Ruptured Appendix

1
Ruptured Appendix?

• Daniel J. Stein M.D.
• David G. Binion
• May 5th, 2008.

2
HPI

• 24-year-old male
• Transferred to FMLH from Great Lakes Hospital to
  the Trauma surgery service on March 20th.
• Outside CT abd and plevis showed intra-abdominal
  abscess secondary to perforated appendix.
• Previously had a 2 week history of right lower
  quadrant abdominal pain.

3
HPI

• Repeat CT done at FMLH showed large abscess in
  the RLQ.
• HD2, patient underwent a CT-guided drain
  placement by IR.
• Drain placed in the right anterior fluid with
  aspiration of 5 cc of serosanguineous fluid.

4
HPI

• On 3/23, AF, VS WNL
• Tolerating a general diet.
• Discharged on PO Cipro and Flagyl
• F/U outpt CT
• Surgical clinic f/u.

5
HPI

• While at home the patient continued to have
  fever, nausea, vomiting, and abdominal pain.
• Returned on 4/1/08 with fever 101.8 and worsening
  of above symptoms.
• Repeat CT showed persistant fluid collection,
  SBO, and changes c/w peritonititis.

6
HPI

• IV antibiotics.
• Taken to the operating room
• On entry into the abdominal cavity, approximately
  1 L of straw-colored fluid was drained.
• Omentum was cocooned around the entire bowel.
  There was no real recognizable anatomy.

7
HPI

• The drain followed down through the omentum into
  a large abscess cavity.
• Abscess was evacuated.
• Dense adhesions prohibited safe further
  dissection of bowel.
• Drains were placed

8
HPI

• Plan
• Continue broad-spectrum antibiotic coverage
• Nutritional supplementation
• Evaluate the need for an appendectomy several
  months down the line.

9
HPI

• IBD team was consulted 4/7 out of a concern for
  possible Crohns disease.
• Concerns for possible fistulizing /stricturing
  disease
• Had a persisting bowel obstructing.

10
HPI

• Had had some loose stool after being put on
  antibiotics.
• Denied preceding diarrhea, abdominal pain, bloody
  stools.
• Had lost about 30lbs since the RLQ abdominal pain
  had started about a month prior.

11
PMH/PSH

• None (prior to this event)

12
PMH/PSH

• SOCIAL HISTORY
• Police officer in Zion, Illinois
• Navy
• No tobacco, rare Etoh
• Married, one child
• FAMILY HISTORY
• Sister, Uncle, Cousin with breast cancer.

13
Medications

• Prior to events None
• Current
• Vancomycin
• Imipenem
• TPN
• sq Heparin
• Protonix

14
Physical Exam

• Vital T 98.8, RR 16, BP 117/67, P 125
• Gen Ill appearing
• CV RRR
• Resp CTA
• Abd Distended, distant bowel sounds, diffuse
  mild tenderness, two JP drains with minimal
  serosanguinous fluid.
• Ext 2 LE pitting edema

15
Labs

• HGB 10.3
• HCT 33
• WBC 33.0
• PLT 681
• Prealbumin 3
• Albumin 2.7

• Renal panel WNL
• AST 99
• ALT 22
• AP 156
• TBili 1.2

16
Labs

• Culture from initial drain Neg
• Had been on antibiotics at that time
• Blood culture - Neg

17
Radiology (CT 4/1)

• Persistence of the right lower quadrant abscess
  not significantly changed with an indwelling
  pigtail catheter described above.
• Changes suggestive of early partial small
  bowelobstruction as described above.
• Enlarging pelvic fluid collection with
  changessuggestive of peritonitis.

18
Radiology (CT 4/6)

• 1. Extensive omental thickening, peritoneal
  thickening with prominent omental vessels.
• 2. Ascites with distribution as above. There is
  probably some element of ascitic redistribution.
• 3. A dominant collection in the pelvis appears
  somewhat smaller in AP dimension.
• 4. There are presumably multiple mesenteric nodes
  as well as other areas having central decreased
  attenuation that could represent loculated fluid
  versus necrotic nodes. 5. Change in small bowel
  caliber suggesting small bowel obstruction. This
  was also suggested on the priorexamination.
• 6. No solid visceral abnormalities.
• 7. New left pleural effusion with increasing
  right pleural effusion.

19
Endoscopy

• No way

20
Differential Diagnosis

• Suspected possible immune compromise (HIV?)
• Peritoneal Tuberculosis
• Peritoneal Fungal infection
• Peritoneal Malignancy
• Either primary or metasatic

21
Further workup

• Suggested work up for HIV, Immunoglobulin
  deficiency, PPD, CXR.
• Peritoneal biopsy
• Re-culture for fungus and mycobacterium.

22
Further workup

• Taken back to OR on 4/12
• Multiple liver nodules biopsied
• Omental biopsies
• Fluid for cultures

23
Pathology

• A. Omentum, nodule, resection
• B. Liver nodule, biopsy
• C. Peritoneal wall, biopsy
• D. Pelvic tissue, biopsy
• E. Liver nodule, biopsy
• F. Peritoneum, biopsy
• - High grade spindle cell malignancy,
  consistent with sarcomatoid mesothelioma.

24
Final Diagnosis

• Peritoneal Mesothelioma
• Presenting as ruptured appendix.
• Complicated by bowel obstruction

25
Discussion

• Peritoneal Mesothelioma

26
Peritoneal Mesothelioma

• Mesotheliomas arise from serosa
• pleura (65-70)
• peritoneum (30)
• tunica vaginalis testis (1-2)
• pericardium (1-2)
• Rare neoplasm
• Prevalence 1-2 cases per million
• Incidence of 200-400 new cases annually.

27
Peritoneal Mesothelioma

• Rapid fatal course
• Median survival 6-12 months
• Mean symptoms-to-survival 345 days
• Rare until 1930
• industry increased the use of asbestos.

28
Peritoneal Mesothelioma

• Main risk factor is asbestos exposure
• Only 50 of patients with a peritoneal origin.
• 80 in mesotheliomas with the pleural origin.

29
Presentation

• Diagnosed in advanced stages
• Most frequent initial symptoms
• abdominal pain (35)
• abdominal swelling (31)
• anorexia, marked weight loss, and ascites

30
Intestinal obstruction

• Rare and/or late presentation
• Presenting symptom in a single case report
• Full thickness infiltration of the small bowel by
  the tumor.
• Local resection

Hepatogastroenterology. 2005 Jul-Aug52(64)1087-9
. Sethna K, Sugarbaker PH.
31
Appendicitis and MPM

• Case series of 4 cases
• All unsuspected MPM
• Presenting as acute inflammatory lesions
• Acute appendicitis in two cases
• Acute cholecystitis
• Incarcerated umbilical hernia
• All diagnosed at the time of surgery

Kerrigan SA, Cagle P, Churg A. Am J Surg Pathol.
2003 Feb27(2)248-53.
32
Appendicitis and MPM

• Two other case reports of a similar presentation
• One suspected ruptured appendicitis
• One with recurrent peritonitis.

Ramaswamy G, Shah UB, Tchertkoff V. NY State J
Med 1984 841257. Gastroenterol Clin Biol.
1996 Feb20(1)99-102.
33
Sarcomatoid MPM Very Rare
34
Patient Course

• Continued to have bowel obstruction
• Profound Leukocytosis without clear positive
  cultures
• Had presumed aspiration event, now intubated for
  respiratory distress
• Possible lysis of adhesions and intraperitoneal
  chemotherapy if improves.
• Prognosis very poor.