“Worm within worm”: acute appendicitis containing an adult Ascaris lumbricoïdes

Appendicitis is the first aetiology for abdominal surgical emergency. Ascariasis is the most common helminth infection in tropical countries where it is endemic. The ability of intestinal helminths to wander through the digestive system means that it can end up in the appendix lumen and lead to appendicitis by luminal obstruction. However, this presentation is still rarely described in the literature. In fact, most of the diagnoses of roundworm associated with appendicitis are made retrospectively by the discovery of its eggs on the pathological examination of an appendectomy specimen. We report the case of a 7-year-old patient living in a tropical area who consulted for acute right lower quadrant pain. The ultrasound suspected the diagnosis of appendicitis and also revealed multiple intestinal worms including one in contact with the inflamed appendix. Surgical exploration confirmed appendicitis associated with roundworm partly in the appendicular lumen through a perforation.

RIPASA versus Alvarado score in the assessment of suspected appendicitis in children: a prospective study

Background Diagnosis of acute appendicitis remains a problem in children with right lower quadrant pain. Challenging diagnosis and fears of missing an inflamed appendix may lead to a negative appendectomy. Many scoring systems have been developed to reduce ambiguities in the diagnosis of appendicitis. Alvarado is one of the most commonly used scoring methods in pediatric patients. The RIPASA score is considered to be a better diagnostic scoring method in adults compared to Alvarado. The present study aims to compare RIPASA and Alvarado scoring systems in determining the possibility of acute appendicitis in children with right lower quadrant pain. This study included 179 consecutive pediatric patients who were referred to pediatric surgery with suspicion of acute appendicitis. The cut-off value was >7.5 for the RIPASA score vs. ≥7 for the Alvarado score. The possibility of appendicitis was divided into three groups for the Alvarado score and four groups for the RIPASA score. Results In this study, 158 of 179 patients were operated on. In 140 of the operated patients, the diagnosis of appendicitis was confirmed by histopathology. The negative appendectomy rate was 11.4%. Specificity and negative predictive value of RIPASA score were higher than those of Alvarado (p<0.001). No difference was found between the two scores concerning sensitivity, positive predictive value, and the area under the receiver operator characteristics curve (p>0.05). Conclusion The RIPASA scoring system can be used as an alternative to the Alvarado scoring system in the management of patients with right lower quadrant pain in emergency services and pediatric outpatient clinics. With the use of the RIPASA score, more patients with a low likelihood of appendicitis can be detected and further contributed to the reduction of the negative appendectomy rate.

Acquired Diverticulosis of the Vermiform Appendix: A Rare Case Report

Diverticulosis of the appendix, as a rare and incident disorder, mimics acute or chronic appendicitis and is characterized by herniation of the appendiceal mucosa through the muscular wall. Symptom and laboratory data of diverticular disease usually represent chronic inflammation. In this study, a 43-year-old female with a history of right lower quadrant pain and anorexia represented abdominal tenderness and rebound tenderness in the physical examination and normal laboratory tests. Abdominal sonography did not show any evidence of acute appendicitis. The removed appendix was 12 cm in length and had multiple diverticular protrusions along with it. The histologic examination showed diverticulosis without evidence of inflammation. The patient was discharged two days later in optimal clinical condition. Diverticulosis of the appendix often is confused with acute or chronic appendicitis based on similar presenting symptoms and imaging studies. Although surgery is the definitive treatment of both conditions, an appropriate diagnosis of diverticular disease before surgery is very important because of the association of appendiceal diverticular disease with neoplasm and other complications.

Acute appendicitis: is it a seasonal disease?

Background: The aim of this study was to review the management of acute appendicitis in a rural hospital. It was generally reported to be more common in men. Appendicitis is the most common surgical cause of abdominal pain worldwide. Appendectomy is the lonely curative treatment of appendicitis.Methods: This was a retrospective study in which we reviewed the records of the patients who had been diagnosed and operated on for appendicectomy from January to December 2017 in a rural hospital. The data were analyzed with SPSS version 25.Results: The total number of the patients was 114. About 69.3% are males. The mean age was 25.11 years. About (39.5%) were above 20 years old. Most of the cases presented in the period between January and March (27.3%). Right lower quadrant pain was the most common presenting symptom (93.9%). Nausea and vomiting mentioned by 57 (50%) and 74 (64.9%) of the participants respectively, fever in 42 (36.8%), muscle guarding in 0.9%, tenderness in 44 (38.6%), abdominal ultrasound was requested in 96 (84%). The most common histological diagnosis was acute suppurative appendicitis with peri-appendicitis in 15 (13.2%). All the cases were treated with open appendicectomy.Conclusions: We concluded that male are more affected with acute appendicitis. The most common presenting symptom was right lower quadrant pain. The vast majority of the cases were in the winter. Ultrasound has been used in the most cases particularly in male more than in females. The most common histological diagnosis was acute suppurative appendicitis. Open appendicectomy is the main operative management in our pts.

A case report of multi-system inflammatory syndrome in adults (MIS-A) associated with heart failure

Background Multi-system inflammatory syndrome in children (MIS-C) is a systemic inflammatory condition where various body organs, such as the heart, kidney, gastrointestinal organs, become inflamed. Several cases have been reported in children linking MIS-C with novel corona virus disease-2019 (COVID-19); however, few cases have been reported in adults [multi-system inflammatory syndrome in adults (MIS-A)]. Case summary A case of a 20-year-old male patient with a history of COVID-19 infection 2 months before presentation who presented with fever and acute right lower quadrant pain. Workup revealed right-sided mesenteric lymphadenopathy and mild colitis that was non-responsive to antibiotics. The patient was found to have significantly elevated inflammatory markers. He also developed myocarditis resulting in acute systolic heart failure with reduced ejection fraction. The diagnosis of MIS-A was made by exclusion. The patient showed improvement with intravenous immunoglobulin and pulse steroids. Based on the available literature, MIS-C was defined till the age of 21; however, we think it is a misnomer for adults more than 18. Hence, we prefer to use MIS-A for our patient. Conclusion It is essential to diagnose and treat patients with the multi-system inflammatory syndrome at an early stage; the management of these patients, especially with heart disease, should include immune-modulatory therapy as well as guideline-directed therapy.

Burkitt-type lymphoma incidentally found as the cause of acute appendicitis: a case report and review of literature

Background Appendectomy remains one of the most common emergency operations. Recent research supports the treatment of uncomplicated appendicitis with antibiotics alone. While nonoperative management of appendicitis may be safe in some patients, it may result in missed neoplasms. We present a case of acute appendicitis where the final pathology resulted in a diagnosis of a Burkitt-type lymphoma. Case presentation An 18-year-old male presented to the emergency department with 24 h of right lower quadrant pain with associated urinary retention, anorexia, and malaise. Past medical history was significant for intermittent diarrhea and anal fissure. He exhibited focal right lower quadrant tenderness. Workup revealed leukocytosis and CT uncovered acute appendicitis with periappendiceal abscess and no appendicolith. Laparoscopic appendectomy was performed and found acute appendicitis with associated abscess abutting the rectum and bladder. Pathology of the resected appendix reported acute appendicitis with evidence of Burkitt-type lymphoma. A PET scan did not reveal any residual disease. Hematology/oncology was consulted and chemotherapy was initiated with an excellent response. Conclusions Appendiceal lymphomas constitute less than 0.1% of gastrointestinal lymphomas. Primary appendix neoplasms are found in 0.5–1.0% of appendectomy specimens following acute appendicitis. In this case, appendectomy allowed for prompt identification and treatment of an aggressive, rapidly fatal lymphoma resulting in complete remission.

Revisiting the Differential for Left Lower Quadrant Pain: A Case of Epiploic Appendagitis

Appropriate triage of abdominal pain in the outpatient setting is critical for safe and effective management of patients. Abdominal pain has a broad differential, heavily dependent on elicitation of a clear history, and pertinent physical exam findings. In adults >50 with left lower quadrant pain, diverticulitis is the most common cause. Diverticulitis can cause significant morbidity in this population, frequently requiring inpatient management, systemic antibiotics, and occasionally surgical intervention. A frequently overlooked cause of left lower quadrant pain in adults is Epiploic Appendagitis (EA). While similar in presentation, unlike diverticulitis, EA rarely requires more than outpatient treatment with non-steroidal anti-inflammatories for pain management. Here we present a report of left lower quadrant pain consistent with diverticulitis in a 55 yo female in the outpatient setting, found to have EA by imaging. This case demonstrates that the differential for LLQ pain without signs of an acute abdomen in an adult, should include EA.

Epiploic Appendagitis: A Riddle for Right Lower Quadrant Pain!

Epiploic appendagitis (EA) is inflammation of epiploic appendages, which are pedunculated fatty structures, extend from the cecum to the rectosigmoid junction, and are covered by the peritoneum. Torsion, infarction, and inflammation of it present with acute lower abdominal pain and localized tenderness in a well-looking patient. It poses as diagnostic conundrum due to its rarity and not picked by conventional radiography. A 50-year-old male presented with pain in RLQ for past 1 day, which kept on increasing without any other symptoms. His abdomen was soft with tenderness localized to the right lower quadrant (RLQ), classically at McBurney’s point along with mild peritonism. Rest laboratory test, chest, and abdominal X-ray were normal except slight leukocytosis. Ultrasound was inconclusive. A working clinical diagnosis of appendicitis was made. Patient did not consent for surgery and was started on antibiotics with pain killers. With no significant improvement, he underwent CT scan which revealed focal area of soft-tissue attenuation along the lateral wall of ascending colon with fat stranding. He was diagnosed as EA and improved on conservative treatment. EA of RLQ of abdomen mimics acute appendicitis and can be considered as an uncommon differential diagnosis in presence of radiological findings of normal-appearing appendix. CT is the investigation of choice, and treatment is essentially conservative. Further, if appendix is found normal at exploration, surrounding epiploic appendages of the cecum and ascending colon should also be evaluated carefully for inflammation/hematoma/gangrene, besides looking for Meckel’s diverticulum.

Complicated acute appendicitis in a child with left atrial isomerism: a case report

Background Heterotaxy syndrome is a rare clinical entity that is characterized by abnormal visceral organ arrangement in the chest and abdomen. Left atrial isomerism is a subcategory of heterotaxy syndrome characterized by the presence of multiple spleens with or without cardiac anomalies. Patients may remain asymptomatic their whole lives until they are diagnosed incidentally. Given that patients with left atrial isomerism might demonstrate atypical presentations of acute intrabdominal pathologies, it is important to keep a high index of suspicion when encountering such cases. Case presentation In this report, we present a case of a 9-year-old boy with a known history of left atrial isomersim who presented with left lower quadrant pain and positive McBurney, psoas, and obturator signs on the left side. A computed tomography scan of the abdomen confirmed the diagnosis of perforated acute appendicitis on the left, which prompted an emergent laparoscopic appendectomy. Conclusion Our case highlights the importance of keeping a high index of suspicion for a heterotaxy syndrome that is complicated by acute appendicitis in pediatric patients presenting with vague abdominal pain. Planning the location of trocar placement in patients with situs anomalies is of paramount importance to avoid technical difficulties in laparoscopic procedures.