S1716 Atypical Appendicitis in the Elderly

Abstract

Introduction: Amyand’s hernia is an extremely rare condition in which the appendix is positioned in the inguinal hernia sac. Acute appendicitis is much less common in this situation and few reports are found in the literature. We present such a case with the hopes that we increase awareness about this uncommon condition one in which preoperative diagnosis remains difficult. Case Description/Methods: A 97 year old male with dementia, urinary stones and chronic bilateral non-reducible inguinal hernias extending down into his scrotum presented to the emergency department (ED) with right-sided abdominal pain. In the ED, physical exam was notable for soft, non-distended abdomen with right lower quadrant tenderness and two large bilateral inguinal hernias. Labs were without any notable leukocytosis or lactic acidosis. CT abdomen/pelvis findings revealed a large hernia on the right side with what appeared to be the cecum and appendix in the hernia sac with stranding and some pericolonic fluid collection. General Surgery was consulted at this time with concerns for incarcerated right-sided inguinal hernia. Patient underwent open right inguinal hernia repair and appendectomy with intraoperative findings of reducible right direct and indirect inguinal hernia and inflammatory changes of the appendix indicative of likely appendicitis. Patient did well post-operatively and was discharged back to his skilled nursing facility. Discussion: Amyand’s hernia is described as a hernia consisting of an incarcerated appendix associated with or without an acute appendicitis. First described in 1735 by Claudius Aymand in an 11-year-old boy, this condition remains rare with an incidence of about 0.5-1%. Even rarer is the presentation of an acute appendicitis within the inguinal sac with an incidence around 0.1%. It is present three times more likely in the pediatric patient due to a patent processus vaginalis and is more common in males. Because patients may present with nonspecific symptoms, this remains a difficult diagnosis to make preoperatively and hence is mainly found intraoperatively during surgical exploration of a complicated inguinal hernia. With the increased use of CT scans, this diagnosis is more frequently being made preoperatively, allowing for both safer preoperative planning and intraoperative decision-making. While the patient will ultimately require surgical interventions, it is important to keep in mind the role of pre-operative imaging to aid in management and improved intraoperative decision-making.Figure 1.: Patchy Ulceration of the Transverse Colon.