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Case Reports and Images in Surgery

 
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Case Report
 
Acute cholecystitis with perforated appendicitis: The first reported case
Abdulwahid M. Salih1, F. H. Kakamad2, Marden Husain Abbas3
1Faculty of Medical Sciences, School of Medicine/Department Surgery, University of Sulaimani, François Mitterrand Street, Sulaymaniyah, Iraq.
2Faculty of Medical Sciences, School of Medicine, Department Cardiothoracic and Vascular Surgery, University of Sulaimani, François Mitterrand Street, Sulaymaniya, Iraq.
3Zhian Private Hospital. Goran St. Sulaimanyiah, Iraq.

Article ID: 100023Z12AS2016
doi:10.5348/Z12-2016-23-CR-15

Address correspondence to:
F. H. Kakamad
Faculty of Medical Sciences, School of Medicine, Department Cardiothoracic and Vascular Surgery
University of Sulaimani, François Mitterrand, Street
Sulaymaniyah
Iraq

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How to cite this article:
Salih AM, Kakamad FH, Abbas MH. Acute cholecystitis with perforated appendicitis: The first reported case. J Case Rep Images Surg 2016;2:57–59.


Abstract
Introduction: Although both conditions are very common, concomitance of acute calculous cholecystitis with perforated acute has never been reported. In this paper, we present a case of acute calculous cholecystitis with perforated acute appendicitis.
Case Report: A 66-year-old female presented with a four-day history of right side abdominal pain associated with nausea, pyrexic and tachycardia (pulse rate 105 beats per minute). An ultrasound of her abdomen and pelvis revealed an inflamed, thick-walled gallbladder with evidence of multiple small gallstones. Her appendix could not be visualized. A diagnostic +/- therapeutic laparoscopy was performed, which revealed an inflamed gallbladder and fluid collection in right iliac fossa with foul smelling. A combined laparoscopic cholecystectomy with open appendectomy was performed. Intraoperatively perforated appendix was found. Postoperative follow-up was uneventful and the patient was free of complaint two weeks later.
Conclusion: While most of the abdominal pain refers to single diagnosis, clinicians should be aware that more than one diagnosis can still coexist.

Keywords: Acute cholecystitis, Appendicitis, Dual abdominal pathology


Introduction

Acute calculous cholecystitis (ACC) is the most common surgical diagnosis in the developed countries and its incidence increases with age [1]. Worldwide, it is accounted as the third most common surgical emergency admission [2]. Acute appendicitis (AA) is another most common cause of emergency admission with approximately 11 in 10,000 people will develop appendicitis throughout their lifetime [3]. Although literature shows decreasing incidence of AA, papers revealed increased fatal complications of this conditions including perforation and septicemia [4].

In spite of the fact that both conditions are common, simultaneous occurrence of these diseases are extremely rare with only four reported cases in literature [5] [6][7][8]. Concomitance of ACC with perforated AA has never been reported. In this paper, we present a case of ACC with perforated AA managed by combined laparoscopy and open appendectomy.


Case Report

A 66-year-old female presented with a four-day history of right side abdominal pain associated with nausea. The pain started gradually from epigastric region and increased in severity in last 10 hours. On physical examination, she had a tachycardia (pulse rate 105 beats per minute) with normal blood pressure but she was pyrexic (38.4°C). Abdominal examination showed tenderness in right sides of abdomen including right iliac fossa. Murphy sign was +ve. Obturator, rovsing and psoas signs were negative. Laboratory tests showed normal white blood cell count and liver function tests.

An ultrasound of her abdomen and pelvis revealed an inflamed, thick-walled gallbladder with the evidence of multiple small gallstones. Her appendix could not be visualized and there was no free fluid in the pelvis. A diagnostic +/- therapeutic laparoscopy was performed, which revealed an inflamed gallbladder and fluid collection in right iliac fossa with foul smelling (Figure 1). A combined laparoscopic cholecystectomy with open appendectomy was performed (Figure 2). Intraoperatively perforated appendix was found. The sample was lost by the family before being examined histopathologically.

Postoperative follow up was uneventful and the patient was free of complaint two weeks later.


Cursor on image to zoom/Click text to open image
Figure 1: Laparoscopic cholecystectomy showing inflamed and distended gall bladder.



Cursor on image to zoom/Click text to open image
Figure 2: Open appendectomy showing perforated appendix.



Discussion

Regarding acute onset of symptoms, an important principle is that combining clinical and laboratory data should fit into professional diagnosis of a condition before any sort of intervention [8]. In this case, the data were more suggestive for ACC rather than an AA as pain and tenderness was more prominent at right hypochondrium with positive Murphy's sign and ultrasound showed multiple small size stones and thick wall gallbladder.

Simultaneous cholecystitis and appendicitis in the same patient has been rarely described in English literature [5][6]. It has been reported with four forms; an acalculous cholecystitis and appendicitis, calculous cholecystitis and appendicitis, perforated cholecystitis and appendicitis as well as during pregnancy [5][6][7][8]. To our knowledge, this is the first time to present a case with ACC with perforated AA.

With few reported cases, it is difficult to explain the etiology of concomitant occurrence of cholecystitis and appendicitis. As previously noted, hyperbilirubinemia can occur in acute appendicitis [5]. Hyperbilirubinemia associated with appendicitis explained by bacterial translocation into the portal venous system, leading to altered bilirubin excretion [5]. This could be an explanation for simultaneous occurrence of both ACC and AA. However, there is no evidence to support the exact etiology of this co-existence.

When diagnosis of an abdominal pain is in question, or when more than one pathologies are suspected, laparoscopic abdominal examination is an ideal approach which gives opportunity for both diagnosis and management of most of the surgical problem [8]. However, when difficulties are faced, timely conversion to open operation should not be delayed. In this case, after successful laparoscopic cholecystectomy has been performed, appendectomy was done in open classical way.


Conclusion

While most of the abdominal pain refers to single diagnosis, clinicians should be aware that more than one diagnosis can still coexist. In this situation, a diagnostic plus/minus therapeutic laparoscopy can be an ideal approach.


References
  1. Mizrahi I, Mazeh H, Yuval JB, et al. Perioperative outcomes of delayed laparoscopic cholecystectomy for acute calculous cholecystitis with and without percutaneous cholecystostomy. Surgery 2015 Sep;158(3):728–35.   [CrossRef]   [Pubmed]    Back to citation no. 1
  2. Shaffer EA. Gallstone disease: Epidemiology of gallbladder stone disease. Best Pract Res Clin Gastroenterol 2006;20(6):981–96.   [Pubmed]    Back to citation no. 2
  3. Ben-David K, Sarosi GA Jr. Appendicitis. In: Feldman M, Friedman LS, Brandt LJ eds. Sleisenger & Fordtran's Gastrointestinal and Liver Disease. Vol 2. 9ed. Philadelphia, PA: Saunders Elsevier; 2010. p. 2599–612.    Back to citation no. 3
  4. Buckius MT, McGrath B, Monk J, Grim R, Bell T, Ahuja V. Changing epidemiology of acute appendicitis in the United States: study period 1993-2008. J Surg Res 2012 Jun 15;175(2):185–90.   [CrossRef]   [Pubmed]    Back to citation no. 4
  5. Sahebally SM, Burke JP, Nolan N, Latif A. Synchronous presentation of acute acalculous cholecystitis and appendicitis: a case report. J Med Case Rep 2011 Nov 14;5:551.   [CrossRef]   [Pubmed]    Back to citation no. 5
  6. Grimes DA. Spontaneous perforation of the gallbladder from cholecystitis with acute appendicitis in pregnancy. A case report. J Reprod Med 1996 Jun;41(6):450–2.   [Pubmed]    Back to citation no. 6
  7. Reimann DL, Reeves, HG. Concomitance of acute appendicitis and acute cholecystitis. Am Surg 1955 Mar;21(3):220–2.   [Pubmed]    Back to citation no. 7
  8. Demuro JP. Simultaneous acute cholecystitis and acute appendicitis treated by a single laparoscopic operation. Case Rep Surg 2012;2012:575930.   [CrossRef]  [Pubmed]    Back to citation no. 8

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Author Contributions
Abdulwahid M. Salih – Substantial contribution to the concept and design, Revising it critically for important intellectual content, Final approval of the version to be published
F. H. Kakamad – Substantial contribution to the concept and design, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Marden Husain Abbas – Substantial contribution to the concept and design, Acquisition of the data, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of submission
The corresponding author is the guarantor of submission.
Source of support
None
Conflict of interest
Authors declare no conflict of interest.
Copyright
© 2016 Abdulwahid M. Salih et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.



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