Ultrasonography-triggered diagnosis of putrid, ulcero-phlegmonous, hemorrhagic appendicitis and periappendicitis with an atypical symptom pattern: A case report

Abstract

Background
Asymptomatic and oligosymptomatic appendicitis are rare and challenging diagnoses that should not be missed.

Case presentation
A young female patient presented with mild to moderate pain in the middle and lower abdomen, and the results of physical examination, including digital rectal examination, were otherwise non-contributory. Ultrasonography demonstrated a marked increase of the outer appendiceal diameter up to 12 mm and a trace of free liquid around the terminal ileum. Subsequent surgical exploration and histological examination allowed for a final diagnosis of putrid, ulcero-phlegmonous, hemorrhagic appendicitis and periappendicitis.

Conclusions
Ultrasonography is increasingly used for the diagnosis of appendiceal inflammation, particularly in military medical settings. Increases in the outer appendiceal diameter up to >6 mm under compression have recently been demonstrated to be indicative of acute appendicitis. At a minimum, in cases with doubtful physical examination results, ultrasonography should be considered as an element in the diagnosis of acute appendicitis.

Full text

C A S E R E P O R T Open Access
Ultrasonography-triggered diagnosis of
putrid, ulcero-phlegmonous, hemorrhagic
appendicitis and periappendicitis with an
atypical symptom pattern: a case report
Hagen Frickmann
1,2*
and Sven A. Jungblut
3
Abstract
Background: Asymptomatic and oligosymptomatic appendicitis are rare and challenging diagnoses that should
not be missed.
Case presentation: A young female patient presented with mild to moderate pain in the middle and lower
abdomen, and the results of physical examination, including digital rectal examination, were otherwise
non-contributory. Ultrasonography demonstrated a marked increase of the outer appendiceal diameter up to
12 mm and a trace of free liquid around the terminal ileum. Subsequent surgical exploration and histological
examination allowed for a final diagnosis of putrid, ulcero-phlegmonous, hemorrhagic appendicitis and
periappendicitis.
Conclusions: Ultrasonography is increasingly used for the diagnosis of appendiceal inflammation, particularly in
military medical settings. Increases in the outer appendiceal diameter up to >6 mm under compression have
recently been demonstrated to be indicative of acute appendicitis. At a minimum, in cases with doubtful physical
examination results, ultrasonography should be considered as an element in the diagnosis of acute appendicitis.
Keywords: Acute appendicitis, Ultrasound, Oligosymptomatic, Surgery
Background
The management of appendicitis is a standard situation
for military surgeons. Among active component mem-
bers of the U.S. Armed Forces, the overall incidence of
appendicitis was 18.4 per 10,000 person-years between
2002 and 2011 [1]. Acute appendicitis is also among the
frequent causes of surgical interventions during deploy-
ment [2, 3]. The high perforation rates abroad [2] typic-
ally result from incorrect initial diagnoses or treatments.
During the missions of the U.S. Armed Forces in Iraq
and Afghanistan, appendicitis was among the most fre-
quent causes of medical evacuations [1].
The use of ultrasound scanning of the abdomen for
the diagnosis of appendicitis has previously been evalu-
ated. In cases of acute appendicitis, the outer appendi-
ceal diameter increases to 7.9 ± 2.0 mm compared with a
typical outer appendiceal diameter value of 4.5 ± 1.2 mm
for healthy populations. Further, periappendiceal in-
flamed fat is frequently detected by ultrasound scanning
in patients with appendicitis [4].
Here, we describe a rare case of progressed appendi-
citis that nevertheless presented with mild to moderate
symptoms and was diagnosed based only on ultrasound
scanning results.
Case presentation
Clinical history
A 21-year old female patient presented at the emergency
department of a hospital with progressive pain in the mid-
dle and lower right abdomen, nausea and vomiting. The
* Correspondence: frickmann@bni-hamburg.de
1
Department of Tropical Medicine at the Bernhard Nocht Institute, German
Armed Forces Hospital of Hamburg, Hamburg, Germany
2
Institute for Microbiology, Virology and Hygiene, University Medicine
Rostock, Rostock, Germany
Full list of author information is available at the end of the article
© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Frickmann and Jungblut Military Medical Research (2016) 3:20
DOI 10.1186/s40779-016-0088-z

symptoms began 12 h prior to her arrival. Defecation and
stool consistency were non-contributory. Fever and chills
were denied. Lactose intolerance was the only reported
pre-existing condition.
Physical examination
The rectal temperature of the patient was 37.4 °C. The
patient was alert and oriented. The described pain in the
middle and lower right abdomen could be induced by
pressure. Apart from these findings, the physical exam-
ination was non-contributory.
Specifically, the patient’s abdomen was soft, and there
were no signs of guarding or peritoneal signs. Auscultation
of the abdomen was non-contributory. A digital rectal
examination did not provoke any pain in the recto-uterine
pouch. The sphincter tone was normal. The stool was
brown and did not exhibit any signs of blood or viscous
secretions. The reported pain was noticeably decreased
following novaminsulfon infusion. Overall, the patient ap-
peared to be only marginally compromised, and dismissal
from the emergency department was therefore considered.
Routine laboratory results
A marked increase in the white blood cell count to
17.8 × 10
9
/L (ref.: 3.8 × 10
9
/L –9.8 × 10
9
/L) was ob-
served, whereas the C-reactive protein level was non-
contributory at 2.4 mg/L (ref.: <5). A slightly increased
free tetraiodothyronine level of 15.7 pmol/L (ref.: 7.7 –
14.2) was observed as an incidental finding. All other
assessed laboratory parameters were normal.
Ultrasonography of the abdomen
There was a trace of free fluid around the terminal
ileum. Further, an intestinal cockade sign was visible,
and the size of the appendix wall was increased to 3 mm
(Fig. 1). In the distal parts of the appendix, the outer
appendiceal diameter was increased up to 12 mm.
The overall accuracy of ultrasonography for the identi-
fication of acute appendicitis was recently estimated at
approximately 90 % based on an analysis of a small co-
hort of 60 patients [5]. In this study, an appendiceal
diameter >6 mm under compression was considered to
be the cut-off point for a reliable diagnosis [5]. On
French submarines, ultrasonography of the abdomen is
routinely performed in cases of suspected appendiceal
abscesses, and the accuracy is high [6].
Diagnosis and therapy
Based on the ultrasound results, a diagnosis of acute ap-
pendicitis was made. Laparoscopic surgical intervention
allowed for the extirpation of an inflamed, phlegmonous
appendix (Fig. 2).
The operation and postoperative management were
without any complications.
Histological assessment
Putrid, ulcero-phlegmonous, hemorrhagic appendicitis
and peri-appendicitis with putrid fibrinous serositis and
fecal impaction were diagnosed. A partial spread of the
inflammatory process beyond the surgical margins was
observed.
Fig. 1 Ultrasonography of the abdomen. An ultrasound-triggered
suspicion of acute appendicitis was based on the free liquid around
the terminal ileum, the intestinal cockade sign and the increase of
the wall thickness of the proximal appendix to 3 mm. D1 (2.7 mm)
ist equal to the increased wall thickness with weak echo signal intensity.
D2 (6.8 mm) is equal to the diameter of the inflamed appendix in its
proximal part
Fig. 2 Intraoperative situs with an inflamed phlegmonous appendix.
The suboptimal shooting angle and range make the observation of
the anatomical relations difficult, which reflects the real-life
surgical situation
Frickmann and Jungblut Military Medical Research (2016) 3:20 Page 2 of 5

Conclusions
Skilled use of abdominal ultrasonography can serve critical
diagnostic purposes for forward deployed troops when
other modalities, such as computed tomography, are not
available due to the austere settings. In such situations,
abdominal ultrasonography is particularly important for
young females for whom the differential diagnoses of
abdominal and pelvic pain are much broader [7, 8] and
including gynecological diagnoses, such as pelvic inflamma-
tory disease [9, 10], torsion, ectopic pregnancy [11], cystitis
[12], other infections [13], and pelvic pain of unclear eti-
ology [12].
The peculiarity of the present case is that ultrasonog-
raphy provided the most important information for the
diagnosis of appendicitis. Oligosymptomatic and asymp-
tomatic cases of appendicitis are both rare [14] and chal-
lenging in terms of differential diagnosis. In the present
case, mild to moderate symptoms without pain in the
recto-uterine pouch were revealed by the physical exam-
ination despite an advanced inflammatory process that
affected the patient’s mesentery. Without the ultrasonog-
raphy results, the patient, who presented with mild to
moderate appendicitis, would have been sent home, and
a watch-and-wait approach would have been employed.
This approach might have resulted in perforation and
the associated complications. However, ultrasonography
demonstrated an increased appendiceal diameter that far
exceeded the >6 mm cut-off point that has recently been
suggested [5]. Furthermore, a trace of free fluid around
the terminal ileum was observed, which supported the
diagnosis. Although the importance of ultrasound scan-
ning for the diagnosis of appendicitis is well established,
the fact that a severely progressed state of inflammation
was associated with symptoms that were sufficiently
mild that the patient would have been sent home with-
out the ultrasound result is quite unusual and should be
kept in mind.
Both computed tomography (CT) and ultrasound
scanning (US) have been demonstrated to be useful mo-
dalities in the diagnosis of acute appendicitis. Both tech-
niques are used to reduce the number of unnecessary
surgical interventions [15], but US also has the advan-
tage of providing results without exposure to ionizing
radiation [15]. The use of US scoring systems can con-
tribute to a reduction in the use of CT scanning while
ensuring the diagnosis [16]. Nonvisualization of the ap-
pendix on US is a highly predictive sign of the absence
of appendicitis with an accuracy of 94.3 % [17], particu-
larly in children when leukocytosis is absent [18]. The
secondary signs of hyperemia, i.e., fluid collection and
the presence of an appendicolith, exhibit 96 % specificity
and 88 % accuracy for the presence of appendicitis in
cases of otherwise equivocal ultrasound results [19].
Next to the visualizations of the appendix and
periappendiceal fluid, an appendiceal diameter >6 mm,
an appendix wall thickness >2 mm, and indirect associ-
ated signs, such as an increased white blood cell count
and an increased polymorphonuclear percentage, are
considered to be predictors of appendicitis [20]. How-
ever, perforations in cases of acute appendicitis are likely
to go undetected based on US [21].
CT is the most accurate imaging modality for cases of
suspected appendicitis and should be considered in cases
of questionable US findings when a CT scanner is avail-
able [22]. If there are contraindications for the use of
contrast enhancers, noncontrast CT also exhibits a high
diagnostic accuracy for the detection of appendicitis
[23]. The interpretation of scores based on a specific
cutoff points, such as the Alvarado score, ease the stan-
dardized interpretation of CT results [22]. However, the
ionizing radiation associated with CT is one of its disad-
vantages. Furthermore, even when CT is employed, the
detection of perforation signs is not easy in the early
stages of the process [24], particularly when an abscess
and phlegmon are still absent. Potential perforation
should be considered if extraluminal air bubbles, in-
creased wall thickness, or the presence of an intralum-
inal fecalith are observed on CT imaging [25]. In cases
of borderline appendix sizes, the combined detection of
wall thickening and the absence of intraluminal air on
CT imaging has been confirmed to be a reliable pre-
dictor of appendicitis [26]. Compared with US, CT-
measured appendiceal diameters may vary by 1–2 mm,
and this variation needs to be considered during the in-
terpretation of the results [27]. Notably, the use of CT
has not been demonstrated to be associated with better
outcomes in patients with appendicitis [28, 29].
If ionizing radiation is to be avoided, magnetic reson-
ance imaging involving gadolinium-enhanced and T
2
-
weighted images has been demonstrated to be an expen-
sive but useful alternative for the detection of acute ap-
pendicitis [30, 31]. Recently, the measurement of the
elastic modulus values via shear wave elastography has
been suggested as a new diagnostic approach for distin-
guishing between inflamed and normal appendices [32].
Larger studies would likely be useful to assess the clin-
ical effects of this procedure.
In cases of less advanced oligosymptomatic appendi-
citis, colonscopy is an alternative procedure that might
support the diagnosis [33]. In contrast, the disease-
associated results of laboratory diagnostic procedures
may be non-specific. Cyclic neutropenia has been de-
scribed in a previous case of asymptomatic appendicitis
[34]. In the presently described case, leukocytosis sug-
gested the presence of an inflammatory process.
As demonstrated by a case of bilateral ureteral ob-
struction following asymptomatic appendicitis [35], the
consequences of the delayed diagnoses of
Frickmann and Jungblut Military Medical Research (2016) 3:20 Page 3 of 5

oligosymptomatic and asymptomatic appendicitis can be
severe. Experience with ultrasonography of the abdomen
may contribute to the prevention of similar unfavorable
clinical courses.
Consent
Written informed consent for the publication of this
case report and any accompanying images was obtained
from the patient. A copy of the written consent is avail-
able for review by the Editor-in-Chief of this journal.
Abbreviations
CT, computed tomography; US, ultrasound scanning
Availability of data and materials
All relevant data and materials are presented in the paper.
Authors’contributions
HF participated in the writing of the article. SAJ provided the clinical data
and participated in the writing of the article. Both authors read and
approved the final manuscript.
Authors’information
HF is a consultant for medical microbiology, virology and infectious disease
epidemiology. He works at the Department of Tropical Medicine at the
Bernhard Nocht Institute of the German Armed Forces Hospital of Hamburg,
Germany. SAJ is a consultant for internal medicine. He works as a general
practitioner in his own practice “Praxis Dr. Jungblut”in Frankfurt/Main,
Germany.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Consent for publication has been obtained.
Ethics approval and consent to participate
Ethical clearance was not required for this retrospective case assessment in
accordance with German law. Anonymous patient data were retrospectively
assessed. No medical procedures were performed for study purposes.
Accordingly, this case report did not fulfill the criteria for description as a
scientific project involving humans according to § 9.2 of the Law of the
Association of Hamburg Physicians (“Hamburgisches Kammergesetz für
Heilberufe”), and ethical counseling was not required according to § 15.1 of
the Professional Guidelines of Hamburg Physicians (“Berufsordnung für
Hamburger Ärzte und Ärztinnen”). Due to the anonymous nature of the
assessment, German data protection law (“Bundesdatenschutzgesetz”) was
not applicable.
Author details
1
Department of Tropical Medicine at the Bernhard Nocht Institute, German
Armed Forces Hospital of Hamburg, Hamburg, Germany.
2
Institute for
Microbiology, Virology and Hygiene, University Medicine Rostock, Rostock,
Germany.
3
Practice Dr. Jungblut, Frankfurt/Main, Germany.
Received: 9 November 2015 Accepted: 10 June 2016
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