Acute on Chronic Appendicitis

Abstract

Purpose: Introduction: Chronic appendicitis is characterized by the pathologic findings of chronic inflammation or fibrosis of the appendix. Clinically, the patients have prolonged right lower quadrant pain with relief of symptoms following appendectomy. We herein present a case of chronic appendicitis that posed a significant diagnostic challenge. Case Presentation: A 60-year-old male with a history of DM/HTN/alcoholic liver cirrhosis presented with diffuse abdominal pain for 3 days. The pain was associated with nausea, vomiting, and subjective fever. He also noticed worsening distended abdomen since the onset of abdominal pain. He admits chronic constipation and right lower quadrant (RLQ) pain for several years which were thought to be attributed to diverticulosis demonstrated by colonoscopy. His vital signs were T 101.3 F, HR 110/min, RR 20/min, BP 145/97 mmHg, SpO2 97% on room air. In general, he was alert and oriented but in distress due to abdominal pain. His conjunctivae were icteric. His abdomen was distended, bowel sounds were diminished, but there was no tenderness. There was trace edema in his lower extremities. His labs revealed WBC 1400/μl, band 41.0%, HGB 14.9 g/dl, PLT 102 K/μl, Na 136 mEq/l, K 4.4 mEq/l, Cl 103 mEq/l, CO2 24 mmol/l, BUN 14.0 mg/dl, Cr 1.4 mg/dl, T-Bil 2.3 mg/dl, D-Bil 1.7 mg/dl, ALP 397 U/l, AST 54 U/l, ALT 33 U/l, Amy 41 U/l, Lipase 22 U/l, TP 6.1 mg/dl, Alb 2.1 mg/dl, PT-INR 1.7, PTT 36.7 sec. Abdominal/pelvic CT showed partial small bowel obstruction, macronodular liver, perihepatic ascites, and splenic varices. Appendix was not visualized. Emergent exploratory laparotomy revealed ruptured appendix surrounded by adhesions. Histologically, there was significant fibrosis of the appendiceal wall as well as periappendicitis and periappendiceal abscess. These findings demonstrated acute infection superimposed on chronic inflammatory process. The patient fully recovered after appendectomy. Discussion: RLQ pain is one of the most common complaints and differential diagnoses are broad. In this case, chronic RLQ pain was probably due to chronic appendicitis confirmed by pathology. The clinical manifestations and histopathological findings of chronic appendicitis are different from those of acute appendicitis. They are characterized by symptoms lasting longer than 4 weeks, confirmation of chronic inflammation through histopathological examination, improvement of symptoms after appendectomy. The imaging studies might show appendicolith but appendices are not always visualized, which poses a significant diagnostic challenge. Therefore, it is prudent to consider chronic appendicitis as a differential diagnosis when approaching to chronic RLQ pain.