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Rare appendicitis-like syndrome: the case of the obstructing broccoli.

Jones S, Narh-Martey P, Patel M, Dhaliwal A, Persson J, Orr D - Case Rep Med (2014)

Bottom Line: The diagnosis of acute appendicitis can be somewhat obscure in a patient that presents with right lower quadrant abdominal pain.The advancement and ease of imaging have made CT scanning readily available in the emergency department.This case report will discuss the appendicitis-like syndrome of an obstructing bezoar and an approach at management.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, Western Reserve Health Education, USA.

ABSTRACT
The diagnosis of acute appendicitis can be somewhat obscure in a patient that presents with right lower quadrant abdominal pain. The advancement and ease of imaging have made CT scanning readily available in the emergency department. Management can be challenging when the patient has a high likelihood of appendicitis based on clinical suspicion and negative CT scan. The purpose of this case report is to demonstrate how an obstructing bezoar caused an appendicitis-like syndrome in a patient with negative CT scan and clinical diagnosis of acute appendicitis. This case report will discuss the appendicitis-like syndrome of an obstructing bezoar and an approach at management.

No MeSH data available.


Related in: MedlinePlus

(a) Mildly dilatated small bowel, (b) turbid fluid paracolic gutter, (c) normal appendix, and (d) serositis at tip of appendix.
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fig3: (a) Mildly dilatated small bowel, (b) turbid fluid paracolic gutter, (c) normal appendix, and (d) serositis at tip of appendix.

Mentions: Needle was inserted at the umbilicus and pneumoinsufflation was obtained. Using OptiView guidance, the laparoscope was inserted through a trocar into the abdominal cavity. Next, the area was inspected for injury, failing to reveal any. Additional ports were placed. The diagnostic laparoscopy immediately revealed exudative fluid in the abdominal cavity. This was yellow-green. It was suctioned and the specimen was sent for Gram stain culture and sensitivity. The fluid was washed out. The appendix was identified and found to be relatively normal with minimal serositis at the tip. The small bowel had serositis and inflammation throughout the majority of the small bowel affecting the proximal bowel more than the distal bowel. The terminal ileum was then identified from the ileocecal valve proximally and identification of a mass in the small bowel was made. The mass was firm and impacted and not able to be significantly milked in either direction. The stomach was inspected along with the duodenum and the gallbladder. The gallbladder was distended, but no signs of acute cholecystitis were appreciated. Next, anesthesia administered air to the stomach as well as methylene blue and neither of these tests revealed a leak in the stomach or duodenum. Therefore, the small bowel was then addressed just distally to the impaction and enterotomy was made. This was done by scoring the small bowel laparoscopically. The decision was made to open the fascia slightly at the umbilical port site and withdraw the small bowel. In doing so, the impacted foreign body had been milked away from the site. The bowel holding the foreign body was unable to be extracted through the enlarged port site, and, therefore, towel clamps were applied. Pneumoinsufflation was reobtained. The bowel was grasped with the grasper and extracted at the umbilical port site. The small bowel was opened with monopolar cautery via the Bovie cautery extracorporeally and then dropped back into the abdominal cavity. Towel clamps were applied to the skin and the impacted foreign body was milked towards the enterotomy (Figure 4). This technique revealed a large unchewed and undigested piece of broccoli measuring approximately 5-6 centimeters in diameter at widest point (Figure 5). The food piece was then scooped up with a bag through the midline port site, which was held in place with the towel clamps and extracted extracorporeally. The bowel was then extracted extracorporeally and the bowel was closed using running 0 Vicryl. After testing the integrity of the enterotomy site, additional Lembert interrupted vertical sutures were placed to reinforce the area. Next, the abdominal cavity was washed out with approximately 1.5 liters of warm saline. The fascia was closed using running 0 PDS sutures, and the skin was closed with subcuticular stitches. The patient tolerated the procedure well (Figure 3).


Rare appendicitis-like syndrome: the case of the obstructing broccoli.

Jones S, Narh-Martey P, Patel M, Dhaliwal A, Persson J, Orr D - Case Rep Med (2014)

(a) Mildly dilatated small bowel, (b) turbid fluid paracolic gutter, (c) normal appendix, and (d) serositis at tip of appendix.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4016857&req=5

fig3: (a) Mildly dilatated small bowel, (b) turbid fluid paracolic gutter, (c) normal appendix, and (d) serositis at tip of appendix.
Mentions: Needle was inserted at the umbilicus and pneumoinsufflation was obtained. Using OptiView guidance, the laparoscope was inserted through a trocar into the abdominal cavity. Next, the area was inspected for injury, failing to reveal any. Additional ports were placed. The diagnostic laparoscopy immediately revealed exudative fluid in the abdominal cavity. This was yellow-green. It was suctioned and the specimen was sent for Gram stain culture and sensitivity. The fluid was washed out. The appendix was identified and found to be relatively normal with minimal serositis at the tip. The small bowel had serositis and inflammation throughout the majority of the small bowel affecting the proximal bowel more than the distal bowel. The terminal ileum was then identified from the ileocecal valve proximally and identification of a mass in the small bowel was made. The mass was firm and impacted and not able to be significantly milked in either direction. The stomach was inspected along with the duodenum and the gallbladder. The gallbladder was distended, but no signs of acute cholecystitis were appreciated. Next, anesthesia administered air to the stomach as well as methylene blue and neither of these tests revealed a leak in the stomach or duodenum. Therefore, the small bowel was then addressed just distally to the impaction and enterotomy was made. This was done by scoring the small bowel laparoscopically. The decision was made to open the fascia slightly at the umbilical port site and withdraw the small bowel. In doing so, the impacted foreign body had been milked away from the site. The bowel holding the foreign body was unable to be extracted through the enlarged port site, and, therefore, towel clamps were applied. Pneumoinsufflation was reobtained. The bowel was grasped with the grasper and extracted at the umbilical port site. The small bowel was opened with monopolar cautery via the Bovie cautery extracorporeally and then dropped back into the abdominal cavity. Towel clamps were applied to the skin and the impacted foreign body was milked towards the enterotomy (Figure 4). This technique revealed a large unchewed and undigested piece of broccoli measuring approximately 5-6 centimeters in diameter at widest point (Figure 5). The food piece was then scooped up with a bag through the midline port site, which was held in place with the towel clamps and extracted extracorporeally. The bowel was then extracted extracorporeally and the bowel was closed using running 0 Vicryl. After testing the integrity of the enterotomy site, additional Lembert interrupted vertical sutures were placed to reinforce the area. Next, the abdominal cavity was washed out with approximately 1.5 liters of warm saline. The fascia was closed using running 0 PDS sutures, and the skin was closed with subcuticular stitches. The patient tolerated the procedure well (Figure 3).

Bottom Line: The diagnosis of acute appendicitis can be somewhat obscure in a patient that presents with right lower quadrant abdominal pain.The advancement and ease of imaging have made CT scanning readily available in the emergency department.This case report will discuss the appendicitis-like syndrome of an obstructing bezoar and an approach at management.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, Western Reserve Health Education, USA.

ABSTRACT
The diagnosis of acute appendicitis can be somewhat obscure in a patient that presents with right lower quadrant abdominal pain. The advancement and ease of imaging have made CT scanning readily available in the emergency department. Management can be challenging when the patient has a high likelihood of appendicitis based on clinical suspicion and negative CT scan. The purpose of this case report is to demonstrate how an obstructing bezoar caused an appendicitis-like syndrome in a patient with negative CT scan and clinical diagnosis of acute appendicitis. This case report will discuss the appendicitis-like syndrome of an obstructing bezoar and an approach at management.

No MeSH data available.


Related in: MedlinePlus