Duodenal fistula associated with a peri-appendiceal abscess: A case report

INTRODUCTIONRetroperitoneal abscess is an unusual presentation of perforated appendicitis. A fistula between the duodenum and an abscess resulting from appendicitis has not been previously reported.PRESENTATION OF CASEA 53-year-old Japanese man with a past medical history of hypertension and iron deficiency anemia presented with a 10-day history of fever and right lower abdominal pain, and was diagnosed with a retroperitoneal abscess secondary to perforated appendicitis. He was then treated with piperacillin and tazobactam after undergoing ultrasound-guided drainage, after which his overall condition improved. Due to iron deficiency anemia, we performed further evaluation for gastrointestinal bleeding and esophagogastroduodenoscopy showed an elevated lesion with granulomatous tissue in the duodenum, without an associated ulcer. At 10 days after abscess drainage, duodenography with contrast showed continuity between the abscess cavity and the duodenum. At 74 days after drainage, we performed laparoscopic appendectomy. Pathological examination showed granulomatous tissue inside the appendix with an inflammatory background and fecaliths infiltrated by macrophages.DISCUSSIONPerforated appendicitis has various presentations and many unusual fistulae have been reported, however, a fistula between a peri-appendiceal abscess and the duodenum has not yet been reported. A retroperitoneal abscess around the duodenum and appendix should be checked to differentiate it from Valentino's syndrome.CONCLUSIONWe present the rare complication of a duodenal fistula during the treatment of perforated appendicitis. The possibility of fistula formation should be considered in patients with complicated appendicitis.     

Cardiac metastasis from gallbladder carcinoma

INTRODUCTIONPrimary gallbladder carcinoma is a rare aggressive neoplasm of elderly with poor prognosis. The tumour is often unresectable at the time of diagnosis. Metastasis to heart is rare and only 6 cases have been reported in the indexed literature. We herein report a case of gallbladder carcinoma metastasizing to heart.PRESENTATION OF CASEA 54 year old female presented with dyspnoea and chest pain with past history of radical cholecystectomy and palliative chemotherapy for adenocarcinoma of gallbladder. Chest X-ray showed cardiomegaly and 2-D ECHO revealed features of tumour deposits on the surface of myocardium and malignant pericardial effusion. Mini-thoracotomy and pericardial window procedure was done to relieve distressing symptoms and biopsy of pericardial tissue revealed metastatic adenocarcinoma. In spite of intensive care, patient succumbed to disease in the post-operative period.DISCUSSIONPrimary adenocarcinoma of gallbladder is the most common malignancy of biliary tract and fifth most common malignancy of gastro-intestinal system with dismal prognosis. It most commonly spreads to liver and regional lymph nodes, very rarely distant metastasis occurs to kidney, adrenal, thyroid and bones as reported in the literature. Metastasis to heart presents with symptoms of cardiac failure due to pericardial effusion. Even with intensive care patients will invariably succumb to the disease.CONCLUSIONMetastatic spread to heart from carcinoma of gallbladder is very rare. Should a patient be suspected of or an operated case of gallbladder carcinoma present with symptoms of congestive heart failure and massive pericardial effusion, cardiac metastasis should be considered.     

Unusual case of persistent unilateral pleural effusion secondary to pancreaticopleural fistula

INTRODUCTIONPancreaticopleural fistula is rare. It occurs as a complication in acute and chronic pancreatitis. Here we report a case of persistent unilateral pleural effusion secondary to pancreaticopleural fistula.PRESENTATION OF CASEA 37 year old non alcoholic gentleman who had no history of pancreatitis and presented with breathlessness and tachypenia. X-ray chest showed massive pleural effusion on the right side. Amylase estimation of the tapping fluid was very high. ERCP showed a pancreaticopleural fistula.DISCUSSIONPancreaticopleural fistula is a rare entity with an incidence of 0.4-4.5%. It occurs either as a complication in pancreatitis, or after injury of the pancreatic duct. A greatly elevated pleural fluid amylase is usually the first step towards the diagnosis. ERCP and CT will identify the fistulous tract in 70%. Treatment is mainly directed towards intercostal drainage and control of the fistula.CONCLUSIONPresentation is misleading in most of cases and needs aware clinicians with a high index of suspicion.     

Erdheim-Chester disease: The role of video-assisted thoracoscopic surgery in diagnosing and treating cardiac involvement

INTRODUCTIONErdheim–Chester disease is a rare, non-Langerhans histiocytosis in which pericardial involvement is diagnosed with increasing frequency and is associated with high mortality rates.PRESENTATION OF CASEA 53-year-old woman presented with progressive exertional dyspnea and pericardial effusion was discovered. Further investigations revealed the presence of a diffuse, infiltrating process and a diagnosis of Erdheim–Chester disease was made. An emergent pericardiocentesis by subxiphoid approach was completed but recurrent drainage obviated removal of the pigtail catheter. A pleuro-pericardial window was placed using video-assisted thoracoscopic surgery (VATS) and analysis of the resected specimen confirmed pericardial involvement.DISCUSSIONIn this case, high pericardial fluid output demanded definitive treatment of the pericardial effusion. Traditionally this would be completed via thoracotomy. VATS is a minimally invasive alternative which permits exploration of the thoracic cavity and the creation of a pleuropericardial window.CONCLUSIONWe describe, for the first time, the successful use of VATS for both diagnostic confirmation and therapeutic relief of recurrent pericardial fluid drainage due to pericardial involvement by Erdheim–Chester disease.     

Pericardial effusion following pulmonary resection

Objective Postoperative pericardial effusion commonly occurs after open heart surgery. However, after general thoracotomy such as pulmonary resection, there have been few reports of pericardial effusion. The purpose of this study is to investigate patients with pericardial effusion following pulmonary resection.Methods: Among 2,385 patients with pulmonary resection for lung neoplasm in our institute, eight patients, whose pericardium had never been opened during the operation, developed pericardial effusion. The clinical characteristics of the eight patients were analyzed.Results: Pericardial effusion after pulmonary resection was divided into two subtypes: pericardial effusion in three patients with left thoracotomy occurring within 30 days postoperatively, and pericardial effusion in the remaining five patients with right thoracotomy occurring more than 30 days postoperatively. Pericardiotomy or pericardiocentesis was performed in three symptomatic patients, and the remaining five asymptomatic patients were treated with diuretics. Pericardial effusion disappeared in three of the five patients about 1–3 months after the conservative treatment, while, in the remaining patients, because pericardial effusion had increased gradually, pericardiocentesis was performed.Conclusion: From our experience, the treatment strategy of drainage for early pericardial effusion and diuretics for late pericardial effusion seems to be appropriate. (Jpn J Thorac Cardiovasc Surg 2006; 54:193-198)     

Eleven years' experience with pericardial-peritoneal window in the management of malignant and benign pericardial effusions

Background: Before 1983 we routinely used subxiphoid drainage for the management of pericardial effusions. Pericardial-pleural window through a left anterior thoracotomy was used in selected patients. Due to frustration over the rate of recurrent pericardial effusions with subxiphoid drainage alone and concern over the higher morbidity with thoracotomy, the creation of a 3-cm pericardial-peritoneal window in the fused portion of the pericardium and diaphragm overlying the left lobe of the liver was added to subxiphoid drainage in 1983. Methods: This study is a retrospective chart review of the 33 patients undergoing pericardial-peritoneal window from 1983 through 1993. Eighteen patients had malignancies, mainly lung and breast, and 15 had benign pericardial effusions. Results: The procedure was well tolerated, with a 30-day mortality of 9%; however, no deaths were directly related to the pericardial effusion or the procedure. No patient developed peritoneal carcinomatosis or diaphragmatic hernia. One patient developed recurrent pericardial effusion during follow-up, and two required pericardiectomy for constrictive disease. Among those with malignancies, patients with breast cancer had the longest survival after pericardial-peritoneal window. Conclusions: Pericardial-peritoneal window is a simple, safe, and effective procedure and applicable to most patients with malignant and noninfectious benign pericardial effusion, including those with tamponade. Presented at the 47th Annual Cancer Symposium of The Society of Surgical Oncology, Houston, Texas, March 17–20, 1994.     

Acute appendicitis presenting as chest pain

IntroductionAbdominal pain is the primary presenting complaint of patients with acute appendicitis. Acute appendicitis presenting as chest pain is extremely rare and according to our search such presentation due to herniation of appendix into thorax through congenital diaphragmatic defect has not yet been reported.Presentation of caseWe present a case of a 12 year old male child who presented with acute chest pain. ECG was suggestive of ischemic changes. Echocardiogram and cardiac enzymes were within normal limits. Chest X-ray and gastrograffin contrast study confirmed the diagnosis of congenital diaphragmatic hernia. On exploration inflamed appendix was found herniated through the diaphragm along with caecum, ascending colon and transverse colon. Histology confirmed the diagnosis of acute appendicitis.DiscussionAcute appendicitis may sometimes have very varied and rare presentation. In late presenting CDH, the most important factor responsible for acute or chronic presentation seems to be the type of herniated viscera.ConclusionThis report presents a rare case of late-presenting CDH with herniated appendix along with caecum, ascending colon and transverse colon. Unusual presentation of chest pain was due to an attack of acute appendicitis. Late-presenting CDH is a very intriguing defect with a wide spectrum of clinical manifestations. It should be suspected in cases of unexplained acute or chronic respiratory or gastrointestinal symptoms, and abnormal chest radiographic findings. The prognosis is favorable with correct diagnosis and prompt surgical repair.     

Gangrenous appendicitis in Amyand’s hernia: Surgical approach under local anesthesia. Case report and review of the literature

Introduction and importanceAmyand hernia is a rare disease seen in approximatively 1% of all hernias, complications of it, like acute appendicitis, or perforated appendicitis are even more rare, about 0.1%. Its diagnosis is very difficult in the preoperative period: it is usually an incidental finding.Case presentationWe report an unusual case of perforated gangrenous appendicitis with peri-appendicular abscess occurring in an irreducible Amyand’s hernia. An 80-year-old male, with chronic obstructive disease and pulmonary emphysema, atrial fibrillation, acute myocardial infarction, underwent urgent surgery, under local anesthesia, for right incarcerated inguinoscrotal hernia.He was found to have a perforated gangrenous appendicitis with peri-appendicular abscess within a right indirect inguinal hernia sac. Appendicectomy and Bassini’s hernia repair were performed under local anesthesia without any complications.Clinical discussionThe treatment of Amyand’s hernia is not standardized. The current generally accepted algorithm for Amyand’s hernia is essentially contingent on the appendix’s condition within the hernia sac.ConclusionAppendectomy and primary herniorrhaphy, under local anesthesia, for type 3 of Amyand’s hernia, is a safe procedure and easy to perform and, if confirmed by further study, could be part of every surgeon’s knowledge.     

Acute appendicitis in a duplicated appendix

INTRODUCTIONDouble appendix represents an extremely rare and commonly “missed” diagnosis, often with life threatening consequences.PRESENTATION OF CASEIn this case report we present an interesting case of operative treatment of acute appendicitis in a doubled vermiform appendix stemming operative pitfalls. A 23-year-old female was admitted to the emergency room department complaining of diffuse abdominal pain, nausea, and vomiting over the past 36 h. As soon as the diagnosis of acute appendicitis was established a laparotomy via a McBurney incision was decided. Intraoperative findings included the presence of mild quantity of free fluid and surprisingly a thin non-inflamed appendiceal process. It was the preoperative ultrasound findings suggestive of acute appendicitis that dictated a more thorough investigation of the lower abdomen that led to the discovery of a second retrocecal inflamed appendix. Formal appendectomy was then performed for both processes. The patient had an uneventful recovery and was discharged on the fourth postoperative day.DISCUSSIONDouble appendix represents a challenging clinical scenario in cases of right lower quadrant pain.CONCLUSIONLife threatening consequences with legal extensions can arise from the incomplete removal of both stumps.     

Pericardioperitoneal and pericardiopleural windows: A drainage technique for the treatment of recurrent cardiac tamponade. A case report

IntroductionGiven that pericardial effusion may sometimes lead to cardiac tamponade and chronic heart failure, its management seems absolutely essential. In case of a poor response to medical therapy, surgical drainage of the effusion is required. Although some drainage procedures for pericardial effusion (e.g., temporary puncture, pericardiopleural drainage, and pericardioperitoneal drainage) are currently used in clinical practice, their long-term efficacy remains unclear.Presentation of caseWe present a case of a 58-year old female with recurrent pericardial effusion secondary to systemic lupus erythematosus. Since she was relatively young and on steroids, long-term patency of pericardial fenestration needed to be insured without any device. Hence, we created 2 pericardial windows, pericardioperitoneal and pericardiopleural, via a single-incision subxiphoid approach to allow the effusion to drain into the abdominal and thoracic cavities.DiscussionIt is important to efficiently manage pericardial effusion because it can lead to more serious conditions such as cardiac tamponade and chronic heart failure. Our technique, which involves making a small incision, can reduce the risk of recurrence.ConclusionSimultaneous creation of pericardioperitoneal and pericardiopleural windows is simple and can be feasibly performed to prevent the recurrence of pericardial effusion.     

Idiopathic omental infraction as a cause of acute abdomen: Case report

IntroductionIdiopathic omental infraction is a rare cause of acute abdominal symptoms that has been known with growing recurrence in the past ten years. It presents as right iliac fossa pain, and it’s sometimes misdiagnosed as acute appendicitis.In this study we present a case Report of idiopathic omental infraction as a cause of acute abdomen.Presentation of caseA 25 year old male, presented to the casualty complaing of intermittent worsening pain in the right side of the abdomen, this symptom which mimiced the other commoner causes of acute abdomen. On further investigations he had leukocytosis, high C-reactive protein and ESR levels, A contrast computed tomography suggested acute appendicitis, In due course patient was operated after taking his consent, inside the operation 70 % of the greater omentum was necrotic with a black colour, An omentectomy was performed and he was discharged after two days with good recovery.ConclusionA right side abdominal pain is not only confined to appendeceal diseases, So other disease should be put in consideration.     

Cardiovascular changes during drainage of pericardial effusion by thoracoscopy

Background. Cardiovascular changes during drainage of pericardialeffusion are not well understood, and most studies are of systemiceffects and not of right ventricular performance. Thoracoscopyis not widely used to drain pericardial effusions because ofhaemodynamic changes in relation to the use of single lung ventilation. Patients and methods. We studied 16 patients undergoing partialpericardiectomy for pericardial effusion, using videothoracoscopywith a low-pressure pneumothorax (6 mm Hg). Cardiac outputwas measured by thermodilution with the patient anaesthetizedin the supine position before the procedure; in the right lateralposition after a low-pressure pneumothorax had been established;and after drainage of the pericardial effusion. Results. Before the procedure, cardiac output was low and centralvenous pressure and pulmonary artery occlusion pressure wereincreased. Systemic vascular resistance and arterial blood pressurewere within normal limits. Cardiac filling pressure and pulmonaryarterial pressure increased during the pneumothorax. After thedrainage cardiac index increased and systemic and pulmonaryvascular resistances were reduced. Conclusions. Pericardial effusion reduces right ventriculardistensibility, right and left systolic ventricular function,and cardiac output. Anaesthesia with mechanical ventilationand a low-pressure pneumothorax do not affect the circulationgreatly. Drainage of the pericardial effusion allows cardiacdistensibility to increase and cardiac performance changes toallow increased ejection. Br J Anaesth 2004; 92: 89–92     

Schistosomal appendicitis in Kuwait A5-year study

BackgroundAppendicular schistosomiasis is an unusual etiology of acute appendicitis, which has been reported in countries endemic in schistosomiasis, such as sub-saharan Africa and South America. Nowadays, due to globalization, this disease has been diagnosed in non-endemic countries. Kuwait is a country possessing a larger percentage of foreigners than national citizens. Therefore, several cases of schistosomal appendicitis were found.MethodThe clinicopathological records of all patients that underwent appendectomy during January 2007 and December 2011 were recorded from the archives of Al-Adan Hospital in Kuwait. All cases of schistosomal appendicitis were retrieved and the histopathologic slides reconfirmed by the histopathologist.ResultsDuring the 5-year study period, 3012 appendectomies were performed and 8 schistosomal appendicitis were found. They were all Egyptian males that were admitted for a clinical suspicion of acute appendicitis. The age ranged between 24 and 42 years, with a mean age of 32.75 years. All cases showed histological features of acute or acute suppurative inflammation, with ova seen in the vasculature of all layers of appendicular wall.ConclusionAlthough schistosomiasis is a rare causative agent of acute appendicitis, this however can’t be confirmed until histological evaluation. Therefore, adequate follow up postoperatively is necessary to insure eradication of the disease and to prevent further serious consequences.     

Acute appendicitis after solid organ transplantation

Appendicitis has rarely been reported following solid organ transplantation and never following liver transplantation. We reviewed records of all patients who received solid organ transplants at UCLA between 1989 and 2002 and subsequently underwent appendectomy for presumed acute appendicitis. Of nearly 8000 transplant patients, 17 (nine male, eight female) subsequently underwent appendectomy for presumed acute appendicitis. Average age at appendectomy was 37 yrs (range 6-73 yrs). Organ transplants included liver (seven patients), heart (four), kidney (three), kidney-pancreas (two), and heart-kidney (one). The mean interval from transplant to appendectomy was 1064 d (16-2977). Presenting symptoms and signs included abdominal pain in 16 patients (94%); nausea and or vomiting in 15 (88%); right lower quadrant tenderness in 16; and leukocytosis (WBC > 10 000) in 13 (76%). Mean interval from presentation to appendectomy was 0.94 d (range 0-4). Computed tomography (CT) was performed in 16 patients and showed signs of acute appendicitis in 15. Open technique was used in all patients, preceded by laparoscopy in one. Pathology showed appendicitis in 15 patients (one with perforation), serositis in one, and a normal appendix in one. Mean duration of hospitalization was 7 d (range 1-20). Complications occurred in four patients (24%) and included intra-abdominal abscess requiring percutaneous drainage, ventral hernia, small bowel obstruction, and hematuria in one patient each. There were no deaths and no cases of acute rejection during hospitalization. Average length of follow-up was 712 d (range 3-2492). We conclude that appendicitis is relatively rare following solid organ transplantation. CT facilitates prompt diagnosis. The clinical presentation is similar to that of non-transplant patients, but complications are more frequent, and hospitalization is longer.     

Case report of multiple mesenteric mycotic aneurysms after perforated appendicitis

Introduction and importanceMycotic aneurysms are a severe and sometimes life-threatening complication of infections or sepsis. However, mycotic aneurysms of mesenteric arteries caused by a purulent peritonitis following perforated appendicitis are very rare and not previously reported. This case report contributes to the awareness and treatment of this rare complication.Case presentationWe present a case of a middle aged patient with a purulent peritonitis after perforated appendicitis. Postoperatively, recovery was not as expected. One week after laparoscopic appendectomy, CRP increased and haemoglobin levels dropped. Abdominal CT imaging revealed several mesenteric mycotic aneurysms. Because of aneurysmatic rupture, coiling of several mesenteric arteries was performed, despite the risk of bowel ischemia. After long-term antibacterial and antifungal treatment, the patient recovered completely.Clinical discussionFormation of mycotic aneurysms in mesenteric arteries is very rare and optimal treatment options are debatable. Given the high mortality of conservative therapy with antibiotics alone, treatment of mycotic aneurysms by surgery or endovascular treatment is strongly advised. In our case, it was decided to treat the aneurysms by endovascular coil embolization and to observe whether bowel ischemia would occur, because aneurysms were present in multiple mesenteric arteries.ConclusionMycotic aneurysms of several mesenteric arteries should be considered as a rare but potential complication of perforated appendicitis with purulent peritonitis. In case of rupture, successful treatment can be achieved by embolization followed by long-term antibiotics. A multidisciplinary approach including surgery, interventional radiology and microbiology is highly recommended and transfer to a tertiary referral centre should be considered.     

Inflammation of the residual appendix stump: a systematic review

Aim A systematic review of the literature was undertaken to examine reported cases of stump appendicitis (SA) to determine the relationship between SA and the original operative strategy (open vs laparoscopic), and to evaluate the clinical features and diagnosis. Method A Pub‐med search was conducted to identify cases of appendicitis of a residual stump following appendicectomy. Two original cases of SA following laparoscopic appendicectomy treated in our own hospitals are also included in the analysis. Sixty cases of SA reported in the English medical literature were analysed. Results The interval from the original appendicectomy ranged from 4 days to 50 years. SA followed appendicectomy in 58% of open and 31.6% of laparoscopic procedures. SA was frequently misdiagnosed as constipation or gastroenteritis, with a significant delay to surgery. Computerized tomography diagnosed SA in 46.6% of cases. Perforation with gangrene of the stump occurred in 40%. Conclusion Stump appendicitis is rare. It may complicate open or laparoscopic appendicectomy. A high level of suspicion should be maintained in any patient with right sided abdominal pain and a history of prior appendicectomy.     

Pancarditis: a rare complication of tropical pyomyositis

Tropical pyomyositis is a bacterial infection of the skeletal muscles leading to abscess formation, occurring in the tropical areas, often following minor trauma. We report a case of pancarditis as the direct complication of pyomyositis in a 10-year-old girl who presented with painful swelling of her right thigh, high grade fever and impaired consciousness. Echocardiography showed pericardial effusion with strands and a large vegetation in the left ventricle cavity. She was treated successfully with open heart surgical drainage and intravenous antibiotics. We emphasize early diagnosis and prompt treatment of pyomyositis to reduce its associated mortality and morbidities.     

Perforated appendicitis after colonoscopy

BACKGROUND: Acute appendicitis is a rare complication of colonoscopy that has been reported only 12 times in the English-language literature and is usually associated with obstruction of the appendiceal lumen with fecal matter during colonoscopy. None of the previous reports have described findings of perforation of the appendix within 24 hours of colonoscopy. METHODS: We present the case report of a patient who underwent urgent laparotomy within 16 hours of colonoscopy for findings of free intraabdominal air and peritonitis from acute perforated appendicitis. RESULTS: Laparoscopy confirmed 2 perforations of the appendix and diffuse peritonitis. Laparotomy was necessary to perform appendectomy, exclude a right colonic injury, and control intraabdominal sepsis. CONCLUSION: In patients with abdominal pain who have had a recent colonoscopy, a high index of suspicion is necessary for accurate diagnosis of perforated appendicitis. Perforation can occur hours after colonoscopy even when a biopsy is not performed.     

Abdominal Mondor disease mimicking acute appendicitis

IntroductionMondor disease (MD), a superficial thrombophlebitis of the thoraco-epigastric veins and their confluents is rarely reported in the literature. The superior epigastric vein is the most affected vessel but involvement of the inferior epigastric vessels or their branches have also been described. There is no universal consensus on treatment in the literature but most authors suggest symptomatic treatment with non-steroid anti-inflammatory drugs (NSAIDs).Case reportWe report the case of a marathon runner who presented with right iliac fossa pain mimicking the clinical symptomatology of an acute appendicitis. The history and the calculated Alvarado score were not in favor of an acute appendicitis. This situation motivated multiple investigations and we finally arrived at the diagnosis of MD.DiscussionAcute appendicitis (AA) is the most common cause of surgical emergencies and one of the most frequent indications for an urgent abdominal surgical procedure around the world. In some cases, right lower quadrant pain remains unclear in spite of US, CT scan, and exclusion of urological and gynecological causes, thus we need to think of some rare pathologies like MD.ConclusionMD is often mentioned in the differential diagnosis of breast pathologies but rarely in abdominal pain assessment. It should be mentioned in the differential diagnosis of the right lower quadrant pain when the clinical presentation is unclear and when acute appendicitis has been excluded. Awareness of MD can avoid misdiagnosis and decrease extra costs by sparing unnecessary imaging.