Unusual Presentation of Perforated Acute Appendicitis: A Case Report

BACKGROUND Acute appendicitis is by far the most common surgical emergency encountered in the United States and with this in mind, unusual presentations are also frequent, thus improper diagnosis, which roughly occurs in 20-40% of cases, can lead to a delayed treatment and bad outcomes. We present this unusual case of abdominal pain secondary to extraperitoneal compartmentalized abscess following perforated appendicitis, diagnosed and managed as ascites secondary to alcoholic liver cirrhosis with subsequent delay in the treatment of the underlying cause, which was appendicitis. CASE REPORT A 45-year-old man presented to the Emergency Department with pain and distention for 1 week duration, who was treated with frequent paracentesis, with worsening pain following the latest drainage, raising suspicion of perforated viscus. Initial abdominal X-ray and computed tomography (CT) scan revealed free air and large tubular fluid sac collection along the right, left, and lower abdominal wall. Surgical drainage of the abscess was performed. A subsequent follow-up CT with oral contrast of the abdomen revealed perforated right lower abdominal viscus, possible perforated appendicitis with pre-peritoneal and retroperitoneal space occupying the abscess cavity compartmentalized along the right, left, and lower abdominal wall and creating a separate space where the inflammatory purulent material was collected. This was followed by a second procedure for ileocecectomy and ileostomy with excision of the extra-preperitoneal compartment space. CONCLUSIONS Abdominal pain secondary to acute appendicitis is by far the commonest surgical condition; therefore, it should be considered high in the differential diagnosis of any patients presenting with unusual abdominal complaints.