A rare case report of an appendiceal abscess with a pneumatocele and direct extension into an anterior abdominal wall abscess

Abstract

: Acute appendicitis, while exceedingly common carries a wide range of clinically variable presentations. We present a case of a perforated appendicitis manifesting clinically as an anterior abdominal wall abscess and its subsequent management. There have been eight documented case reports to date of direct extension into the anterior abdominal wall, in contrast to the commonly documented retroperitoneal perforation. The management of this condition has varied in the published reports from intravenous antibiotics to surgical debridement of the abdominal wall. The aetiology of the direct extension into the abdominal wall remains nebulous. In our patient it was felt that the appendicolith could be a contributing factor for perforation through the abdominal wall. Our patient was initially managed with intravenous antibiotics and percutaneous abscess drainage, followed by an interval laparoscopic appendectomy three weeks later. The patient’s age and her dementia precluded conservative management of the appendix post percutaneous abscess drainage, as an elective appendectomy is no longer the standard of care. A colonoscopy performed three months later also excluded a colonic malignancy. We believe this is the first documented case of an abdominal wall pneumatocele which formed as part of the abdominal wall abscess. It is our fervent desire that this case report contributes to the surgical armamentarium of acute care surgeons in the management of this complex condition.