Delayed Presentation of a Chronic Abscess Which was Caused by a Retained Fecolith Following Appendicectomy: An Interesting Case Report and Review of the Literature
Correspondence Address :
Praveen Kumar K,
Dept of Surgery,
Fr. Muller Medical College,
Kankanady, Mangalore, India - 575002
Phone: 09480576235
E-mail: drpkkumar@yahoo.com
A chronic abscess which is caused by a retained fecolith (appendicolith) is an uncommon complication following appendicectomy. It is more common after laparoscopic appendicectomy than open appendicectomy. It’s incidence has increased due to the increased use of laparoscopic appendicectomy. We are reporting an interesting case report of a delayed presentation of a chronic abscess after 4years following open appendicectomy, which was caused by a retained fecolith.
Praveen Kumar K., Erel A.I. Diaz, Rupa M. Mascarenhas
A 24-years old male presented with a discharging sinus in the right iliac fossa, of 8 months duration. He gave a past history of an open appendicectomy which was done 4 years back. The patient was haemodynamically stable. On examination, his abdomen was found to be soft and there was a sinus in the right iliac fossa, just below the appendicectomy scar, with a purulent discharge. There was a flexion deformity of the right hip joint and on palpation, the right iliac fossa was found to be tender. His routine blood investigations were normal, except for a raised ESR (80mm/hr). His chest X-ray and X-ray of the abdomen were normal. MRI of the lower abdomen and hip showed a chronic abscess over the right iliacus muscle with a fecolith. The patient underwentexploration and drainage of the abscess and removal of the fecolith. He recovered well, his wound healed well and he was discharged to go home after 3 weeks.
A chronic abscess which is caused by a retained fecolith (appendicolith) at open (i.e., conventional) appendicectomy (1) or at laparoscopic appendicectomy (2), (3) has rarely been reported in the surgical literature. Fecoliths are composed of inspissated faecal material, mucus with trapped calcium phosphate and inorganic salts. Fecoliths can be detected in a plain abdominal radiograph in 10 to 15% of the patients with acute appendicitis. With the recent popularity of ultrasound and CT-scan, the rate of their detection has increased (2). A laparoscopic approach has become increasingly common in recent years, because it offers several potential advantages over the traditional open approach. Prospective studies have shown that the laparoscopic appendicectomy patients have less pain, a faster recovery time after the surgery, better cosmetic results, and a somewhat lower rate of wound infection. The adoption of laparoscopic appendicectomy is not yet universal (1), (4). Some controversy continues about the appropriateness of laparoscopic appendicectomy in certain situations, especially in perforated appendicitis (4). A dropped fecolith which is associated with an abscess formation can be compared with a similar complication which is associated with gallstones which are dropped during a cholecystectomy for acute cholecystitis which is associated with an intraabdominal abscess. It is reasonable to assume that most, if not all, dropped fecoliths are also potentially infectious (2). When laparoscopic appendicectomy becomes a more common procedure; the complications which are related to it will probably become more common also. About 10 cases of dropped fecoliths have been reported, that caused an abscess after an open appendicectomy (1), (2). Only three cases involved laparoscopic appendicectomy.Dropped fecoliths from laparoscopic appendicectomies are rare, but they are potential sources of an intraabdominal abscess (3). The time between the laparoscopic appendicectomy and the presentation with the abscess ranged from 2 months to 4 years (5). Hence, a retained fecolith should be suspected and investigated in any patient who presents with a discharging sinus in the right iliac fossa after appendicectomy. The nidus of the infection – the fecolith must be removed as soon as it is identified, to prevent recurrence of the abscess (1),(2),(3), (6), (7)
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