Contemporary Surgery

Treating acute appendicitis
following blunt trauma

Department of Surgery, University of California-Davis, Sacramento

An otherwise healthy 21-year-old man drove his all-terrain vehicle into a wire at approximately 40 mph. The wire struck him in the mid-abdomen and he was thrown from the vehicle. He remained conscious.

At an outside hospital, he complained of back and abdominal pain. An abdominal CT scan revealed an L3 Chance fracture along with trace-free fluid in the pelvis, but no solid organ injury. He was observed overnight and then transferred to our facility 30 hours postinjury.

Pain and abdominal abrasion

The patient was afebrile with normal vital signs. He had some periumbilical tenderness and a visible abdominal abrasion corresponding to the impact of the wire. The spine was tender in the upper and mid-lumbar region, but neurologically intact. He reported no antecedent abdominal pain or prodromal symptoms.

Initial laboratory findings were normal except for a slightly elevated white blood cell count (WBC) of 11.2 X10⁹/L and a low hematocrit (35%).

Due to the injuries and initial CT findings of free fluid, we suspected a hollow viscus injury. Given the elapsed time, we decided to continue with conservative management. A lumbar orthotic brace was fitted, and he began physical therapy.

Downturn

The patient was tolerating clear liquids at 48-hours postinjury, but had some difficulty with a regular diet. By postinjury day 6, his abdominal discomfort progressed to discrete lower-right quadrant pain, and he had an episode of emesis. He developed a low-grade fever of 38.3° C, and his WBC count rose to 14.5X109/L. A repeat CT scan showed trace-free fluid in the pelvis, appendiceal dilatation to 17 mm, and periappendiceal stranding (FIGURE 1).

Exploratory surgery

During laparoscopic exploration on postinjury day 7, we found several minor mesenteric tears and resolving mesenteric hematomas, but no enterotomies or solid organ injuries. The pelvic fluid appeared inflammatory. When we noted a phlegmon in the lower-right quadrant, we converted to an open procedure.

We found an inflamed appendix with a phlegmon but no perforation, and removed it (FIGURE 2). No sign of mechanical luminal obstruction was evident.

Pathology confirmed the diagnosis of appendicitis. The patient made a full recovery, and was discharged home on postoperative day 4. He was doing well at follow-up one month later.

  Appendicitis and blunt trauma

Commonalities

Acute appendicitis affects 7% of the Western population, making it the most common surgical cause for acute abdominal pain.^1,2 Blunt abdominal trauma is another common condition prompting surgical evaluation.

The prevalence of both appendicitis and blunt abdominal trauma is highest in the young adult and pediatric populations, but the two conditions rarely coexist.³

What’s Houdini got to do with it?

Interest in the association between appendicitis and blunt abdominal trauma may have begun with illusionist Harry Houdini’s untimely death in 1926. He suffered a violent blow to the abdomen followed by perforated appendicitis and peritonitis.

During the 1930s, reports of blunt abdominal trauma and subsequent appendicitis began to appear.³ Animal studies attempting to define the causative relationship between blunt trauma and appendicitis showed conflicting results.²

By the late 1930s, researchers began to study the pivotal role of luminal obstruction in the etiology of acute appendicitis.²

The process of appendicitis

Continued mucosal secretions and bacterial overgrowth despite luminal obstruction seem to result in appendiceal distention. When pressure in the submucosa first exceeds venous, then arterial pressures, ischemia results. Necrosis and perforation then follow. This process typically progresses over 24–48 hours.

The most common causes of luminal obstruction are lymphoid hyperplasia in the pediatric population and fecaliths in adults. Other etiologies, including leukemia, endometriosis, and emotional stress are rare.⁴

Cause or coincidence?

Most surgeons explain the anecdotal relationship between blunt abdominal trauma and appendicitis as coincidental rather than causal.

However, growing documentation cites a temporal relationship.^2-10 Plausible explanations for the relationship between blunt abdominal trauma and acute appendicitis have emerged, some directly related to the injury itself, and others to the post-injury hospital course (BOX).

Disclosure

The authors did not disclose any relationships.

References

1. Burkitt  DP. The aetiology of appendicitis.  Br J Surg. 1971;58:695–699.
2. Hennington  MH, Tinsley  EA  Jr,  Proctor  HJ, Baker  CC. Acute appendicitis following blunt abdominal trauma. Incidence or coincidence?  Ann Surg. 1991;214:61–63.
3. Ramsook  C. Traumatic appendicitis: fact or fiction?  Pediatr Emerg Care. 2001;17:264–266.
4. Ciftci  AO, Tanyel  FC, Büyükpamukçu  N, Hiçsönmez  A. Appendicitis after blunt abdominal trauma: cause or coincidence?  Eur J Pediatr Surg. 1996;6:350–353.
5. Etensel  B, Yazici  M, Gürsoy  H, Ozkisacik  S, Erkus  M. The effect of blunt abdominal trauma on appendix vermiformis.  Emerg Med J. 2005;22:874–877.
6. Houry  D, Colwell  C, Ott  C. Abdominal pain in a child after blunt abdominal trauma: an unusual injury.  J Emerg Med. 2001;21:239–241.
7. Musemeche  CA, Baker  JL. Acute appendicitis: a cause of recurrent abdominal pain in pediatric trauma.  Pediatr Emerg Care. 1995;11:30–31.
8. Osterhoudt  KC. Hocus-pocus: A case of abdominal pain after blunt abdominal trauma.  Pediatr Ann. 2000;29:93–96.
9. Serour  F, Efrati  Y, Klin  B, Shikar  S, Weinberg  M, Vinograd  I. Acute appendicitis following abdominal trauma.  Arch Surg. 1996;131:785–786.
10. Takagi  Y, Yasuda  K, Abe  T. Seat belt compression appendicitis.  J Clin Gastroenterol. 2000;31:184.