Perforated appendicitis

The patient was admitted a week ago with unspecific, generalized abdominal pains. She was passing stool regularly and was not vomiting.

The full haemogram revealed a granulocytosis at about 15,000/ml. Stool test was positive for cysts of amoeba (which is a very common finding in our area). 

Widal test showed a mild positivity of 1:80 for both antigens O and H. Abdominal U/S was completely negative; there was no abdominal distention, no guarding, and intestinal sounds were present.

At first, we have considered the patient not to be surgical and we have put her on antibiotics (IV CAF and IV Metronidazole), thinking of enterocolitis secondary to enthamoeba histolitica and some kind of salmonella spp.

Three days later the patient has developed severe abdominal pains, important distension, some guarding, while intestinal sounds disappeared.

We have repeated the full haemogram and the WBCs were 14,000: we would have expected an increase of leucocytosis which we did not find.

Considering the condition of the abdomen, we have nevertheless chosen to do a laparatomy.

Opening the abdomen we have found the peritoneal cavity full of pus.

The abdominal distension was caused by a sigmoid volvolus which was responsible of the mechanical obstruction. But the volvolus itself was the result of adhesions caused by pus.

It was quite easy to release the adhesions and to suck the pus. At the beginning we were thinking of a gynaecological origin of the infection, but tubes, ovaries and uterus were normal.

We have then checked the intestine for signs of perforation, starting from the rectum, because the small intestine was looking good and not involved in any inflammatory process.

We have actually found the cause of the peritonitis, when we have reached the caecum: there was a very necrotic, perforated appendix. 

We have therefore performed appendicectomy.

Finally we have put an NGT to the patient; thereafter, we have washed the abdominal cavity, put drainages and closed.

The patient is now recovering well.

The lesson we have learnt is that the diagnosis of appendicitis is sometimes very difficult, either clinically or through laboratory tests: even the axiom that appendicitis causes a leucocytosis of 20,000 and above is not always true. Abdominal U/S is seldom useful for the above diagnosis, unless already there is a peri-appendicular abscess. Eventually we have experienced once again that any delay in the diagnosis of appendicitis can cause severe increase in morbidity.

Dr Bro Giuseppe Gaido