P2330 - Acute Appendicitis Resulting in Sigmoid Obstruction

Ayla Benge, DO¹, Khalid Ahmed, MD², Abdul Ahad Ehsan Sheikh, MD², Mladen Jecmenica, MD^2
1Wright Center for Graduate Medical Education, Scranton, PA; ²Wright Center for GME, Scranton, PA

Introduction: Appendicitis is an inflammation of a vestigial worm-like appendix that leads to one of the most common surgeries around the world. The diagnosis of appendicitis can be difficult in patients with atypical symptoms, resulting in delayed treatment and a higher rate of complications. We present a case of appendicitis presenting as large bowel obstruction in an elderly male.

Case Description/Methods: A 65 year old male without significant past medical history presented with abdominal pain, distension, and constipation for two months. Hypoactive bowel sounds and moderate tenderness was noted on abdominal exam, and labs were significant for mild leukocytosis. Computed tomography revealed nonspecific diffuse colitis with focal mass-like thickening of the sigmoid colon. He was treated with levofloxacin and metronidazole for suspected diverticulitis. His abdominal pain improved and he was discharged home.

A week later, he returned to the hospital with recurrence of symptoms. Repeat computed tomography demonstrated diffuse dilatation of the colon and the distal small bowel concerning for partial sigmoid obstruction. Decompressive colonoscopy showed severe rectosigmoid inflammation and was unsuccessful in relieving the obstruction. His pain worsened and abdominal x-ray demonstrated increasing distension of bowel loops warranting emergent surgical resection. Intraoperative visualization showed an inflamed appendix densely adherent to the rectosigmoid and encircling the large bowel by 270 degrees. Low anterior resection with transverse loop colostomy and appendectomy was performed, after which the patient recovered well.

Discussion: Intestinal obstruction resulting from appendicitis is a relatively uncommon phenomenon. The appendix is a peculiarly mobile structure that, when inflamed, can attach to the bowel and cause twisting or pulling that results in mechanical obstruction. A review conducted by Makama et al identified only 45 cases of obstruction due to appendicitis in the past 60 years.¹ Of these, only one reported large bowel obstruction. Imaging appears to have limited utility in identifying appendicitis when obstruction is present. Bowel obstruction is a rare but life-threatening presentation of appendicitis. Clinicians should consider the diagnosis of appendicitis in patients with bowel obstruction without identifiable cause on initial presentation.

1. Makama JG, Kache SA, Ajah LJ, Ameh EA. Intestinal obstruction caused by appendicitis: A systematic review. J West Afr Coll Surg. 2017;7(3):94-115.


Figure: A) Appendiceal base; microscopic description consistent with acute appendicitis
B) Opened sigmoid colon with an attached 3.5 cm x 0.5 cm tubular shaped portion of appendix vermiformis
C) Closer view of mucosal surface of the sigmoid colon composed of multiple diverticula occluded with fecaliths as well as several areas with perforations of diverticula into the pericolonic fat with exudate


Disclosures:
Ayla Benge indicated no relevant financial relationships.
Khalid Ahmed indicated no relevant financial relationships.
Abdul Ahad Ehsan Sheikh indicated no relevant financial relationships.
Mladen Jecmenica indicated no relevant financial relationships.


Ayla Benge, DO¹, Khalid Ahmed, MD², Abdul Ahad Ehsan Sheikh, MD², Mladen Jecmenica, MD². P2330 - Acute Appendicitis Resulting in Sigmoid Obstruction, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.