Appendicitis with psoas abscess successfully treated by laparoscopic surgery

Although acute appendicitis is a common disease, retroperitoneal abscesses are rarely observed. Here, we report a case consisting of a psoas abscess and cutaneous fistula caused by appendicitis. The patient was a 56-year-old male who was introduced to our institution due to an intractable right psoas abscess. Imaging tests had been performed over the previous 3 years; however, clinicians could not find the origin of the abscess and failed to resolve the problem. A successful operation was performed via a laparoscopic approach, and 17 mo have passed without recurrence. The advantage of laparoscopic surgery is well understood in cases of appendicitis with abscesses. However, the indication for laparoscopic approach is not clear for retroperitoneal abscesses. From our experience, we can conclude that appendicitis with retroperitoneal abscesses can be managed and treated using a laparoscopic approach.     

Computed tomography in complicated acute appendicitis

Due to the position and length of the appendix, intraabdominal abscesses after perforation in complicated acute appendicitis may occur in several different and sometimes unsuspected anatomical locations. Five patients are described with proven complicated acute appendicitis and inflammatory processes in multiple sites: anterior pararenal space, general retroperitoneum, subcutaneous fat space, intraperitoneal cavity, and small bowel mesentery. A confusing case of ileocecal carcinoid with mesenteric involvement is also presented. In all cases complicated acute appendicitis was diagnosed on CT prior to surgery, except in 1 case in which a pelvic abscess developed after intramural cecal bleeding in a patient with hemophilia B.     

Gas-containing hepatic abscess from an unusual etiology

Pyogenic hepatic abscesses used to be caused by an abdominal infection. Cholangitis due to stones is the commonest cause, followed by diverticulitis or appendicitis. Most patients presenting with pyogenic liver abscesses have a polymicrobial infection usually with Gram negative aerobic and anaerobic organisms. Escherichia coli or Klebsiella pneumoniae are frequently implicated but they do not usually produce gas into the abscesses. We comment a case of a gas-containing liver abscess after an acute pancreatitis without any risk factor associated.     

3 Imaging and intervention in patients with acute right lower quadrant disease

US using graded compression plays a central role in the diagnostic work-up of acute right lower quadrant disease, but its results should always be integrated with clinical data and results of other possible radiological examinations.Direct US visualization of an inflamed appendix is solid proof of appendicitis. Pitfalls are secondary enlargement in perforated peptic ulcer, caecal carcinoma or Crohn's disease.If a normal appendix is visualized in its full length, appendicitis can be excluded. However, this is rarely the case. In practice, the only means to exclude appendicitis is to demonstrate an alternative condition, which in most cases is possible by US alone. Concomitant adynamic ileus is a valuable US finding. Abscesses related to appendicitis, Crohn's disease and colonic carcinoma respond well to percutaneous drainage, which is technically possible in 95% of cases. Some of these abscesses evacuate spontaneously to neighbouring bowel. For abscesses due to caecal diverticulitis spontaneous evacuation to the caecal lumen is the rule.For indication and drainage strategy, integration of US, CT and clinical data are indispensable.The use of US in right lower quadrant disease will not only lead to a strong improvement of diagnostic accuracy, but also to a better understanding of the incidence and natural course of various conditions such as abortive appendicitis, appendiceal abscess, caecal diverticulitis, bacterial ileocaecitis and right-sided segmental infarction of the omentum.     

Extensive retroperitoneal and right thigh abscess in a patient with ruptured retrocecal appendicitis： An extremely fulminant form of a common disease

As a disease commonly encountered in daily practice,acute appendicitis is usually diagnosed and managedeasily with a low mortality and morbidity rate.However,acute appendicitis may occasionally becomeextraordinarily complicated and life threatening.A56-year-old man,healthy prior to this admission,wasbrought to the hospital due to spiking high fever,poorappetite,dysuria,progressive right flank and painfulswelling of the thigh for 3 d.Significant inflammatorychange of soft tissue was noted,involving the entireright trunk from the subcostal margin to the kneejoint.Painful disability of the right lower extremity andapparent signs of peritonitis at the right lower abdomenwere disclosed.Laboratory results revealed leukocytosisand an elevated C-reactive protein level.AbdominalCT revealed several communicated gas-containingabscesses at the right retroperitoneal region with masseffect,pushing the duodenum and the pancreatic headupward,compressing and encasing inferior vena cava,destroying psoas muscle and dissecting downward intothe right thigh.Laparotomy and right thigh explorationwere performed immediately and about 500 mL of frankpus was drained.A ruptured retrocecal appendix was thecause of the abscess.The patient fully recovered at theend of the third post-operation week.This case remindsus that acute appendicitis should be treated carefullyon an emergency basis to avoid serious complications.CT scan is the diagnostic tool of choice,with rapidevaluation followed by adequate drainage as the key tothe survival of the patient.     

Acute appendicitis presenting with abdominal wall and right groin abscess： A case report

We report a case of right lower abdominal wall and groin abscess resulting from acute appendicitis. The patient was an 27-year-old man who had no apparent abdominal signs and was brought to the hospital due to progressive painful swelling of right lower abdomen and the groin for 10 d. Significant inflammatory changes of soft tissue involving the right lower trunk were noted without any apparent signs of peritonitis. Laboratory results revealed leukocytosis. Abdominal ultrasonography described the presence of abscess at right inguinal site also communicating with the intraabdominal region. Right inguinal exploration and laparotomy were performed and about 250 mL of pus was drained from the subcutaneous tissue and preperitoneal space. No collection of pus was found intraabdominally and subserous acute appendicitis was the cause of the abscess. The patient fully recovered at the end of the second post-operation week. This case reminds us that acute appendicitis may have an atypical clinical presentation and should be treated carefully on an emergency basis to avoid serious complications.     

Effective Laparoscopic Drainage for Intra-Abdominal Abscess Not Amenable to Percutaneous Approach: Report of Two Cases

PURPOSE The usefulness of the laparoscopic approach for massive intra-abdominal abscesses is controversial. We report two patients who underwent laparoscopic abscess drainage for massive intra-abdominal abscesses not amenable to the percutaneous approach that were suspected to be caused by acute appendicitis.METHODS In both patients, four ports were placed at their abdominal walls under general anesthesia. Intra-abdominal abscess cavities were punched out, and the purulent exudates that spilled out from the cavities were aspirated completely. Copious irrigation was performed under direct vision. These procedures were completed laparoscopically.RESULTS The postoperative clinical courses of the patients were uneventful. The intra-abdominal abscesses did not recur, and no wound complications were recognized. The patients were discharged from our hospital in excellent condition within two weeks.CONCLUSIONS Laparoscopic drainage for massive intra-abdominal abscess is a minimally invasive and useful procedure compared with the open method or the percutaneous approach. It offers the advantage of being able to explore of the abdominal cavity without an unnecessary wide incision, and aspiration of a purulent exudate is possible under direct vision.     

Scrotal abscess originating from appendicitis: a case report

There are numerous reports concerning the presentation of appendicitis as a urologic problem. However, scrotal abscess originating from appendicitis has rarely been described. We report a right scrotal abscess due to a preceding retroperitoneal abscess originating from retrocecal appendicitis. The scrotal abscess developed progressively following appendectomy. Scrotal exploration was carried out under the presumptive diagnosis of abscessed epididymo-orchitis. However, the patient remained febrile and had productive pus drained from the scrotum after exploration. Abdominal computerized tomography demonstrated that a large retroperitoneal abscess had accumulated at the appendectomy site. Percutaneous drainage of the retroperitoneal abscess resulted in resolution of the scrotal abscess. In cases of scrotal abscess following previous abdominal events (e.g. appendectomy), we recommend that abdominal origins should be carefully surveyed before scrotal exploration.     

A case of leukemia of the appendix presenting as acute appendicitis

A 71-year-old man was admitted to our hospital because of right lower abdominal pain. He was suspected of having acute appendicitis and soon after admission, appendectomy was performed. Macroscopically, the appendix was greatly swollen and reddened, but had no abscess. Microscopically, polymorphonuclear leukocytes were not found, but diffuse infiltration of atypical cells was observed. Examination of a bone marrow aspirate revealed 74% blasts that were peroxidase stain positive. We diagnosed acute myelogenous leukemia (FAB classification, M2). He received induction chemotherapy, but died 49 days after admission. Leukemic cell infiltration of the appendix is rare and acute appendicitis as the initial manifestation of leukemia is even rarer.     

Treatment options of inflammatory appendiceal masses in adults

At present, the treatment of choice for uncomplicated acute appendicitis in adults continues to be surgical. The inflammation in acute appendicitis may sometimes be enclosed by the patient’s own defense mechanisms, by the formation of an inflammatory phlegmon or a circumscribed abscess. The management of these patients is controversial. Immediate appendectomy may be technically demanding. The exploration often ends up in an ileocecal resection or a right-sided hemicolectomy. Recently, the conditions for conservative management of these patients have changed due to the development of computed tomography and ultrasound, which has improved the diagnosis of enclosed inflammation and made drainage of intra-abdominal abscesses easier. New efficient antibiotics have also given new opportunities for nonsurgical treatment of complicated appendicitis. The traditional management of these patients is nonsurgical treatment followed by interval appendectomy to prevent recurrence. The need for interval appendectomy after successful nonsurgical treatment has recently been questioned because the risk of recurrence is relatively small. After successful nonsurgical treatment of an appendiceal mass, the true diagnosis is uncertain in some cases and an underlying diagnosis of cancer or Crohn’s disease may be delayed. This report aims at reviewing the treatment options of patients with enclosed appendiceal inflammation, with emphasis on the success rate of nonsurgical treatment, the need for drainage of abscesses, the risk of undetected serious disease, and the need for interval appendectomy to prevent recurrence.     

The usefulness of technetium-99m hexamethylpropyleneamineoxide labeled white blood cell abdomen scan to differentiate periappendiceal abscess from acute appendicitis--a preliminary report

BACKGROUND/AIMS: The purpose of this study is to assess the usefulness of Tc-HMPAO (technetium-99m hexamethylpropyleneamineoxide) labeled white blood cells abdomen scan to differentiate acute appendicitis from periappendiceal abscess. METHODOLOGY: Forty-five patients with atypical symptoms and signs of appendicitis were included in this preliminary study. At 4 hours after an intravenous injection of Tc-HMPAO labeled white blood cells, static images over the anterior abdomen were obtained using a gamma camera. Two regions of interest were selected, one was over the lumbar spine and the other was over the appendiceal area. The mean count ratio of the appendiceal area over the mean pixel count of the lumbar spine was calculated. Sixteen patients were diagnosed with acute appendicitis and 19 patients with periappendiceal abscess by final operative findings. Meanwhile, the other 10 patients with acute abdomen but with no appendicitis served as controls. RESULTS: The mean count ratio of controls, acute appendicitis and periappendiceal abscess was 0.65 +/- 0.05, 0.82 +/- 0.07, and 1.25 +/- 0.11, respectively. If the mean count ratio > or = 1.00 was defined as the cutoff value to diagnose periappendiceal abscess, the specificity and the positive predictive value was 100%. CONCLUSIONS: We concluded that Tc-HMPAO white blood cells abdomen scan should be a potential tool to differentiate periappendiceal abscess from acute appendicitis.     

Pathology of the alimentary tract in Salmonella typhimurium food poisoning.

The pathology of the alimentary tracts of nine patients dying of Salmonella typhimurium infection is reviewed. Two patients had previous gastric operations, supporting previous reports that such patients are more susceptible to food poisoning. Four had no parietal (oxyntic) cells in the gastric mucosa, suggesting hypo- or anacidity. Only one had acute gastritis. None had acute enteritis, but in half of the patients, subtle histological changes suggested an 'enteropathy'. Acute diffuse colitis with abundant crypt abscesses, without stromal abscesses in the lamina propria, was the most constant finding and reparative features started very early, and occurred in later deaths. Under ideal circumstances this crypt abscess is readily distinguished from that of idiopathic ulcerative colitis, but can be confused with the crypt abscess of acute bacillary (sonne) dysentery. While the florid colonic changes may have settled in the late deaths, active inflammation is commonly present in the appendix mucosa on histology. The pathology of the alimentary tract in S typhimurium infection differs from that of S typhi and S paratyphi infections. There is little evidence of gastroenteritis, although subtle changes occur in the stomach and small intestine. The features are those of acute diffuse colitis with histological appendicitis, distinguishable from idiopathic ulcerative colitis.     

Ascending retrocecal appendicitis presenting with right upper abdominal pain： Utility of computed tomography

Acute appendicitis is a common surgical condition that is usually managed with early surgery, and is associated with low morbidity and mortality. However, some patients may have atypical symptoms and physical findings that may lead to a delay in diagnosis and increased complications. Atypical presentation may be related to the position of the appendix. Ascending retrocecal appendicitis presenting with right upper abdominal pain may be clinically indistinguishable from acute pathology in the gallbladder, liver, biliaw tree, right kidney and right urinary tract. We report a series of four patients with retrocecal appendicitis who presented with acute right upper abdominal pain. The clinical diagnoses at presentation were acute cholecystitis in two patients, pyelonephritis in one, and ureteric colic in one. Ultrasound examination of the abdomen at presentation showed subhepatic collections in two patients and normal findings in the other two. Computed tomography （CT） identified correctly retrocecal appendicitis and inflammation in the retroperitoneum in all cases. In addition, abscesses in the retrocecal space （n = 2） and subhepatic collections （n = 2） were also demonstrated. Emergency appendectomy was performed in two patients, interval appendectomy in one, and hemicolectomy in another. Surgical findings confirmed the presence of appendicitis and its retroperitoneal extensions. Our case series illustrates the usefulness of CT in diagnosing ascending retrocecal appendicitis and its extension, and excluding other in- fiammatory conditions that mimic appendicitis.     

Appendicovesical fistula: case report and review

Appendicovesical fistulae are rare and occur secondary to acute or missed acute appendicitis. A 15 year old boy presented with urinary symptoms and a pelvic abscess on imaging studies. At laparotomy an appendicovesical fistula was encountered and was successfully managed by a right colectomy and ileal transverse colon anastomosis. The presentation and management of appendicovesical fistula is discussed.     

Sonography in the diagnosis of appendicitis--a prospective study

In a prospective study the significance of ultrasonography in the diagnosis of appendicitis was evaluated. On 104 patients--57 women and 47 men between the ages of 5 and 88 years--with a preliminary diagnosis of acute appendicitis, ultrasonography was performed using a graded compression technique with small curved-array transducers following physical examination. In 32 of 36 patients with operatively confirmed appendicitis the inflamed appendix could be visualized clearly. All 6 perityphlitic abscesses and 4 of 5 perforations were detected correctly by ultrasonography. In 18 patients the use of sonography led to important differential diagnoses other than appendicitis, which in 4 cases required surgery. By direct visualization of the inflamed appendix and its periappendicidal complications the clinical diagnosis of acute appendicitis can be improved. As a result of sonographic detection or exclusion of other diseases, ultrasonography facilitates the--often difficult--clinical differential diagnosis of right lower abdominal pain.     

Primary adenocarcinoma of the vermiform appendix: Report of seven cases and review of the literature

Summary There have been 158 recorded cases of adenocarcinoma of the appendix reported in the literature. Seven additional cases are documented. The great majority of patients have symptoms of acute appendicitis or appendiceal abscess when first seen. Appendectomy with right hemicolectomy yields the best long-term survival rates.     

A case of adult T-cell leukemia (ATL) complicated with multiple nocardial abscesses]

A 45-year-old woman was admitted to our hospital with complaints of fever and lumbago. She was treated for adult T-cell leukemia and thrombocytopenia with 20 mg/day of prednisolone. CT scan showed multiple abscesses in right peri-kidney, right iliopsoas muscle, left subcutaneous region in the abdominal wall and the brain. Left subcutaneous abscess was drained. Gram-positive organisms consisting of filaments were found, and Nocardia farcinica was grown in cultures. After two months of chemotherapy (FMOX, MINO and AMK), all abscesses except one in the brain disappeared. Cerebral abscess was cured fifty days after the start of the treatment with oral administration of Sulfamethoxazole-trimethoprim (SMX/TMP). The mortality of Nocardial cerebral abscess is high. This patient is a very rare case in which multiple Nocardial abscesses including brain abscess was cured by chemotherapy.     

Liver abscess after implantation of dental prosthesis

Pyogenic liver abscesses are rare but a life-threatening important condition. Dental procedures constitute only rare cases of pyogenic liver abscesses, with only a few cases in the literature. We report a patient with liver abscess following a dental procedure. A 74 years old diabetic male patient was admitted to our hospital with complaints of fatigue, 40 ℃ fever, rigors and right upper quadrant pain, 3-4 d after a dental procedure. Physical examination revealed fever and tenderness in the right upper quadrant. Laboratory examination revealed leucocytosis, elevated erythrocyte sedimentation rate and Creactive protein and moderately elevated transaminases. An abscess was detected in radiological examination in the medial part of the left lobe of liver, neighboring the gall bladder. He was suc-cessfully treated with percutaneous abscess drainage and antibiotherapy.     

Sonography of ruptured appendicitis

Three girls and 4 boys with the final diagnosis of ruptured appendicitis underwent 19 sonographic studies, 5 before any therapy was instituted and 14 follow-up studies. Four abscesses identified before treatment and 2 seen postoperatively were ovoid, irregularly marginated, and contained low-amplitude echoes. Gastrointestinal ileus with gas-and fluid-filled loops of bowel made the studies technically difficult. Follow-up studies also showed fluid collections distant from the original abscesses. The complete resolution of the abscess was followed sonographically in 1 patient treated with antibiotics. Ultrasound can be useful in confirming or suggesting the diagnosis of ruptured appendicitis in the child with abdominal pain, but careful attention to detail is necessary in these technically difficult studies.     

Pyogenic and amebic liver abscesses

Pyogenic and amebic liver abscesses are the two most common hepatic abscesses. Amebic abscesses are more common in areas where Entamoeba histolytica is endemic, whereas pyogenic abscesses are more common in developed countries. Pyogenic abscess severity is dependent on the bacterial source and the underlying condition of the patient. Amebic liver abscess is more prevalent in individuals with suppressed cell-mediated immunity, men, and younger people. The right lobe of the liver is the most likely site of infection in both types of hepatic abscess. Patients usually present with a combination of fever, right-upper-quadrant abdominal pain, and hepatomegaly. Jaundice is more common in the pyogenic abscess. The diagnosis is often delayed and is usually made through a combination of radiologic imaging and microbiologic, serologic, and percutaneous techniques. Treatment involves antibiotics along with percutaneous drainage or surgery.