Case Report
A 30-year-old female patient with a height of 1.62 m and weight of 110
kg (BMI 41.91) having pain in the lower abdomen was admitted to the
emergency department. The previous day, symptoms started with pain in
the epigastrium. As time went on, the pain was located around the navel
and finally settled in the right iliac fossa. The patient did not report
having nausea, episodes of vomiting, or fever at home. The patient’s
bowel habits were unaltered, and she reported loss of appetite the
previous two days.
The physical examination raised the suspicion of appendicitis since a
positive McBurney’s sign was found - right lower abdominal quadrant pain
- and rebound tenderness, indicating peritoneum irritation. The blood
test results revealed leucocytosis, with WBC
12.730/mm3 (66.4% Neut, 23.6% Lym, 8.1% Mono) and
increased levels of the C-reactive protein (2.06). Our patient had an
Alvarado score 9 [1]. Additionally, neither the urine analysis nor
the abdominal X-ray revealed any findings.
Afterward, an examination of the abdomen was performed with an
ultrasound. The coarse examination revealed no particular findings. The
graded compression technique was then performed using the 8 MHz probe
set above the position of maximum sensitivity with gradually increasing
pressure exerted to displace the normal supernatant gas. The appendix
was identified (Figure 1) with the blind end of the appendix arising
from the base of the caecum. The appendix was dilated (diameter 1.5cm)
in target appearance (axial section) [a], was non-compressible when
compression was applied [b] and had hyperechoic appendicolith with
posterior acoustic shadowing and periappendiceal fluid collection (white
arrow) [c]. After the application of the coloured Doppler, it showed
intense vascularization of the wall as an image of mural hyperaemia
[d].
The patient was hemodynamically stable but, during admittance, presented
with a low-grade fever (37.5 oC). After reviewing the
test results, a decision was made to perform an open appendectomy via a
McBurney’s incision.
Intraoperative findings included a mild quantity of free fluid in the
right iliac fossa and an inflamed appendix. Surprisingly, another thin,
mildly inflamed appendix was found when the appendectomy was completed
(Figure 2).
Both the appendices could be separated at the bases and were ligated
individually. Our case presented a B2 type appendiceal duplication
[2]. An inspection of the small bowel for the presence of Meckel’s
diverticulum followed, which was negative. Histopathological examination
of the surgical specimen confirmed the clinical findings. Both specimens
showed identical features: appendiceal mucosa with extensive transmural
chronic, active inflammation associated with suppurative peritonitis
(Figure 3a,b). The patient had an uneventful recovery and was discharged
on the sixth postoperative day.