Intermesenteric Appendicular Abscess a Diagnostic Challenge; Case Report and Review
I.N. Mateş, S. ConstantinoiuImage Quiz for surgeons, no. 2, 2014
The appendicular origin of an intermesenteric abscess is rarelysuspected prior to surgery, due to atypical clinical presentationand poor sensitivity of exploratory methods. A 43-year-oldmale was admitted for recent pain and mild tenderness in theepigastrium, slight emesis, leucocytosis (C-reactive protein wasnot determined), with no pathological findings on simpleabdominal radiological examination (Rx). Abdominal ultrasound(US) and endoscopy were irrelevant. The abdomenbecame moderately tender, distended; diffuse enteric gas,slightly impaired bowel movement could be demonstrated by anew Rx. CT (oral contrast) was performed in the 3rd day:edematous infiltration of the mesentery and of a left-flankdigestive loop (jejunal, sigmoidian?), small-size fluid collection(with extraluminal air-level) and paretic loops in theproximity, but normal wall-appearance of the caecum and itssurrounding fat; the CT result was inconclusive (perforateddiverticulosis or malignancy?). Barium enema: normal,including the caecum. Installation of vesperal fever, progressivemid-abdominal pain, tenderness and formation of a mass werethe rationale for open mid-line laparotomy, discovering a largeintermesenteric abscess, secondary to perforated gangrenousintermesenteric appendicitis. Surgical outcome of appendectomy was normal. A high index of suspicion may besuggested by: atypical clinical presentation (fever; ileus;presence or formation of a tender, periumbilical, mass) and CTfindings (abscess; extraluminal air; ileus).
