RLQ Pain Long after an Appendectomy

1New York University, New York, NY

Meeting: Hospital Medicine 2007, May 23-25, Dallas, Texas

Abstract number: 139

Case Presentation:

An 11‐year‐old girl presented to the pediatric emergency department complaining of 3 days of right lower quadrant (RLQ) abdominal pain. Her pain was sharp, intermittent, exacerbated by touch or movement, alleviated by lying still, and radiated to the right flank. She reported a tactile fever. She had been tolerating oral intake, with no nausea, vomiting, diarrhea, or genitourinary symptoms. Her medical history was notable for a laparoscopic appendectomy 2 years previously, without perforation. Her physical exam was remarkable for a fever of 103.5°F and RLQ abdominal tenderness and guarding consistent with localized peritoneal irritation. Her white blood cell count was 14.8 K, with 90% neutrophils. Plain films and abdominal ultrasound were performed, demonstrating lucency in the RLQ. A subsequent CT of the abdomen and pelvis revealed an 8‐mm density surrounded by a minimal rim of fluid and an extensive phlegmonous inflammatory reaction. She was diagnosed with a retained appendicolith with surrounding phlegmon and admitted for intravenous piperacillin/ tazobactam therapy as recommended on pediatric surgical consultation. She continued to tolerate oral intake and experienced symptomatic improvement over her 8‐day hospital course. She was discharged home on a 1‐week course of ciprofloxacin and metronidazole, with outpatient surgical follow‐up.

Discussion:

Retained appendicolith is a rare complication of appendectomy, whether performed as an open or laparoscopic procedure, usually occurring because of either preoperative appendiceal perforation or inadvertent loss of a fecalith during surgery. Inflammation or abscess surrounding an appendicolith may occur at any point after surgery, from days to years later, often presenting as a recurrence of RLQ abdominal pain with or without systemic inflammatory signs. A thorough review of the patient's operative course, along with adequate imaging, is essential in this clinical circumstance for consideration of retained appendicolith. Typical treatment includes drainage of any abscess cavity if present, appropriate antimicrobial coverage, and operative intervention for fecalith extraction if symptoms persist despite initial therapy.

Conclusions:

Evaluation of abdominal pain is a common reason for pediatric admission. A history of an appendectomy does not rule out future appendiceal pathology. Although rare, a retained appendicolith needs to be considered in the differential diagnosis of RLQ pain with or without signs of systemic inflammation in postappendectomy patients, regardless of the timing or method of operation. Adequate imaging for detection of fecaliths and appropriate antimicrobial therapy are of paramount importance in the initial management of these patients.

Author Disclosure:

J. P. Mintzer, None; E. P. Nadler, None; A. H. Fierman, None; D. A. Rauch, Baxter, consulting fees or other remuneration (payment).

To cite this abstract:

Mintzer J, Nadler E, Fierman A, Rauch D. RLQ Pain Long after an Appendectomy. Abstract published at Hospital Medicine 2007, May 23-25, Dallas, Texas Abstract 139. Journal of Hospital Medicine. 2007; 2 (suppl 2). https://www.shmabstracts.com/abstract/rlq-pain-long-after-an-appendectomy/. Accessed September 22, 2019.

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