Page 21 - Delaware Medical Journal - September 2016
P. 21
CASE REPORT
Conditions that could predispose toward occurrence of stump appendicitis include anatomic presentation and limitations encountered at initial appendectomy.
that time the workup, which included complete blood count, basic metabolic panel, liver function tests, urinalysis, and urine hCG, was unremarkable. The patient was afebrile and mildly tender to palpation of the epigastrium. Bedside ultrasound of the right upper quadrant during the initial visit demonstrated
wall thickening, or ductal dilation. The patient received pain medication and reported relief. She was discharged with a diagnosis of biliary colic and epigastric abdominal pain. During her return visit, the patient reported continued nausea and worsening pain, now more prominent in the right lower quadrant. Other than the increase in severity and change in location, the patient’s pain was otherwise unchanged from her prior visit to the emergency department. Past medical history 14 months prior to her current presentation.
During the current visit, the patient was febrile to 38.8 degrees Celsius, tachycardic with a heart rate of 106 beats per minute, tachypneic with a respiratory rate of 21 breaths per minute, and hypotensive with an initial blood pressure 96/43 mmHg. On physical examination, she was tender to palpation of the right lower quadrant. Lab work was remarkable for a leukocytosis gallstone from her previous emergency department visit,
a HIDA scan was conducted and resulted as negative for cholecystitis or obstruction. Transvaginal ultrasound was testing in the emergency department, the patient was admitted to the inpatient service for further workup. Antibiotic treatment with vancomycin and cefepime for sepsis was initiated, pending
the abdomen pelvis with intravenous (IV) contrast was ordered to evaluate for further abdominal etiologies of the patient’s pain and symptoms. Results of the scan demonstrated dilation of the appendiceal stump, measuring up to 1.3 cm, with appendiceal wall thickening and appendicoliths. Adjacent to a tip of the
with noted wall thickening of the surrounding cecum and terminal ileum.
Upon receiving the imaging results, the patient was transferred to the General Surgery service for further management. Vancomycin and cefepime were discontinued, with initiation of treatment with ciprofloxacin and metronidazole. Given the CT findings of ruptured appendicitis of the appendiceal stump, placement of a drainage catheter was attempted. Using CT-guidance, serosanguinous fluid was drained, however secondary to freely layering fluid between bowel loops, a catheter could not be successfully be placed. At that time, it was noted
by the General Surgery service that if the patient showed signs of deterioration, a laparoscopic washout would be considered. Formal resection of the appendiceal stump was deferred, given extensive inflammation.
Throughout her inpatient stay, IV antibiotics were continued and the patient showed signs of clinical improvement, defervescing and reporting subjective improvement of her abdominal pain and nausea. Three days after admission, repeat CT scan of the abdomen and pelvis demonstrated mild increase in size of the peri-appendiceal abscess. Following imaging results, the patient was referred to vascular and interventional radiology for placement of a drainage catheter. Under CT-guidance, a multiloculated, thick walled fluid collection was identified; a drainage catheter was placed in the central aspect of the collection with notable drainage
of purulent and serous fluid. Three days after placement of the drainage catheter, as the patient continued to improve clinically, she was discharged home with instructions to continue antibiotics by mouth for 14 days.
On follow up with the surgical service two weeks after discharge, patient reported compliance with antibiotics.
She was pain free and the percutaneous drain was intact without any drainage. She was then evaluated by the vascular interventional radiology service with an abscessogram for removal of the percutaneous drain. No significant residual abscess cavity or communication to adjacent bowel were visualized with contrast. The catheter was subsequently removed and the patient was instructed to follow up for surgical removal of the appendiceal stump.
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