Case report
A 39-year-old gentleman presented to emergency department with five hours of diffuse abdominal pain, localized to epigastric and periumbilical regions, associated with nausea and one episode of vomiting. He endorsed eating a diet of saturated fats from meat, greasy, and oily foods. His physical examination was significant for epigastric and periumbilical tenderness without rebound, guarding, or rigidity. The rectal examination was notable for the absence of blood and an evacuated rectal vault.
Objective parameters were as follows: Total count: 16,300/cumm3 with neutrophils: 70%, hematocrit: 43%, platelet count: 330,000/cumm3, Serum lipase: 2100 U/L (Vitros lipase; normal range 23-300U/L), lactate dehydrogenase: 225 U/L, calcium: 7.5 mg/dl, Blood Urea Nitrogen: 12.1 mg/dl, Random blood sugar: 120mg/dl triglycerides: 523 mg/dl. The Liver function test, Renal function test and coagulase test were within normal limit. Ultrasonography (USG) of abdomen showed edematous with heterogeneous echotexture of pancreas, without other significant abnormality (Fig.1). A postero-anterior chest X-ray found consolidation in the right lower zone with a minimal pleural effusion. Hence, patient was admitted to the hospital with the diagnosis of Hypertriglyceridemia induced acute Pancreatitis (Ranson’s score =1) with right lower zone pneumonia and pleural effusion. Conservative management with empirical antibiotic Piperacillin/tazobactam was commenced.
Over the following 48 hours, the patient’s Ranson’s score deteriorated to three, serum calcium decreased and partial pressure of oxygen on arterial blood gas analysis fell. Despite the worsening in these parameters, the serum lipase decreased (Fig.2). An abdominal contrast enhanced computed tomography (CECT) demonstrated the features suggestive of acute pancreatitis (Modified CT severity index; CTSI 6) with acute appendicitis (Fig.3 a,b,c,d). However, medical and surgical team opted for a nonsurgical intervention, where Piperacillin/tazobactam was switched to meropenem and a somatostatin analogue (Inj. Octreotide 200mg SC Q8h) was added for supportive therapy.
After the initial improvement of the patient’s clinical status his abdominal pain worsened and localized to the right iliac fossa. Upon repeat physical examination and ultrasound (Fig.4) didn’t show improvement of acute appendicitis. Hence, an open appendectomy with abdominal drain placement was performed on the ninth day of admission.
The operative findings were notable for an inflamed, retrocecal appendix. The base of appendix was non-inflamed. Approximately 100 ml of peritoneal fluid was aspirated from the periappendicular space. (Fig. 5 a,b). The peritoneal fluid was measured for lipase and amylase, both were normal. Additionally, the bacterial culture of the fluid was sterile at five days. The drain output was mixture of serosanguineous and ascitic in nature, which gradually decreased and removed on postoperative day three. This subsequent recovery was unremarkable. The histopathology analysis of Vermiform Appendix demonstrated neutrophilic infiltration of the muscularis propria layer and mesoappendix. There was sparing of the mucosa and lumen. These findings were consistent with acute appendicitis with periappendicular acute inflammation. (Fig. 5 c,d,e). The patient followed up in the postoperative clinic on day 14 and was found to be symptom-free.