Acute appendicitis is a surgical emergency, which is treated by either open surgery or laparoscopic surgery. Causes of acute appendicitis include primary obstruction of the appendix lumen (the inside space of a tubular structure), bezoars, foreign bodies, trauma, intestinal worms, lymphadenitis and, most commonly, calcified faecal deposits known as appendicoliths or faecaliths. The typical presentation is a history of nausea, anorexia, vomiting and abdominal pain that starts periumbilically then shifts to the lower right quadrant.1 There may be tenderness in the lower right quadrant with rigidity, guarding and rebound tenderness. Rovsing’s sign and/or the psoas sign may or may not be evident; it will depend on the position of the inflamed appendix and the severity of the case. A blood test will usually show neutrophilia.2
Pancreatitis is caused by gallstones or alcohol in 80% of patients and needs urgent medical management.3 Gallstones are the most common cause of acute pancreatitis, while alcohol is the most common cause of chronic pancreatitis. Other causes of pancreatitis include drugs and viruses, but these are less common. Diagnosis is based on characteristic abdominal pain, elevated serum amylase and lipase levels, ultrasound of the abdomen or computerized tomography scan.4
The case reported here is classified as pancreatitis with appendicitis.
A 27-year-old male presented to Hatta Hospital, Dubai, United Arab Emirates (UAE), with symptoms characteristic of acute abdomen. The patient’s history showed central abdominal pain that shifted to the lower right quadrant in association with vomiting (once) and mild fever. He also had a history of recurrent epigastric pain, which had been treated using antacids and antibiotics. There was no established diagnosis of peptic ulcer or pancreatitis. There was no history of surgery, alcohol consumption or hospitalization. Nothing in his family history was of significance. The patient was not known to have a chronic illness or allergy.
After careful evaluation and assessment, he was diagnosed with acute appendicitis. During clinical examination he was found to be dehydrated and exhibiting mild jaundice and tachycardia. His abdomen was rigid and tender in the lower right quadrant. Rebound tenderness was positive. The systemic review was unremarkable. The results of the patient’s laboratory tests are shown in Figure 1.
The patient’s full blood count showed neutrophilia. His haemoglobin levels were normal and white blood cell counts within the normal range. His direct bilirubin level was 1 mg/dl on admission preoperatively, while total bilirubin was 3.3 mg/dl. His abdominal radiograph was unremarkable.
The patient was prepared for a laparoscopic appendectomy. During surgery the appendix was found to be severely inflamed with suppuration (Figure 2). The post-operative period was uneventful. His condition improved and his serum amylase and lipase levels gradually decreased. During hospitalization he received antibiotics, analgesia and proton pump inhibitors. Histopathology reports showed acute suppurative appendicitis with periappendicitis.
Post-operative ultrasound excluded any signs of biliary obstruction. There was no evidence of hepatitis, either clinically or from laboratory tests. Serum amylase and lipase levels decreased gradually during follow-up.
It is clear that the patient had acute or chronic pancreatitis that was overlooked because of his recurrent abdominal pain, which, according to the patient, was referred to the back. He denied any history of diabetes mellitus, jaundice or alcohol consumption. It is clear that the diagnosis of acute pancreatitis depends, clinically, on the nature and character of epigastric pain, which is referred to the back, increased serum amylase or lipase levels and radiological evidence (computerized tomography).1 Acute appendicitis is diagnosed by abdominal pain that shifts to the lower right quadrant, in most cases, in association with gastrointestinal upset in the form of nausea, anorexia and vomiting (once).5 According to a Chinese paper6 on pancreatitis complicated by periappendicitis, acute appendicitis remains possible even in cases of mild acute pancreatitis. We did not find any other studies similar to this case. However, in general, colonic complications of pancreatitis do not exceed 7% of cases, according to a study by Adams et al.7 that included all colonic complications such as colonic infarction, infection and fistulas. There is no isolated involvement of the appendix in complicated pancreatitis.7