A case of perforated appendicitis induced by a fish bone

Abstract

A 59-year-old man was admitted to our department because of pain in the right lower quadrant region for two days. He had been taking hydrocortisone for 22 years adrenocorticotropic hormone (ACTH) syndrome. On physical examination, tenderness and rebound tenderness was noted in the right lower quadrant of the abdomen. Laboratory data revealed a white blood cell (WBC) count of 7,100/μl, and C-reactive protein (CRP) of 14.1mg/dl. Abdominal US depicted an appendicular swelling of 10mm in diameter with an internal high echoic area. Based on the investigations an acute appendicitis was suspected and initiated surgery. There was severe adhesion around the appendix. We found a fish bone of 2.0cm in length penetrating from the wall of appendix. An appendectomy was performed. Appendicular perforations associated with a fish bone are to be deleted rare compared with other sites of lower intestine. It is difficult to differentiate the mass formed by chronic inflammation from cancer. We emphasize the importance of high echoic lesion in appendix by US or CT for diagnosis to avoid an unnecessary extensive surgery.