A complication of a dropped appendicolith misdiagnosed as Crohn’s disease

Abstract

Appendicoliths are formed by calcium salts and faecal debris layered and lodged within the appendix. They are detected on unenhanced x-rays in less than 10% of patients with appendicitis. When an appendicolith is found extraluminally, it is pathognomonic for perforation of the appendix. Moreover, retained appendicoliths act as a nidus for infection and are likely to be the source of a postoperative intraperitoneal abscess. However, this is very rare with only 30 reported cases of intra-abdominal abscess secondary to an appendicolith in the literature over the past 40 years.Retained, or dropped, appendicoliths most commonly present as an area of high attenuation less than 1cm in diameter with an associated abscess close to the caecum or Morrison's pouch on computed tomography (CT). A study published in 2006 showed that although there is initial success with CT-guided drainage of abscesses secondary to faecaliths, all will recur and formal surgical drainage with removal of the appendicolith is required.This case report highlights not only an unusual complication of a retained appendicolith but also the importance of taking a thorough history and interpreting investigations in the context of the patient's past medical history so as to produce a differential diagnosis and prevent treatment of incorrect conditions. 2011; 93: e117-e118 Ann R Coll Surg Engl

Perihepatic abscesses caused by dropped appendicoliths in a child

“…Also given that patients may present for imaging at a time remote from their initial surgery [13] , radiologists need to be aware of and consider the diagnosis in patients with a prior history of appendicitis. There are cases in the medical literature of late presentations of dropped appendicoliths and dropped gallstones, which can have an identical appearance, being misdiagnosed as both inflammatory and metastatic conditions on CT [14] , [15] . Lastly, this case demonstrates the usefulness of intraoperative ultrasound in the retrieval of these stones, which is of particular importance because if the appendicolith is left after abscess drainage, the abscess will likely recur.…”

Shortness of breath, fever and abdominal pain in a 21-year-old student

“…Less than 10% of these appendicoliths are radiopaque3 making diagnosis of retained or spilled appendicoliths more difficult. Complications from spilled appendicoliths have been reported previously, becoming symptomatic up to 10 years after the original operation 4…”

Dropped Appendicolith: Complications and Management

“…Sites where retained faecalith can be found are most commonly in the pelvis [17] or Morrison's pouch [16] [18]. In rare instances, the appendicolith has been localized in the iliopsoas compartment [19], gluteal region [20] or subcutaneous plane [21]. The combination of pneumoperitoneum and irrigation used during laparoscopic appendicectomy might be responsible for the migration of appendicolith and for the unusual sites of presentation.…”

“…History of appendicectomy in the past will be present in most situations. The sites of abscess formation which are documented in the literature are subhepatic abscess [16][18] pelvic abscess [17], tubo-ovarian abscess [25], paracaecal [26], psoas abscess [19] and gluteal abscess [20][27].…”