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Case 314

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Male patient, 16 years old, at the 2nd postoperative day (POD) after a video laparoscopic appendectomy, develops abdominal pain at the right hypogastric region, associated with fever, diarrhea, and hyporexia. CT scan of the abdomen and pelvis was performed.

Considering the clinical history and the CT findings, which one is the most likely diagnosis?

a) Free appendicolith associated with abscess formation

25%

b) Appendicular plastron

25%

c) Right ureteral obstruction due to urolithiasis

25%

d) Epiploic appendagitis

25%
   

Image analysis

Image 1 - Analysis: Non-contrast-enhanced Computed Tomography (CT) image of the abdomen and pelvis, axial view, at the L5-S1 vertebral level. Radiopacity with metallic density, adjacent to the cecum, at vermiform appendix region, compatible with surgical staple from the previous appendectomy - clinical data (yellow arrow). Mild small bowel loops distension associated with intraluminal air-fluid levels (in orange).

 

Image 2 - Analysis: Contrast-enhanced Computed Tomography (CT) image of the abdomen and pelvis, axial view, at the S3-S4 vertebral level, portal venous phase. Thick-walled (in green) fluid collection (in red) associated with air-fluid level and nonspecific radiopaque concretion in its lateral right border (yellow arrow) suggesting possible appendicolith.

 

Image 3 - Analysis: Contrast-enhanced Computed Tomography (CT) image of the abdomen and pelvis, coronal reconstruction, portal venous phase. Radiopacity with metallic density, adjacent to the cecum, at vermiform appendix region, compatible with surgical staple from the previous appendectomy - clinical data (yellow arrow). Thick-walled (in green) pelvic fluid collection (in red) with infiltrating air collections (blue arrows) and nonspecific radiopaque concretion in its lateral right border (red arrow) suggesting possible appendicolith. Mild small bowel loops distension (in orange).

Highlights

- Appendicoliths are usually asymptomatic and incidentally found at imaging diagnostic tests in a large number of children and young adults with acute appendicitis;

- CT is the most used imaging exam and usually indicated when ultrasonography is not conclusive for acute appendicitis;

- The presence of appendicoliths with acute appendicitis is associated with a higher probability of appendix perforation and abscess formation;

- The physiopathology of the appendicoliths formation is uncertain and idiopathic: it may be associated with foreign body and low-fiber diet;

- The isolated presence of appendicolith does not establish formal indication to appendectomy, prevailing clinical follow-up, especially when it is its first appearance and without associated complications.

References

- Brown MA. Imaging acute appendicitis. Semin Ultrasound CT MR. 2008 Oct;29(5):293-307.

- Karul M, Berliner C, Keller S, Tsui TY, Yamamura J. Imaging of appendicitis in adults. Rofo. 2014 Jun;186(6):551-8. doi: 10.1055/s-0034-1366074. Epub 2014 Apr 23.

- Butler P, Mitchell A, Healy JC. Applied Radiological Anatomy. Cambridge University Press. (2012) ISBN:0521766664.

- Petroianu A. Diagnosis of acute appendicitis. Int J Surg. 2012;10(3):115-9 full-text.

- Kaya B, Eris C. Different Clinical Presentation of Appendicolithiasis. The Report of Three Cases and Review of the Literature. Clin Med Insights Pathol. 2011; 4: 1–4. Published online 2011 Mar 30. doi:  10.4137/CPath.S6757.

- D’Ippolito G, Caldana R, Gastrointestinal – Série Colégio Brasileiro de Radiologia e Diagnóstico por Imagem. 1st Edition. Rio de Janeiro: Elsevier, 2011.

Author

Rafael Valério Gonçalves, 6th year medical student at Universidade de Minas Gerais.

E-mail: rafaelvg[at]gmail.com

Supervisors

Dr. Júlio Guerra Domingues, Substitute Professor at the Department of Anatomy and Image at Medical School of Universidade de Minas Gerais.

E-mail: jgdjulio[at]gmail.com

Reviewers

Lucas Bruno Rezende, Bruno Campos, Ariádna Andrade, Giovanni Oliveira Carvalho, professor José Nelson M. Vieira and professor Viviane Parisotto.

Translated by

Gabriella Yuka Shiomatsu, 3rd year medical student at Universidade de Minas Gerais.

E-mail: gabi.yuka[at]hotmail.com

Test question

(Federal University of Goiás/UFG - MEDICAL RESIDENCY 2016 - Adapted) In acute appendicitis, the most accurate ultrasonographic finding is the presence of:

a) Periappendicular fat blurring

25%

b) Diameter greater than 6 mm with obstruction

25%

c) Appendicolith

25%

d) Thickening of the appendicular wall

25%

e) Loss of compressibility

25%
   

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