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.