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CASE REPORT |
https://doi.org/10.5005/njem-11015-0021 |
Abdomen: A Pandora’s Box that Never Fails to Surprise Us
1–3Department of Emergency Medicine, Zydus Hospital, Ahmedabad, Gujarat, India
Corresponding Author: Yash K Brahmbhatt, Department of Emergency Medicine, Zydus Hospital, Ahmedabad, Gujarat, India, Phone: +91 9712729398, e-mail: yash.brahmbhatt619@gmail.com
How to cite this article: Brahmbhatt YK, Patel R, Patel K. Abdomen: A Pandora’s Box that Never Fails to Surprise Us. Natl J Emerg Med 2023;1(3):84–85.
Source of support: Nil
Conflict of interest: None
Received on: 12 December 2023; Accepted on: 03 January 2024; Published on: 25 January 2024
ABSTRACT
Background: The emergency department (ED) is a place where there is an encounter of various surgical and medical emergencies. However, timely diagnosis and early treatment are paramount for good outcomes. Here we present an interesting case of abdominal pain who underwent laparoscopic appendicectomy later diagnosed with stump appendicitis.
Case summary: A 28-year-old male presented to ED with complaints of right lower abdominal pain for 2 days which was sudden in onset, intermittent, colicky, non-radiating, no exacerbating and relieving factors nausea and vomiting. History of laparoscopic appendicectomy one month back. Family and personal history were insignificant. On arrival, the patient was hemodynamically stable with a pain score of 5/10. On examination, abdomen was soft, non-distended, there were scars over the lower abdomen, tenderness in the right iliac fossa without guarding and rigidity, and bowel sounds were present. Laboratory investigations were suggestive of the total count of 19,990 cells/cumm with a neutrophilic predominance and CRP was 24. The plain radiograph of the abdomen as well as ultrasonography were normal. We proceeded with contrast-enhanced computerised tomography (CECT) of the abdomen which was suggestive of stump appendicitis. A surgical reference was done.
Discussion: In the case of stump appendicitis, the time interval for the onset of symptoms could range from 2 weeks to years after appendicectomy. Appendicectomy is one of the most commonly performed surgical emergencies. Stump appendicitis is one of the rare and delayed complications after appendicectomy with a reported incidence of 1 in 50,000 cases. The advantage to ongoing reporting on this relatively rare diagnosis is to continue to raise awareness so it is part of the provider’s differential. Prompt recognition is important to lead to early treatment, thus avoiding serious complications like intra-abdominal abscess, intestinal perforation, and peritonitis. Clinically, patients present with signs and symptoms mimicking appendicitis or acute abdomen along with the previous history of appendicectomy as seen in our case.
Conclusion: By presenting this case, it is highly recommended to consider stump appendicitis as one of the differential diagnoses in patients with a history of appendicectomy who present with abdominal pain to avoid detrimental complications due to missed diagnosis.
Keywords: Case report, Computerised tomography abdomen, Emergency medicine, Pain.
INTRODUCTION
Pain in the abdomen is one of the most common emergencies encountered by an emergency physician. Here we present an interesting case of abdominal pain who underwent an appendicectomy and was later diagnosed with stump appendicitis. Stump appendicitis is a rare complication with an incidence of 1 in 50,000 appendicectomy cases which can cause detrimental complications and can be life-threatening if missed!1
CASE PROFILE
28 year/male.
History of laparoscopic appendicectomy around 1 month back, no other surgical or medical history.
Right lower abdominal pain since 2 days: Sudden, intermittent, colicky, no aggravating or relieving factors, non-radiating, associated with nausea and 2 episodes of vomiting.
Vitals-within normal limit with a pain score of 5/10.
Positive examination findings-tenderness over right iliac fossa without guarding or rigidity.
COURSE IN EMERGENCY
Initial treatment with analgesics and IV fluids.
Point-of-care ultrasound was inconclusive.
Blood investigations were suggestive of leucocytosis (19,990 cells/cumm) with neutrophilic predominance and CRP of 24.
A plain radiograph and ultrasound abdomen were inconclusive.
Contrast enhanced computerised tomography of abdomen diagnosed stump appendicitis.
DISCUSSION
Stump appendicitis is a rare complication of appendectomy because of recurrent inflammation of the residual appendix.2 Stump appendicitis can occur mainly in a patient who has undergone either laparoscopic or open appendectomy and may pose a serious diagnostic dilemma. Diagnosis of stump appendicitis can be challenging.3 Computerised tomography (Fig. 1) of the abdomen is the most commonly used diagnostic modality. Due to a prior surgical history of appendectomy and low index of suspicion, the diagnosis of stump appendicitis is often delayed which may result in serious complications like stump gangrene, perforation, and peritonitis.
Fig. 1: Abdomen diagnosed stump appendicitis
CONCLUSION
Generally, we don’t consider appendicitis as one of the differentials when a patient has a history of appendicectomy. By presenting this case, we must recommend considering stump appendicitis as one of the differential diagnoses who present with abdominal pain so as to avoid detrimental complications due to “missed diagnosis”.
ORCID
Yash K Brahmbhatt https://orcid.org/0009-0005-4496-237X
REFERENCES
1. Liang MK, Lo HG, Marks JL. Stump appendicitis: A comprehensive review of literature. Am Surg 2006;72(2):162–166.PMID: 16536249.
2. Leff DR, Sait MR, Hanief M, et al. Inflammation of the residual appendix stump: A systematic review. Colorectal Dis 2012;14(3):282–293.DOI: 0.1111/j.1463-1318.2010.02487.x.
3. Hendahewa R, Shekhar A, Ratnayake S. The dilemma of stump appendicitis-A case report and literature review. Int J Surg Case Rep 2015;14:101–103.DOI: 0.1016/j.ijscr.2015.07.017.
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