Presentation
Fever, nausea, vomiting, abdominal pain, and no bowel movements for the past 3 days.
Patient Data
Acute appendicitis occurring within a large right-sided inguinal hernia. There are associated rim-enhancing fluid loculations within the hernia with the largest collection measuring 9.2 x 8.7 x 4.5 cm. These findings are concerning for perforation and abscess formation. Inflammatory changes extend into the abdomen in the right paracolic region. There is no evidence of free air.
Diffuse small bowel dilatation which may represent reactive ileus in the setting of appendicitis.
Mild diffuse colonic wall thickening.
Ancillary findings:
moderate prostatomegaly
small hiatal hernia. Esophagus is mildly distended with air and fluid and has wall thickening
mild cardiomegaly and moderate coronary artery calcification
trace right-sided pleural effusion
peripherally enhancing 9 mm lesion in the right hepatic dome, possibly representing a hemangioma
Interval postsurgical changes include enterectomy, right hemicolectomy with appendectomy, colostomy, and partial reduction/repair of large right inguinal hernia.
There is a small loculated fluid collection in the right paracolic gutter measuring approximately 3.4 x 3.2 x 4.9 cm in size and extending superiorly into the pericholecystic space.
The large right inguinal hernia no longer contains bowel, but still contains fat and phlegmonous fluid as well as a tiny locule of air. There is no evidence of frank abscess or bowel obstruction.
There is a focal hyperdensity in the splenic flexure measuring approximately 2.4 cm in size concerning for mass.
Diffuse fatty infiltration of the walls of the transverse and descending colon compatible with colitis.
Pathology report demonstrating invasive adenocarcinoma from the cecum/right colon without metastasis.
Gene analysis of the specimen was significant for high microsatellite instability (MSI-H) which is associated with Lynch syndrome.
Case Discussion
The patient has had this right Amyand's hernia for nearly 30 years without any major issues. Upon presentation, he was septic which required immediate IV antibiotics. After imaging confirmed perforated appendicitis, he received emergent exploratory laparotomy and ultimately underwent hernia repair with enterectomy, right hemicolectomy, and colostomy with mucus fistula.
The most common causes of appendicitis involve lumen obstruction, typically due to lymphoid hyperplasia or fecalith. Notably, the pathology report of the resected specimen showed moderately differentiated invasive adenocarcinoma of cecum/right colon in origin. While rare, the presence of neoplasm as the source of appendiceal lumen occlusion for appendicitis has been documented in various case reports in older patients. According to Shroff et al., the incidence of cecal or right-sided colon cancer as a cause of acute appendicitis has been reported in 2% to 15% of such cases throughout the literature.
Moreover, genetic analysis of the specimen was significant for high microsatellite instability which is associated with Lynch syndrome.
Upon stabilization and discharge, the patient was arranged to receive outpatient colonoscopy and chemotherapy.
Unable to process the form. Check for errors and try again.