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CASE REPORT
Year : 2014  |  Volume : 34  |  Issue : 3  |  Page : 121-122

Successful nonsurgical treatment for synchronous acute cholecystitis and acute appendicitis: A case report and review of the literatures


Department of Surgery, Division of General Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China

Date of Submission05-Nov-2012
Date of Decision25-Dec-2012
Date of Acceptance25-Jan-2013
Date of Web Publication12-Jun-2014

Correspondence Address:
Dr. Guo-Shiou Liao
Department of Surgery, Division of Cardiovascular Surgery, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Cheng-Gong Road, Taipei 114, Taiwan
Republic of China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1011-4564.134385

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  Abstract 

Acute appendicitis and acute cholecystitis are commonly seen in acute abdominal disease. However, it is rarely described that synchronous acute cholecystitis and acute appendicitis presented. Here, we present a case of 78-year-old male suffered from cholelithiasis with acute cholecystitis synchronized with acute appendicitis treated with nonsurgical management successfully.

Keywords: Acute cholecysitis, synchronous acute appendicitis, chloelithiasis


How to cite this article:
Lee TY, Chang HM, Shih ML, Chen TW, Hsieh CB, Chan DC, Yu JC, Liao GS. Successful nonsurgical treatment for synchronous acute cholecystitis and acute appendicitis: A case report and review of the literatures. J Med Sci 2014;34:121-2

How to cite this URL:
Lee TY, Chang HM, Shih ML, Chen TW, Hsieh CB, Chan DC, Yu JC, Liao GS. Successful nonsurgical treatment for synchronous acute cholecystitis and acute appendicitis: A case report and review of the literatures. J Med Sci [serial online] 2014 [cited 2019 Oct 22];34:121-2. Available from: http://www.jmedscindmc.com/text.asp?2014/34/3/121/134385


  Introduction Top


Acute abdominal pain makes diagnosis extensity and challenge for clinicians including acute cholecystitis and acute appendicitis. Clinically, it is rarely seen that acute cholecystitis and acute appendicitis synchronously presented. However, it may lead to fatal complication such as peritoneal sepsis if misdiagnosed one of them. The management of these concomitant diseases is not conclusive. Here, we present a 78-year-old man suffered from synchronous acute cholecystitis and acute appendicitis treated with nonsurgical management successfully.


  Case Report Top


The patient was a 78-year-old male who presented sudden onset of diffused abdominal pain with nausea for 1-week and sent to the emergency department. The abdominal pain was described sharp and localized to right upper quadrants and lower quadrants, especially after a meal. It also radiated to right back. He had a habit of social alcoholic and no history of operation before.

During the hospitalization, his temperature was mild elevated (37.8°C) and hemodynamically stable. His exam revealed significant local tenderness over right abdomen, including epigastric pain and positive Murphy's sign, obturator sign and tenderness over McBurney's point. He had no peritoneal signs and a negative psoas, Rovsing's sign. No sepsis was performed from his general clinical appearance. The labor test revealed that white cell count was 9650/uL but elevated C-reactive protein (19.96 mg/dL). His chemistry test was normal, but hepatic profile revealed elevated total bilirubin (4.7 mg/dL), direct bilirubin (4.6 mg/dL), lipase (1383 U/L), alkaline phosphatase (290 U/L), and normal transaminases. His urinalysis was normal.

The computed tomography (CT) of the abdomen and pelvis with contrast revealed one gallstone (0.6 cm) and sludge with marked pericholecystic fatty stranding, perifocal fluid accumulation, and distention (measuring 4.5 cm). Gallbladder wall thickness and cystic duct dilation (more than 6 mm in diameter) and also a huge appendix with fatty stranding were seen. There was also a dilated appendix (measuring 0.7 cm in diameter) without fluid filled [Figure 1]. We did endoscopic retrograde cholangiopancreatography that revealed bile sludge and dilation of common bile duct. The initial impression was acute cholecystitis with cholelithiasis and pancreatitis synchronized with acute appendicitis.
Figure 1: A distended gallbladder with calcified gallstones and sludge fulfilled. The pericholecystic fatty stranding was also marked (black arrow). There was no ascites accumulated in Morrison pouch or pelvic region. And there were no fatty stranding over intestine. The mild distended appendix with fatty stranding was also performed (white arrow)

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On admission, the patient stopped oral intake. He received intravenous (IV) fluid hydration and parenatal nutrition. We did sono-guide percutaneous transhepatic gallbladder drainage (PTGBD) for drainage the bile juice and prescribed IV antibiotics (flomoxef 1 g/day) for control infection. We also prescribed meperidine for pain control. His symptoms were relieved after treatment for 1-week. He left the hospital within 2 weeks under stable hemodynamic condition and oral intake. We did laparoscopic cholecystectomy after outpatient department follow-up for 2 months. No complication related nonsurgical management for appendicitis was noted. He was advised to regularly follow-up his abdominal condition because he refused to undergo laparoscopic appendectomy.


  Discussion Top


Cholelithiasis can induce multiple biliary tract complication, including acute cholecystitis, acute pancreatitis, cholangitis, and hepatitis that can be life-threatening. The clinical features of acute cholecystitis can perform diffused abdominal pain and fever that lead to misdiagnosis for acute appendicitis even it is rarely seen. [1] When cholelithiasis induced hyperbilirubinemia show up, the bacterium can translocate into portal venous system and lead to alter the bilirubin excretion. The bacterium accumulates at appendix and the lead acute appendicitis occurs. [2] This is a rare case that there are only few case literatures reported. [1],[2] The evaluation for acute diffused abdominal pain must be careful and integral. Radiological examinations including contrast CT and sonography are optimal tools for quickly screening acute abdominal pain.

The selection of treatment and timing of definitive therapy for acute cholecystitis depends upon the severity of symptoms and the patient's overall risk of surgery. Once acute cholecystitis complicate with other biliary tract disease, the immediately surgical intervention is not favorable. [3] Adequate gallbladder drainage with pain control and empiric antibiotics is a reasonable treatment for this late course of the disease process (>3-5 days). [4] Further surgical intervention is indicated when the inflammatory process is improved. Varadhan et al. have reported a meta-analysis of randomized controlled trials, showed that antibiotics are both effective and safe as primary treatment for patients with uncomplicated acute appendicitis. Initial antibiotic treatment merits consideration as a primary treatment option for early uncomplicated appendicitis. [5] In our case, empiric antibiotic with adequate PTGBD drainage covered inflammatory process of both appendicitis and cholecystitis and was successful treated conservatively.


  Conclusion Top


Synchronous acute appendicitis and cholecystitis are rarely seen and easy to confuse under physical examination. To evaluate acute abdomen pain in the emergency department must include completed radiological study. Nonsurgical management is one of reasonable treatment for acute cholecystitis and acute appendicitis synchronous presented.


  Disclosure Top


The authors have no conflicts of interest to declare.

 
  References Top

1.Sahebally SM, Burke JP, Nolan N, Latif A. Synchronous presentation of acute acalculous cholecystitis and appendicitis: A case report. J Med Case Rep 2011;5:551.  Back to cited text no. 1
    
2.Estrada JJ, Petrosyan M, Barnhart J, Tao M, Sohn H, Towfigh S, et al. Hyperbilirubinemia in appendicitis: A new predictor of perforation. J Gastrointest Surg 2007;11:714-8.  Back to cited text no. 2
    
3.Papi C, Catarci M, D'Ambrosio L, Gili L, Koch M, Grassi GB, et al. Timing of cholecystectomy for acute calculous cholecystitis: A meta-analysis. Am J Gastroenterol 2004;99:147-55.  Back to cited text no. 3
    
4.Ito K, Fujita N, Noda Y, Kobayashi G, Kimura K, Sugawara T, et al. Percutaneous cholecystostomy versus gallbladder aspiration for acute cholecystitis: A prospective randomized controlled trial. AJR Am J Roentgenol 2004;183:193-6.  Back to cited text no. 4
    
5.Varadhan KK, Neal KR, Lobo DN. Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: Meta-analysis of randomised controlled trials. BMJ 2012;344:e2156.  Back to cited text no. 5
    


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