Clinical History
Acute pain in the right iliac fossa, fever and biliary vomiting.
Imaging Findings
Patient presented in our E.R. with acute abdominal pain, biliary vomiting, fever with chills, and constipation since two days. Physical examination showed a soft tender abdomen with painful abdominal
palpation in right iliac fossa, absent bowel sounds and fever of 38.7 C°. Laboratory analysis revealed leucocytosis( blood white cells:19.200 with 91% of neutrophilies). US examination was first
performed: cecum-appendicular region couldn’t be depicted because of bowel distension ; no abdominal parenchymatous pathological findings were demonstrated . CT study was then performed and
showed a very swollen appendix with a longitudinal diameter of 9 cm, a transverse diameter of 10 mm and increased wall thickness. It was distended with gas and presents an intraluminal air-fluid
level and a calcified appendolith in the proximal tract. An adyacent phlegmon characterized by diffuse and substantial inflammation of the periappendiceal fat and some mesenteric adenopathies of
about 2 cm were depicted. The last 25 cm of terminal ileum was entrapped in the pelvis with thickened wall; target pattern of the bowel wall, because of oedematous thickened submucosa layer, was
present. Effusion in Douglas was also demonstrated. At operation the appendix was distended and gangrenous; there were also tenacious mural and visceralis adherences, effusion in peritoneum and in
Douglas and the last terminal ileum was intrapped in the pelvis. An appendectomy was performed and the final surgical diagnosis was: acute peritonitis and gangrenous appendicitis perforated in
terminal ileal loops entrapped in the pelvis.
Discussion
Gas in the appendix occurred in 2% cases of appendicitis [1]. The phenomenon occurs as a result of total obstruction of the appendix, with infection by gas-forming organisms. But a gas-filled
appendix may not therefore be a specific finding of gangrenous appendicitis because it can occur when the inflamed appendix remains in comunications with the cecum and rarely as a normal variant
especially when the appendix is in an ascending retrocecal location. Today, with MSCT, we can reliably confirm the diagnosis of gangrenous appendicitis by demostrating the association of gas in the
lumen with the other caratteristic findings of appendicitis such as pericecal inflammation, abscess or phlegmon, calcified appendicolith and thickened appendiceal wall. The right diagnosis of
gangrenous acute appendicitis is very important to address the patient to the most adeguate surgical treatement; in fact nowadays patients with appendicitis are generally treated with a laparoscopic
approach but in case of gangrenous appendicitis a laparotomic operation is the tratement of choise.
Differential Diagnosis List
Gangrenous acute appendicitis
Final Diagnosis
Gangrenous acute appendicitis