Ruptured Acute Appendicitis With Calcified Appendicolith Mimicking Acute Gastroenteritis

摘要

A rare case of a man who presented with clinical features suggestive of acute gastroenteritis after a meal, and was subsequently diagnosed with ruptured acute appendicitis (AA) and calcified appendicolith on account of radiological findings, is reported. The diagnosis of AA can be difficult in the atypical case, and radiological imaging plays a vital role. The finding of calcified appendicolith in a patient presenting with acute abdomen should raise the index of suspicion of AA, especially in a developing country. Introduction Appendicitis is more common in developed than in developing countries and appendicoliths have an aetiologic role in the disease. The prevalence of appendicolith is higher in developed countries than in developing countries, and also higher in patients with than in those without appendicitis. This has been attributed to the low-fibre diets consumed in developed countries which lead to appendicolith formation1. Calcified appendicoliths are found in 10% of patients with acute appendicitis, but they are seen more frequently in perforated appendicitis and in abscess formation2. The clinical diagnosis of acute appendicitis (AA) is based primarily on patient history and on physical examination findings. The classic presentation of AA is seen in only 50% - 60% of patients, and the diagnosis may be missed or delayed in atypical presentations. The differential diagnosis of AA are abdominal pain of unknown cause, pelvic inflammatory disease and other gynaecologic disorders, mesenteric lymphadenitis, acute gastroenteritis and other gastrointestinal tract diseases, and urinary tract infection and obstruction3. This case is reported because firstly, it is uncommon for AA to mimic acute gastroenteritis in clinical presentation, secondly the calcified appendicolith was quite large, measuring 19 x 18mm, and thirdly to highlight the importance of radiological imaging in the diagnosis of acute abdominal pain. Case Report AA is a 45 year old man who presented with the history of abdominal pain of sudden onset, diarrhoea, fever, headache, and vomiting. His last meal (which he ate with other members of his family) was eight hours before presentation. No other member of the family had any of these symptoms. The past medical and surgical history and the drug history were not contributory. On examination, he was ill-looking, febrile (temperature of 37.6 degrees centigrade), and dehydrated. The pulse rate was 78/minute; regular and the blood pressure was 140/90 mmHg. The chest was clinically clear. The abdomen was full and mildly tender generally. The clinical impression was ?malaria, ?gastroenteritis secondary to food poisoning. He was commenced on intravenous (IV) fluids, IV hyoscine butylbromide, IV Maxolone, and intramuscular diclofenac. A plain abdominal radiograph was requested on account of increasing abdominal distension.Abdominal ultrasonography revealed free extraluminal intraperitoneal fluid as evidenced by fluid in the hepatorenal recess. There was an aperistaltic, non-compressible, blind-ended, tubular structure in the right iliac fossa, measuring 13.9 mm in diameter, representing an inflamed appendix . There was periappendiceal inflammatory fluid and pericecal inflammation. The sonographic diagnosis was perforated AA with peritonitis, with perforated typhoid Ileitis as a differential diagnosis. Abdominal radiograph showed splaying of the properitoneal fat lines in keeping with abdominal distension, and a rounded, laminated, calcified mass (about 2 cm in diameter) in the right iliac fossa, representing a calcified appendicolith (Figure 1). Abdominopelvic computed tomography (CT) scan showed a rounded, high attenuation mass measuring 19 x 18 mm in diameter in the lumen of the distended appendix, indicating a calcified appendicolith (Figure 2). Minimal, free, extraluminal, intraperitoneal fluid was observed. The gall bladder, spleen, pancreas, and both kidneys were normal. Minimal, bilateral pleural effusion and mild c