Uncommon Presentation of Perforated Appendicitis: Abdominal Wall Abscess and Fistula Formation

BACKGROUND Acute appendicitis is a common surgical emergency, and perforated appendix is one potential complication. Acute appendicitis can be complicated by perforation and peritonitis, but chronic abscess formation is less common. This report presents the case of a 45-year-old woman with a 7-day history of right lower-abdominal pain and swelling due to perforated acute appendicitis and abdominal wall abscess that required laparotomy and drainage. The presentation of this particular case is unique in that a fistulous tract formed subsequent to perforation of the appendix, with the resultant abscess forming in the abdominal wall. The current case study serves to showcase the diagnostic challenges associated with such a presentation. CASE REPORT A 45-year-old woman presented to the emergency department with a 7-day history of right lower-quadrant and midline lower-abdominal pain and swelling. Computed tomography (CT) scans with intravenous (IV) and rectal contrast showed an abdominal wall abscess with no signs of obstruction, perforation, or appendicitis. Incision and drainage of the abdominal wall abscess with debridement of the abdominal wall was complicated by peritoneal adhesions, and open laparotomy was thus performed. Upon entry into the abdominal cavity, the appendix was found to be adherent to the abdominal wall. It was noted that the appendix had perforated, allowing for fistula formation with the abdominal wall. CONCLUSIONS Clinicians should maintain a high index of suspicion for perforated appendicitis in cases of abdominal wall abscesses with leukocytosis and right lower-quadrant pain, even when initial imaging does not show obvious appendicitis.