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Acute appendicitis is the commonest emergency condition requiring surgery in the United Kingdom. Its precise aetiology, however, remains unproven: dietary, genetic factors, and infectious agents have been implicated.1 Trauma has also been proposed as a cause of acute appendicitis, but there are doubts as to whether this is a casual or causal relation. In this case report we produce compelling evidence that trauma can cause acute appendicitis.
CASE REPORT
A previously fit 60 year old man was admitted with abdominal pain three days after a fall from a ladder. The mechanism of injury was that the foot of the ladder slipped away with the patient falling from about six feet to land prone on the rungs of the ladder. The patient presented with increasing right lower quadrant pain, worse on movement. Appetite was reduced; the patient was not vomiting and was passing flatus. He was becoming short of breath with a productive cough. On examination he was feverish, 39.7°C, and tachycardic. Abdominal examination revealed tenderness in the right iliac fossa and right groin. There was a firm swelling in the right groin with overlying bruising extending over the femoral triangle of the right thigh with associated scrotal oedema. Routine blood tests showed a leucocytosis. A chest roentgenogram demonstrated patchy consolidation at the base of the right lung; dilated loops of small bowel were seen on an abdominal roentgenogram. Computed tomography revealed dilated loops of small bowel, incarceration of oedematous bowel in a right inguinal hernia, and oedematous changes in the right perirenal tissues (fig 1). At operation the right indirect inguinal hernia was found to contain a gangrenous appendix with free pus in the abdominal cavity. Appendicectomy was performed, a tube caecostomy was brought out, and the hernia was repaired with a darn repair. After an initially stormy postoperative course the patient had made a full recovery by follow up at six weeks.
Computed tomogram demonstrating dilated loops of small bowel, and incarceration of oedematous bowel in a right inguinal hernia (arrowed).
DISCUSSION
Blunt trauma has been proposed as a cause of acute appendicitis: Houdini is said to have died from a rupture appendix after a blow to the abdomen.2 Crush injury, a fall on bicycle handlebars, and seat belt compression after a road traffic accident have all been implicated.3,4 Haematoma or oedema of the appendiceal wall with consequent luminal obstruction proposed as the initiating pathophysiological event in the development of acute appendicitis. The difficulty with the previous reports in explaining whether trauma could cause appendicitis resides in the fact that a free lying or retrocaecal appendix would be unlikely to be injured in isolation, subsequent development of acute appendicitis after trauma being coincidental. In this case though, an appendix lying in an inguinal hernia would be more vulnerable to injury, allowing blunt trauma to compress the appendix against the unyielding pubic bone. We believe this case presents compelling evidence that blunt trauma can be a causative agent in the development of acute appendicitis.
Contributors
R Hagger had main responsibility for writing the manuscript. J Constantinou produced the figure and commented on the manuscript. S Shrotria reviewed and helped write the manuscript.