Acute appendicitis

Abstract

A 50-year-old morbidly obese man was hospitalized because of nausea, vomiting, diarrhea, and abdominal pain. CT revealed a dilated and mildly thickened small bowel, with an apparent transition point in the terminal ileum, consistent with partial small bowel obstruction. Diagnostic laparoscopy was planned, but aspiration during bowel preparation resulted in a respiratory arrest that necessitated mechanical ventilation. The patient was transferred to our institution. At colonoscopy with terminal ileal intubation, the appendix was bulging into the cecum and frank pus was flowing from the orifice (A, B) Probing with a biopsy forceps resulted in extrusion of more pus. The terminal ileal mucosa was edematous but otherwise normal (confirmed by subsequent histopathologic evaluation of biopsy specimens). CT immediately after colonoscopy disclosed thickened loops of ileum, but the appendix was not definitely identifiable. At laparoscopy, an inflamed retrocecal appendix was found and resected. The small bowel looked normal. Histopathologic evaluation of the resected appendix (C; H&E, orig. mag. ×2) revealed acute inflammation limited primarily to the lumen and mucosa, which was mostly ulcerated although a rare residual epithelial crypt could be identified (D, middle left; H&E, orig. mag. ×40). A submucosal lymphoid follicle was present (D, center). The inflammatory infiltrate in the lumen was composed of neutrophils, mononuclear cells, and blood (D, inset; H&E, orig. mag. ×400), above what remained of a partially denuded epithelium (D, asterisk). Recovery was uneventful, and the patient was discharged at 48 hours after surgery. View Large Image Figure Viewer View Large Image Figure Viewer View Large Image Figure Viewer