Acute peritonitis secondary to post-traumatic appendicitis: A case report and literature review

Abstract

BACKGROUND

Blunt abdominal trauma has rarely been reported as a cause of acute appendicitis in the literature. However, the coexistence of the two conditions can cause issues for the patient. We present here a systematic review of cases of traumatic appendicitis as well as our own experience with a 12-year-old male patient.

CASE SUMMARY

A 12-year-old male was admitted 3 d after abdominal trauma, experiencing peritoneal syndrome. A pelvic formation was discovered during abdominal ultrasound, and surgical exploration revealed a perforated appendix. A literature review was conducted applying the keywords “appendicitis,” “abdominal,” and “trauma” to the PubMed, Embase, and Medline databases. Our initial search included 529 papers published between 1991 and 2022, of which 33 papers were finally included. They revealed 51 reported cases. The trauma mechanisms included road traffic accidents, falls, assaults, ball accidents, a horse kick, and a colonoscopy. Eight patients underwent surgical exploration with no prior radiological investigation, and twenty-six patients underwent an initial radiological examination. All reports indicated a perforated appendix.

CONCLUSION

Acute traumatic appendicitis represents a diagnostic quandary that can be misdiagnosed resulting in significant morbidity and potential mortality. A high level of suspicion combined with radiological examination may aid in the diagnosis and treatment of this condition.

Key Words: Appendicitis, Abdominal, Trauma, Pediatric, Surgery, Case report

Core Tip: Appendicitis and abdominal trauma represent the two most common surgical emergencies in both adults and children. However, their coexistence may pose a diagnostic dilemma depending on whether the finding is incidental. Appendicitis should be considered in the differential diagnosis of right lower quadrant pain after abdominal or perineal trauma.

INTRODUCTION

Appendicitis and abdominal trauma represent the two most common surgical emergencies in both adults and children. However, their coexistence may pose a diagnostic dilemma depending on whether the finding is incidental. Traumatic appendicitis has been a rarely reported but was first recognized in the case of Harry Houdini[1]. In this case, the Hungarian escapologist allowed his student to punch him repeatedly in the right side of his abdomen, and he subsequently died from appendicular peritonitis.

Herein, we reported the case of a 12-year-old male patient who was admitted with acute appendicitis following a blunt abdominal trauma. In addition, we reviewed the literature regarding this uncommon condition.

CASE PRESENTATION

Chief complaints

A 12-year-old male was admitted to the emergency department 3 d after sustaining a fall injury.

History of present illness

The trauma was minor as the patient had fallen from his own height, landing on a concrete floor on his right side and injuring his right hand.

History of past illness

The patient had no surgical history and appeared to be in good health prior to the accident.

Personal and family history

The patient had no relevant personal or family history.

Physical examination

Initially, the patient had attended a consult at a local clinic where a physical examination provided normal findings apart from a fifth metacarpal fracture. There were no bruises or tenderness on the abdomen. No further investigation was performed, and the patient was discharged with a plaster cast.

Later that day, he experienced abdominal pain and emesis. By the 3^rd day, he developed bilious vomiting and diarrhea prompting his evaluation in the emergency department. Upon examination, his blood pressure, heart rate, and respiratory rate were all normal. His temperature was 37.7 °C. He developed hypogastric tenderness with no rebound or guarding.

Laboratory examinations

Laboratory results revealed an elevated white blood count of 14.5 × 10⁹/L (normal range: 4.5-11.0 × 10⁹/L) and C-reactive protein level of 243 mg/L (normal range: 0.3-1.0 mg/L). Serum electrolytes, lipase, and urinalysis results were all normal.

Imaging examinations

A plain abdominal X-ray revealed multiple gas-fluid levels with no free peritoneal gas (Figure 1). Abdominal ultrasound revealed intestinal dilation as well as a well-limited hypoechoic pelvic formation associated with infiltration of the adjacent intestinal loops.

Figure 1 Abdominal X-ray revealed gas-fluid levels.

FINAL DIAGNOSIS

Acute traumatic appendicitis.

TREATMENT

An urgent exploratory laparotomy was performed. Abdominal exploration revealed an intra-abdominal pelvic abscess surrounded by a perforated mesocolic appendix. There were no associated lesions. Appendectomy was performed, and the stump was managed by double ligation.

OUTCOME AND FOLLOW-UP

The postoperative course was uneventful with no postoperative complications. The patient received intravenous triple antibiotic therapy that consisted of cefotaxime, metronidazole, and gentamicin for 10 d. He was then discharged home with no associated treatment. The histopathological examination confirmed the diagnosis of acute appendicitis.

DISCUSSION

Blunt abdominal trauma is a rare cause of acute appendicitis. However, the direct association is difficult to establish. Ciftci et al[2] discovered a higher incidence of appendicitis after blunt abdominal trauma in pediatric patients. Fowler[3] developed four essential criteria for defining traumatic appendicitis: (1) No history of previous abdominal attacks; (2) Direct abdominal trauma or severe indirect abdominal wall trauma; (3) Symptom onset soon after the trauma; and (4) Progressive symptoms requiring treatment and diagnosis of appendicitis. In this review, all patients met the inclusion criteria, and the diagnosis was confirmed by a histopathological study.

Limited data are available regarding the pathogenesis of traumatic appendicitis. Direct trauma may cause edema and inflammation of the appendicular lymphoid tissue, resulting in obstruction and acute appendicitis. In cases of indirect trauma, an increase in intra-abdominal pressure may cause an increase of intra-cecal pressure resulting in rapid appendiceal distension and appendicitis. Direct trauma of the mesoappendix has also been reported[4]. One patient developed traumatic appendicitis following a perineal trauma[5]. These mechanisms could be isolated or combined, but they are still speculative. Wangensteen et al[6] demonstrated the development of acute appendicitis following direct trauma with no luminal obstruction in a rabbit model. However, this study represents the only experimental theory.

We identified a high incidence of traumatic appendicitis in pediatric patients (52.9%). This can be explained by the smaller abdominal cavity and quality of the muscular anterior abdominal wall in pediatric cases. As a result, clinicians should be suspicious of traumatic appendicitis after blunt abdominal trauma particularly in children. In addition, children are at higher risk of trauma from gaming accidents, such as from balls and bicycles, and animal-related injuries (being kicked by a horse[7]).

Initially, the clinical and radiological signs of traumatic appendicitis may be nonspecific and/or misleading. Routine hematological and biochemical investigations are ineffective as well. Only a strong suspicion of this pathology may lead to a diagnosis. The difficulty of diagnosis may come from the unfamiliarity of traumatic appendicitis and the numerous differential diagnoses of the causes of abdominal pain after an abdominal trauma. However, ultrasound has proven to be beneficial in several cases[4] (Table 1).

Table 1 Literature review of post-traumatic appendicitis.

Ref.	Year	Cases, n	Age in yr	Mechanism of injury	Time of presentation	WBC as /mm3	Investigations	Surgery	Findings
Hennington et al[13]	1991	2	46; 12	RTA; fall	48 h; 12 h	16900; 13000	CT (free fluid); none	Laparotomy; laparotomy	Isolated; isolated
Bangs[14]	1991	1	20	RTA	A few hours	3250	CT	Laparotomy	Isolated
Musemeche and Baker[15]	1995	1	4	RTA	A few hours	22900	CT	Laparotomy	Isolated
Stephenson and Shandall[16]	1995	1	32	Seat belt	120 h	NA	NA	Laparotomy	Wedge fracture of T10
Serour et al[17]	1996	3	11; 8; 7	Assault; fall; assault	1 h; 3 h; 7 d	4500; 20100; NA	CT; none; CT	Laparotomy; laparotomy; laparotomy	Isolated; isolated; isolated
Ciftci et al[2]	1996	5	8; 5; 13; 14; 7	RTA; fall; ball; RTA; assault	2 h; 6 h; 12 h; 4 h; 12 h	9800-18000	NA; NA; NA; US; US	Laparotomy; laparotomy; laparotomy; laparotomy; laparotomy	Head injury; rib fracture; isolated; head injury; head injury
Edwards et al[11]	1999	1	41	RTA	Hours	NA	CT	Laparotomy	Ileocecal lesion and ileocecal resection
Osterhoudt[8]	2000	1	9	RTA	Hours	NA	CT (NL)	Laparotomy	Isolated
Takagi et al[18]	2000	1	45	Seat belt	24 h	NA	NA	Laparotomy	Isolated
Ramsook[19]	2001	1	12	Assault	7 h	15400	CT	Laparotomy	Isolated
Houry et al[20]	2001	1	5	Fall	1 h	NA	CT	Laparotomy	Isolated
Hagger et al[21]	2002	1	60	Fall	72 h	NA	CT	Laparotomy	Incarcerated direct hernia
Ramesh et al[22]	2002	1	11	Bicycle	48 h	NL	US	Laparotomy	Isolated
Karavokyros et al[23]	2004	1	21	Assault	Hours	NA	US	Laparotomy	Isolated
Etensel et al[10]	2005	5	5; 8; 14; 9; 13	RTA; RTA; RTA; fall; RTA	4 h; 1 h; 1 h; 1 h; 15 min	18700; 19500; 12200; 17700; 19400	US; US; US; US, CT; CT	Laparotomy; laparotomy; laparotomy; laparotomy; laparotomy	Multiple hepatic lacerations; right diaphragmatic rupture, liver laceration, and retroperitoneal hematoma; retroperitoneal hematoma; isolated; left diaphragmatic rupture, splenic laceration, and left ureteropelvic junction rupture
Volchok and Cohn[24]	2006	1	60	Colonoscopy	60 h	13700	CT	Laparoscopy	Isolated
Derr and Goldner[25]	2009	1	41	Fall	24 h	NA	US, CT	Laparoscopy	Isolated
Amir et al[5]	2009	1	10	Fall	2 h	NL	US, CT	Laparotomy	Isolated
Toumi et al[26]	2010	1	11	Assault	3 d	NA	CT	Laparotomy	Isolated
O'Kelly et al[27]	2012	1	29	Ball	24 h	17470	CT	Laparotomy	Isolated
Paschos et al[28]	2012	1	17	Bicycle	12 h	12700	US	Laparotomy	Isolated
Wani[29]	2013	8	9-63	3 falls; 4 assaults; 1 bicycle	24 h-4 d	NA	US, CT	Laparotomy	Isolated
Bouassria et al[4]	2013	1	24	Stab	24 h	14000	US (2nd)	Laparotomy	Retroperitoneal hematoma
Moslemi et al[30]	2013	1	13	Bicycle	6 h	14700	US, CT	Laparotomy	Rupture of the small bowel mesentery
Go et al[31]	2016	1	23	Seat belt	0.5	NA	US, CT	Laparotomy	Tearing of the distal ileum mesentery
Khilji et al[32]	2017	1	43	RTA	2 h	11000	US, CT	Laparoscopy	Isolated
Cobb[33]	2017	1	17	RTA	24 h	10800	CT	Laparoscopy, laparotomy	Isolated
Aljaberi et al[34]	2018	1	24	Seat belt	24 h	NA	CT	Laparotomy	Transection of the omentum
Çağlar et al[35]	2018	1	12	Fall	24 h	21020	CT	Laparotomy	Isolated
Siddiqui et al[36]	2018	1	22	Fall	3 h	7500	CT	Laparoscopy	Isolated
Zvizdic et al[7]	2019	1	7	Horse kick	10 h	11500	US, CT	Laparotomy	Isolated
Salinas-Castro et al[37]	2023	1	14	Soccer ball	6 h	NA	US, CT	Laparoscopy	Isolated
Goldman et al[38]	2022	1	11	Assault	24 h	22000	MRI	Laparoscopy	Isolated
Our study	2023	1	12	Fall	3 d	14500	US	Laparotomy	Isolated

CT: Computed tomography; MRI: Magnetic resonance imaging; NA: Not available; NL: Normal; RTA: Road traffic accident; US: Ultrasound; WBC: White blood cell.

In our case, ultrasound did not aid in the diagnosis of appendicitis but did rule out other clinical entities. An X-ray revealed a mechanical obstruction, which led us to perform surgery. Computed tomography scans and magnetic resonance imaging scans are more sensitive for diagnosis. However, a computed tomography scan was normal in 1 patient with traumatic appendicitis[8]. These imaging modalities also may not be accessible in all circumstances.

Contrary to other visceral injuries, traumatic appendicitis may have few early indirect signs of its presence[9], which causes a significant delay in diagnosis and increases the risk of an abscess, peritonitis, and mortality. Moreover, the underdevelopment of the omentum in children may result in the diffusion of the infection. Thus, we emphasize the importance of repeated examinations.

In all cases, surgical treatment is required. Due to the trauma and the risk of associated hemorrhagic lesions that may necessitate additional treatment, laparotomy is commonly performed[10]. Laparoscopy may be indicated in stable cases with a positive preoperative diagnosis. In cases of isolated appendicular lesions, an appendectomy with ligation or plicature of the appendicular stump may be curative, and resection of the injured bowel along with the appendectomy may be performed[11,12].

CONCLUSION

Traumatic appendicitis is rarely reported due to the difficulty of associating the trauma as a direct cause. The causative relationship is proposed based on the basis of circumstantial evidence. It should, however, be considered in the differential diagnosis of right lower quadrant pain after abdominal or perineal trauma. There are also legal implications of traumatic appendicitis because the trauma can occur from aggression or road traffic accidents.