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The opinions and assertions contained herein are the private views of the authors and are not to be construed as official policy or reflecting the views of the Army or Department of Defense.
Key Words:
Appendicitis, fistula, and abdominal abscess
Introduction:
Delayed diagnosis of appendicitis can result in the complications of suppuration, rupture, and localized abscess formation.1,2 The fixation of the inflamed appendix to an adjacent structure or hollow organ with spontaneous fistulous drainage is an uncommon occurrence.3 Persistence of the fistulous communication, may resolve spontaneously or require surgical correction.4,5 We report a case of appendiceal abscess complicated by spontaneous fistulous decompression into the sigmoid colon. CT scan was helpful in defining the nature of the abscess and the degree of fistulous communication. Antibiotic therapy was successful in acute management followed by elective laparoscopic appendectomy.
Case Report
An 18 year old male was admitted to our hospital for evaluation of a four day illness characterized by nausea, vomiting, and fever with associated diarrhea and abdominal pain. On physical examination the patient appeared toxic with a temperature of 104 degrees F. The abdomen was diffusely tender, but without guarding or signs of peritoneal irritation. Rectal examination was non tender and stool guaiac negative. Leukocyte count was 11,500 with 10% band forms. The remainder of the screening biochemical blood tests was unremarkable. Plain x-rays of the abdomen showed a nonspecific bowel gas pattern. Ultrasound of the appendix was reported to be normal. Pancultures of bodily fluids were obtained and antibiotic therapy initiated for suspected intra-abdominal sepsis. The patient rapidly and completely resolved all findings within 24 hours and antibiotics were stopped. Complete clinical resolution of symptoms, normalization of bowel habits off antibiotics for 3 days lead to the presumptive diagnosis of viral gastroenteritis.
Seven days after hospital discharge, the patient experienced acute onset of sharp lower abdominal pain, increased by defecation. This was followed by fecal urgency of numerous small bowel movements. Stools were initially formed, but progressed to a loose and watery consistency. There was no associated hematochezia. The abdominal pain with defecation was excruciating and localized to the left lower quadrant and suprapubic area. The patient had experienced mild fever and was re-admitted for further evaluation. Directed inquiry was negative for recent travel, exposure to other ill individuals, rectal trauma, or family history of inflammatory bowel disease. The patient had a core temperature 101.4 F. Physical examination was remarkable for a soft abdomen with mild tenderness in both lower quadrants. Screening blood chemistries were normal except for a leukocyte count of 23,600 with 90% PMN forms. An un-prepped sigmoidoscopic examination was performed to evaluate for possible infections, idiopathic or antibiotic related colitis. Examination to the splenic flexure showed no evidence of colitis. Endoscopic findings were remarkable for a focal 5 cm mound of friable mucosa with extrinsic compression of the sigmoid colon about 18 cm from the anal verge. Within the center of this friable mass was an 8 mm hole in the colon with free flow of fibrinous white strands and brown-white mucopurulent material, Figure 1. Histologic examination of mucosal biopsies showed colonic mucosa with ulceration, acute inflammation and crypt abscesses, but no granulomas.
Rapid clinical and laboratory improvement occurred after initiation of antibiotic therapy. Computerized tomography (CT), Figure 2a of the abdomen identified thickening of sigmoid colon and a contained parasigmoid fluid collection. No changes suggestive of inflammatory bowel disease were identified with a dedicated contrast examination of the small bowel. After 10 days of intravenous antimicrobial therapy, CT imaging was repeated, Figure 2b. The sigmoid fistulous communication was closed and the paracolonic fluid collection resolved. Six weeks later, sigmoidoscopy showed complete healing of the fistulous communication, Figure 3. At laparoscopy the appendix was adherent to the sigmoid colon, Figure 4. Adhesions were lysed and the appendix successfully removed. After four months of follow up the patient remained well.
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Figure 2a |
Figure 2b |
Figure 3 |
Figure 4 |
Discussion
The diagnosis of appendicitis and its complications is usually straight forward. In our case, the patient initially presented with clinical signs of appendicitis and an Alvarado score of 5, but a negative abdominal ultrasound (See Table 1).6,7,8,9,10 Additionally, his complete and rapid resolution of symptoms promoted a conservative approach. The failure of abdominal ultrasound to help in the diagnosis of appendicitis in this patient is not surprising, since sensitivity for diagnosis of appendicitis drops significantly in cases of retrocecal and perforated appendicitis. 11,12 As evidenced in later evaluation of this patient, computerized tomography is the most accurate radiologic test for acute appendicitis.12
Table 1. Alvarado score6
| Symptom |
Score |
| Migration of pain |
1 |
| Anorexia |
1 |
| Raised temperature T>37.3C |
1 |
| Rebound pain |
1 |
| Tenderness in right iliac FOSSA |
2 |
| Nausea, vomiting |
1 |
| Differential WBC>75% PMN |
1 |
| Leucoyte count |
2 |
| Total |
10 |
| Alvarado score > 7 predictive of appendicitis: sensitivity of 95% and specificity 46%; with PPV 87% (95% CI 74–99%), and NPV 72.4% (95% CI 61–83%).7 |
The perforation of the appendiceal abscess into the adjacent hollow organ (sigmoid colon), served to decompress the primary lesion and give rise to the atypical presentation of our patient. Appendicitis complicated by vesico-, cutaneous- and enteral-enteral fistulae have been previously reported in literature. 8,9,10 Urinary urgency and multi-organism urinary infection should alert the clinician of the possibility of entero-vesicular fistulae.13 Compensated chronic entero-appendiceal fistulae have been reported.3 Though some patients have been reported as asymptomatic, others present with diarrhea, obstruction, abdominal mass, or lower abdominal pain. Once a fistula is diagnosed, surgical intervention in the form of appendectomy and simple closure of the fistula is recommended.4,5
Sigmoid stricture may also complicate appendiceal-colonic fistula.1,4 In our patient there was luminal narrowing due to extrinsic mass effect which in the older patient may be misinterpreted as a neoplastic process.17,18 In the elderly, complicated sigmoid diverticulitis has been shown to fistulize to the normal appendix. 19,20
In our patient, spontaneous internal drainage and decompression of the appendix by fistulous communication with the sigmoid obviated the need for emergent surgery or percutaneous catheter drainage.21,22 In fact, emergent surgical intervention may have resulted in much more moribund two stage open surgical procedure.23 This case demonstrates that acute antibiotics, followed by elective, interval laparoscopic appendectomy can be an effective management option for the contained appendiceal abscess with spontaneous enteral decompression.
References
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20. Van Hillo M, Fazio VW, and Lavery IC. Sigmoidoappendiceal fistula- An unusual complication of diverticulitus. Dis Colon Rectum 1984; 27: 618-620.
21. Livingston EH, Woodward WA, Sarosi GA, Haley RW. Disconnect between incidence of nonperforated and perforated appendicitis: Implications for pathophysiology and management. Annals of Surgery. 2007;245:886-892.
22. Nicolaou S, Talsky A, Khashoggi K, Venu V. Ultrasound-guided interventional radiology in critical care. Critical Care Medicien. 2007;35[Suppl.]:S186-S197.
23. Andersson RE and Petzold MG. Nonsurgical treatment of appendiceal abscess or phlegmon: A systematic Review and Meta-analysis. Annals of Surgery. 2007;246:741-748.
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