Sumida-ku Tokyo Japan
| | - Kazuhiro Sugiyama
- Tertiary Emergency Medical Center Tokyo Metropolitan Bokutoh Hospital Sumida-ku Tokyo Japan
| | - Akiko Akashi
- Tertiary Emergency Medical Center Tokyo Metropolitan Bokutoh Hospital Sumida-ku Tokyo Japan
| | - Yuichi Hamabe
- Tertiary Emergency Medical Center Tokyo Metropolitan Bokutoh Hospital Sumida-ku Tokyo Japan
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Pages-Bouic E, Millet I, Curros-Doyon F, Faget C, Fontaine M, Taourel P. Acute pelvic pain in females in septic and aseptic contexts. Diagn Interv Imaging 2015; 96:985-95. [PMID: 26441019 DOI: 10.1016/j.diii.2015.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 07/05/2015] [Indexed: 12/29/2022]
Abstract
Acute pelvic pain in women is a common reason for emergency department admission. There is a broad range of possible aetiological diagnoses, with gynaecological and gastrointestinal causes being the most frequently encountered. Gynaecological causes include upper genital tract infection and three types of surgical emergency, namely ectopic pregnancy, adnexal torsion, and haemorrhagic ovarian cyst rupture. The main gastrointestinal cause is acute appendicitis, which is the primary differential diagnosis for acute pelvic pain of gynaecological origin. The process of diagnosis will be guided by the clinical examination, laboratory study results, and ultrasonography findings, with suprapubic transvaginal pelvic ultrasonography as the first-line examination in this young population, and potentially cross-sectional imaging findings (computed tomography and MR imaging) if diagnosis remains uncertain.
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Affiliation(s)
- E Pages-Bouic
- Centre hospitalier universitaire régional Lapeyronie, department of medical imaging, 191, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France.
| | - I Millet
- Centre hospitalier universitaire régional Lapeyronie, department of medical imaging, 191, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France
| | - F Curros-Doyon
- Centre hospitalier universitaire régional Lapeyronie, department of medical imaging, 191, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France
| | - C Faget
- Centre hospitalier universitaire régional Lapeyronie, department of medical imaging, 191, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France
| | - M Fontaine
- Centre hospitalier universitaire régional Lapeyronie, department of medical imaging, 191, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France
| | - P Taourel
- Centre hospitalier universitaire régional Lapeyronie, department of medical imaging, 191, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France
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Feasibility of low-dose unenhanced multi-detector CT in patients with suspected acute appendicitis: comparison with sonography. Clin Imaging 2014; 38:296-301. [DOI: 10.1016/j.clinimag.2013.12.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Revised: 09/30/2013] [Accepted: 12/26/2013] [Indexed: 12/29/2022]
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