Contemporary SurgeryCASE QUIZ
Treating acute appendicitis Matthew
following blunt trauma
Department of Surgery, University of California-Davis, Sacramento
Cause or coincidence? An ATV accident provides an interesting case.
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.
The patient drove his ATV into a wire at 40 mph. The wire struck him in the abdomen, and he was thrown from the vehicle.
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.
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).482
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
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.483
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
How to diagnose traumatic appendicitis
Diagnosing traumatic appendicitis may be difficult due to a low index of suspicion, critical illness, or symptom masking due to distracting injuries.
Failure to diagnose and treat post-traumatic appendicitis has the potential to increase morbidity, mortality, and hospital costs.
Three proposed diagnostic criteria are:3
No history of abdominal pain prior to trauma.
Direct and violent blunt force to the abdomen of limited duration.
Progressive worsening of signs and symptoms that merge into the clinical presentation of appendicitis, confirmed and relieved by surgical intervention.—JS, JL, MS
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?
Fluid resuscitation, poor intestinal perfusion, or marginal hemodynamics may predispose hospital patients to acute appendicitis.
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).
The relationship between blunt trauma and appendicitis
Plausible explanations for the relationship between blunt abdominal trauma and acute appendicitis have emerged. Among those directly related to the injury itself:
Intramural hematoma. Blunt injury to the cecum may cause an intramural hematoma that could compress and obstruct the appendiceal lumen.4,5
Increased intraluminal pressure. A sudden increase in intraluminal pressure could acutely burst the appendix or cause stool to become impacted, functioning as a fecalith.3
Intestinal compression. This can cause pressure to be preferentially transmitted to the appendiceal orifice in the cecum due to the law of LaPlace, causing significant edema and obstruction at the orifice.3-5 These postinjury hospital events may predispose a patient to develop acute appendicitis:5
Fluid resuscitation. A rise in fluid can cause bowel edema and lead to appendiceal obstruction secondary to an edematous orifice.
Poor intestinal perfusion. This is a telling sign of hemorrhagic shock. Fluid resuscitation with subsequent perfusion restoration may cause a reperfusion that compounds the edema with potential for obstruction.
Marginal hemodynamics. Edema within the appendiceal wall compromises local blood flow, and, in the patient with marginal hemodynamics, increases the risk of ischemia and necrosis.—JS, JL, MS
The authors did not disclose any relationships.
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