A case report on recurrent appendicitis: An often forgotten and atypical cause of recurrent abdominal pain

Abstract

IntroductionRecurrent appendicitis is a disease process, distinct from acute appendicitis, which occurs with an approximate incidence of 10%. This clinical entity can pose diagnostic and therapeutic dilemma for clinicians resulting in delayed diagnosis and severe complications.Presentation of caseHerein, we described a case of recurrent appendicitis with a history of 18 years of right lower quadrant (RLQ) abdominal pain with very mild tenderness that we encountered in our hospital in January 2016, which has been misjudged as other abdominal conditions and got complete relief after appendectomy. The case report could help to improve the awareness of medical practitioners who come across similar cases so that they can consider recurrent appendicitis in their differential diagnosis; and hence outline appropriate diagnosis as well as early medical interventions.DiscussionRecurrent appendicitis can be missed or delayed secondary to atypical presentation or prior treatment with antibiotics, which may lead to resolution of the infection. Missed diagnosis can lead to serious complications such as perforation, abscess formation and peritonitis. Medical practitioners who encounter patients with recurrent right flank pains with an extended duration should suspect for recurrent appendicitis and carefully analyze patient history as well as line up their diagnosis.ConclusionTherefore, recurrent appendicitis should be considered as differential diagnosis in patients with recurring right lower quadrant abdominal pain and mild/or no tenderness.

Chronic Appendicitis, the Lesser-Known Form of Appendiceal Inflammation: A Case Report

“…The diagnosis of chronic appendicitis in our patient was further confirmed by histopathological findings from the surgical specimen, which were consistent with those reported in other cases of chronic appendicitis [9,10]. At follow-up our patient reported resolution of his RLQ pain, consistent with other reports in which appendectomy resolved pain associated with chronic appendicitis [2,[5][6][7]10].…”

“…Even though traditional and updated definitions of chronic appendicitis exist, their application, and even the existence of chronic/recurrent appendicitis as a clinical entity, has been a matter of debate [ 6 , 7 , 10 , 12 ]. Mattei et al (1994) concluded that “acute appendicitis can resolve spontaneously and recur repeatedly in the same individual,” and that in many cases of chronic or recurrent appendicitis, “they can be avoided by the accurate diagnosis and operative management of acute appendicitis” at initial presentation [ 12 ].…”

“…As most initial presentations of appendicitis are resolved with appendectomy, estimates of the incidence of chronic and/or recurrent appendicitis are few, suggesting the condition is relatively rare [ 2 , 3 , 9 ]. Some common features of chronic and recurrent appendicitis reported in the literature include administration of antibiotics for another preceding condition [ 2 , 5 , 7 , 10 ], milder symptoms than acute appendicitis [ 2 , 9 , 10 , 12 ], and often a normal white blood cell count [ 2 , 6 , 10 ] and/or afebrile presentation [ 2 , 5 ].…”

“…Traditionally chronic appendicitis has been defined as long-standing inflammation or fibrosis of the appendix manifested as right lower quadrant (RLQ) pain of more than 48 hours or intermittent RLQ pain [ 6 ]. Chronic and recurrent appendicitis are terms used interchangeably in the literature; however, at least one source differentiates between chronic and recurrent appendicitis, defining chronic appendicitis as appendicitis associated with three or more weeks of continuous RLQ pain and recurrent appendicitis as presenting with serial episodes of similar RLQ pain [ 7 ]. Patients with chronic appendicitis can present with recurring RLQ abdominal pain not associated with any febrile illness [ 8 ], or with symptoms that self-resolve [ 9 ].…”

“…These cases are milder than acute appendicitis, and their presentation is often non-specific or atypical for appendicitis [ 9 ]. As with acute appendicitis, chronic and recurrent appendicitis are treated with appendectomy [ 2 , 5 - 7 , 10 ]. Chronic appendicitis is not considered a surgical emergency [ 2 ]; however, it can go undiagnosed or be misdiagnosed and develop complications including perforation, abscess formation, peritonitis, and infertility, most of which require surgical intervention [ 1 , 2 , 8 , 11 ].…”