Post-operative Appendix Retention Presenting as Bowel Obstruction Tiffany Proffitt, DO, Kristen Whitworth, DO, and Christopher Trigger, MD

Introduction Case Report Discussion Appendicitis is a common surgical A 50 year old male with a past medical Two rare complications of appendectomy emergency with over 270,000 history of ulcerative colitis on azathioprine are stump appendicitis and retained appendectomies performed in the and mesalamine, clostridium difficile appendicoliths. Patients may present United States each year.1 There are colitis, and hernia repair presented to the hours to years after surgery. Stump many post-operative complications emergency department with an outpatient appendicitis is caused by a retained from laparoscopic surgery that abdominal series concerning for small appendicular stump and presents similar emergency physicians may be prone to bowel obstruction one-week status post to appendicitis, although is not usually dismiss due to the prevalence and less laparoscopic appendectomy at an out of considered in the differential diagnosis as invasive nature of the procedure. state hospital (Figure 1). patients report a history of a prior appendectomy.2 Treatment requires This unique case highlights the Physical Exam surgery to remove the remnant of the importance of keeping the possibility of • Afebrile, uncomfortable appearing male appendiceal base. An appendicolith is a infection of remnants as well as the • Abdominal distension with decreased collection of fecal debris and calcium salts rarer occurrence of retained surgical bowel sounds with generalized residing in the appendix that can lead to specimens in the differentials for tenderness to palpation with no acute appendicitis. Appendicoliths can be abdominal pain patients. guarding or rigidity Figure 2. CT scan of the abdomen and pelvis retained secondary to rupture of the demonstrated a mildly distended small bowel appendix prior to surgery or from failure Course loop in the left anterior abdomen with an of their removal during surgery3. • Blood work and initial vitals adjacent surgical staple line contiguous with a Management of retained fecaliths unremarkable small tubular density filled with air and a single requires drainage of the abscess and calcification. • NG tube placed with 200mL bilious surgical removal. output • General Surgery consulted and Conclusion requested CT scan for suspected As emergency physicians, it is crucial to abdominal abscess include these rare surgical complications • CT scan with a small tubular density in in the differentials, alongside the more the left lower abdomen concerning for a common pathologies when approaching retained appendix in addition to a small and treating the patients with abdominal bowel obstruction and intraabdominal pain. abscess (Figure 2) References: • Diagnostic laparoscopy performed with 1. Kozak L, Hall M, Owings M. National hospital discharge survey: 2000 annual summary with detailed diagnosis and procedure data. Vital Health removal of a necrotic appendix Stat 13. January 2003:1–194. Figure 1. Acute abdominal series demonstrating containing an appendicolith with a Figure 3. Specimen removed at surgery. A https://www.ncbi.nlm.nih.gov/pubmed/12518555. Accessed November 15, numerous dilated small bowel loops with air 2016 staple line across the base (Figure 3) necrotic appendix with a staple line across the 2. Subramanian A and Liang MK. A 60-year literature review of stump fluid levels suggestive of small bowel base of the appendix containing an appendicitis: The need for a critical view. Am J Surg. 2012;203(4):503–507. 3. Sarkar S, Douglas L, Egun A. A complication of a dropped appendicolith obstruction. appendicolith. misdiagnosed as Crohn’s disease. Ann R Coll of Surg Engl. 2011;93(6):e117– e118.