Traumatic appendicitis: A case report and literature review

Abstract

The primary cause of acute appendicitis is obstruction of the proximal lumen of the appendix, although the underlying etiology remains unclear in many cases. Trauma is a rare but documented cause of appendicitis.

We present the case of a 38-year-old man who developed right lower quadrant abdominal pain four days after jumping from the second floor of a department store. He reported no prior episode of lower abdominal pain. Abdominal computer tomography (CT) confirmed the diagnosis of acute appendicitis, and the patient subsequently underwent an emergency appendectomy.

This case report and literature review highlight the importance of promptly considering appendicitis in patients presenting with acute abdominal pain following abdominal trauma and underscore the need for timely evaluation and appropriate management.

Highlights

• •Trauma, though rare, is a recognized cause of appendicitis.
• •Traumatic appendicitis should be considered in patients presenting with acute abdominal pain following abdominal trauma.
• •Imaging plays a key role in confirming the diagnosis and improving diagnostic accuracy.

Introduction

Acute appendicitis (AA) is the most common cause of acute abdomen, often prompting visits to the emergency department [1]. Its peak incidence occurs between ages 10 and 30, with a lifetime risk of 9% in the USA, 8% in Europe, and 2% in Africa [2], [3], [4]. The primary cause of AA is obstruction of the proximal lumen of the appendix, although the underlying etiology remains unclear in many cases. Trauma is a rare but documented cause of appendicitis [5].

Several clinical and laboratory scoring systems aid in predicting the likelihood of AA. The classic presentation included right lower quadrant abdominal pain, anorexia, and nausea/vomiting. However, some patients may exhibit atypical symptoms such as abdominal distension, constipation, or dysuria. Various imaging modalities, including ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI), are commonly used to enhance diagnostic accuracy [1].

Case presentation

A 38-year-old man was referred to this tertiary hospital. Four days prior to admission, he experienced a delusional episode and jumped from the second floor of a department store. At the primary hospital, evaluation by a trauma surgery consultant revealed no significant injuries. An Extended Focus Assessment Sonography of Trauma (E-FAST) showed no intraabdominal free fluid, and computed tomography (CT) of the brain and cervical spine demonstrated no intracranial hemorrhage, skull fracture, or cervical spine fracture. He was subsequently transferred to this hospital for further management of his schizophrenia.

Two days after admission, the patient developed right lower quadrant abdominal pain. He denied any prior episodes of lower abdominal pain or symptoms suggestive of chronic appendicitis. The trauma surgeon team was consulted for evaluation. On examination, his vital signs were stable: temperature of 37.5 °C, heart rate of 80 beats per minute, blood pressure of 120/60 mmHg, and respiratory rate of 16 breaths per minute. Abdominal examination revealed localized guarding and rebound tenderness in the right lower quadrant. The blood test results are shown in Table 1.

Table 1.

Laboratory data.

Variable	Reference rangea	Result
Hematocrit (%)	40.0–55.0	36.9
Hemoglobin (g/dl)	13.0–18.0	12.1
White-cell count (per ul)	4000–10,000	10,580
Differential count (per ul)
•Neutrophils	1600–7400	7600
•Lymphocytes	760–4800	2100
•Monocytes	120–900	500
•Eosinophils	0–700	300
•Basophils	0–200	100
Platelet count (per ul)	140,000–450,000	534,000

^aReference values vary based on factors such as patient population and laboratory methods.

A CT scan of the abdomen (Fig. 1A, B, and C) showed an enlarged appendix with decreased mucosal enhancement at the tip (arrows), surrounding fat inflammation, and an adjacent 6.9-cm fluid collection (arrowheads). A contusion at the right lower quadrant abdominal wall (asterisks) at the same level as the appendix was also observed. Based on these findings, the patient was diagnosed with acute appendicitis and was scheduled for emergency surgery.

Fig. 1.

CT of the abdomen.

A contrast-enhanced CT was performed in the portal venous phase. An axial image (Panel A) and coronal reformats (Panel B and C) show an enlarged appendix with decreased mucosal enhancement at the tip (arrows), surrounding fat inflammation and adjacent 6.9 cm-fluid collection (arrowheads). A contusion at the right lower quadrant abdominal wall (asterisks) at the same level as the appendix was also observed.

Initially, laparoscopic surgery reveals minimal hemoperitoneum in the right lower quadrant with suspected bleeding from intra-abdominal vessels in that region (Fig. 2A). The appendix was not clearly identified, prompting conversion to open laparotomy. Upon exploration, an enlarged, inflamed appendix with fibrinous exudate was found, along with suspected bleeding from appendiceal vessels (Fig. 2B). A gross examination of the specimen showed an enlarged, inflamed appendix with fibrinous exudate. Histopathological analysis confirmed acute appendicitis with periappendicits (Fig. 3).

Fig. 2.

Intraoperative finding.

Laparoscopy reveals minimal hemoperitoneum in the right lower quadrant with suspected bleeding from intraabdominal vessels in that region (A). The appendix was not clearly identified, prompting conversion to open laparotomy. Upon exploration, an enlarged, inflamed appendix with fibrinous exudate was found, along with suspected bleeding from appendiceal vessels (B).

Fig. 3.

Gross and microscopic examination of the appendix.

Gross examination reveals an enlarged, inflamed appendix (A). Hematoxylin and eosin staining confirms acute appendicitis with periappendicitis (B). At 400× magnification, acute inflammatory cells, predominantly neutrophils, are seen infiltrating the muscularis propria (C).

The patient made an excellent recovery and was discharged from the surgical ward to the psychiatric ward two days later.

Discussion

Traumatic appendicitis is rare, with clinical presentation typically including right lower quadrant abdominal pain, anorexia, and nausea/vomiting. However, some patients may present with atypical symptoms such as abdominal distension, constipation, or dysuria. Various imaging modalities, including ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI), are commonly used to enhance diagnostic accuracy [1]. Surgery is the treatment of choice for this condition, while antibiotic therapy may also be considered, as reported by Albalawi et al. [6]. The exact relationship between appendicitis and trauma remains unclear. A literature review revealed that only 11 cases of traumatic appendicitis have been reported between 2010 and 2024 (Table 2).

Table 2.

Literature review of previous case reports of traumatic appendicitis.

First author (year), country	Sex	Age (years)	Mechanism of injury	Time of presentation	Imaging modality	Treatment	Gross or microscopic examinations
Toumi et al. (2010), UK [5]	M	10	Accident (trampoline)	72 h	CT	Open appendectomy	•Gross examination shows an inflamed and necrotic appendix •Microscopic examination shows acute suppurative appendicitis with serositis
Bouassria et al. (2013), Morocco [7]	M	24	Stab wound	1 h	US	Exploratory laparotomy with appendectomy	•Gross examination shows hyperemic and edematous appendix
Ahmed et al. (2014), India [8]	M	12	Accident	2 days	US	Exploratory laparotomy with appendectomy	•Microscopic examination shows acute appendicitis
Jensen et al. (2016), USA [9]	M	7	Accident (bicycle)	Few hours	CT	Laparoscopic appendectomy	•Microscopic examination shows acute appendicitis with the presence of a fecalith
Cobb. (2017), USA [10]	M	17	Road traffic accident	24 h	CT	Exploratory laparotomy with appendectomy	•Microscopic examination shows acute appendicitis
Chalh et al. (2021), Morocco [11]	M	8	Accident (ball)	24 h	US and CT	Open appendectomy	•Gross examination shows an inflamed appendix. •Microscopic examination shows acute appendicitis
Albalawi et al. (2023), Saudi Arabia [6]	M	10	Fall	1 day	CT	Antibiotics	–
Salinas-Castro et al. (2023) [12]	F	14	Accident (ball)	6 h	CT	Laparoscopic appendectomy	•Microscopic examination shows acute suppurative and necrotizing appendicitis
Jaramillo et al. (2024), Colombia [13]	F	18	Road traffic accident	6 h	CT	Open appendectomy	•Gross examination shows inflamed appendix
Shawasha et al. (2024), Palestine [14]	M	28	Fall	2 weeks	CT	Exploratory laparotomy with appendectomy, abdominal lavage, and drainage	•Gross examination shows a perforated appendix with its distal end connected to the urinary bladder with mass formation and friable tissue.
Alabdulaaly et al. (2024), Saudi Arabia [15]	M	21	Road traffic accident	5 days	CT	Laparoscopic appendectomy	•Microscopic examination shows acute perforated appendicitis and periappendicitis

M: male; F: female; US: ultrasound; CT: computed tomography.

In our case, the patient was diagnosed with appendicitis four days after falling from a height. He developed localized abdominal pain in the right lower quadrant and denied any prior episodes of lower abdominal pain or symptoms suggestive of chronic appendicitis. A CT scan of the abdomen revealed an enlarged appendix with decreased mucosal enhancement at the tip, surrounding fat inflammation, and an adjacent fluid collection. The patient was scheduled for emergency laparoscopic surgery. However, due to intraoperative findings of hemoperitoneum suspected of active bleeding from the appendiceal vessel, the procedure was converted to a laparotomy. In this patient, the acute appendicitis appears to be associated with abdominal trauma, as the CT scan also showed a contusion in the right lower quadrant of the abdominal wall. Interestingly, the patient did not exhibit abdominal pain immediately after the trauma. It developed on the fourth day post-accident. Based on the patient's history, clinical presentation, and imaging findings, the diagnosis of acute appendicitis following trauma was confirmed.

Conclusion

Traumatic appendicitis is rare; However, it should be considered in patients presenting with acute abdominal pain following abdominal trauma. Imaging plays a crucial role in confirming the diagnosis and enhancing diagnostic accuracy.

CRediT authorship contribution statement

Visarat Palitnonkiat: Writing – review & editing, Writing – original draft, Methodology, Investigation, Conceptualization. Sirote Wongwaisayawan: Writing – review & editing, Methodology, Investigation. Tharin Thampongsa: Writing – review & editing, Methodology, Investigation, Conceptualization.

Patient consent

The case was reviewed and approved, with patient consent obtained in accordance with institutional guidelines.

Funding

None.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.