A case of appendicocele

Abstract

A 58-year-old woman with an unconfirmed diagnosis of uterine fibroids, and a past medical history of uterine polyps, two cesarean sections and a right inguinal herniorraphy presented to the emergency department with 1 month of sharp right lower quadrant pain that had become debilitating 24 h prior to presentation. She also complained of vaginal discharge and bleeding while denying nausea, vomiting and fever. Physical examination revealed a mass in the right inguinal area that was exquisitely tender to palpation and irreducible at the bedside. Her symptoms were exacerbated with a valsalva maneuver. Bowel sounds were present in all four quadrants. Laboratory findings were all within normal limits. She remained afebrile. The patient had an abdominal/ pelvic MRI earlier that day at an outlying facility ordered by her gynecologist. Unfortunately, the results were not available at the time the patient presented. On further consultation, recommendations were made for outpatient follow up. Given the patient’s presentation, undifferentiated gynecologic pathology and history of multiple abdominal surgeries, further evaluation was warranted to solidify the diagnosis, and to confirm the need for surgical intervention for the most likely diagnosis of an incarcerated inguinal hernia. Computed tomography (CT) of the abdomen revealed a fibroid uterus, focal lesions in the urinary bladder and right indirect inguinal hernia containing the appendix with mild stranding and thickening of the hernia sac wall concerning for acute appendicitis (Figs. 1, 2 and 3). The appendix measured 7.0 cm in length and 0.7 cm in diameter on pathologic evaluation.