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Acute appendicitis located within Amyand’s hernia—a complex case with concurrent acute cholecystitis

Acute appendicitis located within Amyand’s hernia—a complex case with concurrent acute cholecystitis Amyand’s hernia is the presence of the vermiform appendix within an inguinal hernia sac. It is rare, and even rarer is the presence of acute appendicitis within the sac. It presents in a variety of different ways and often is only diagnosed intra- operatively. We present the case of a 90 year old male with extensive co-morbidities presenting with right upper quadrant pain, who on computed tomography scan of the abdomen, had acute cholecystitis alongside acute appendicitis within Amyand’s hernia. Ultimately given his co-morbidities, a conservative approach with prolonged antibiotic therapy was adopted, with a successful outcome. This case highlights that although classifications for treatment of Amyand’s hernia exist, careful clinical assessment is warranted in each case to ensure optimal outcome based upon individual circumstances. pyrexial, tachycardic markedly tender in the right upper INTRODUCTION quadrant of his abdomen. There was also a reducible non-tender Amyand’s hernias are rare subtypes of inguinal hernias whereby right-sided inguinal hernia present. His past medical history the vermiform appendix is present within the hernial sac. They included atrial fibrillation (anti-coagulated with apixaban) occur in just 1% of inguinal hernias. Even rarer is the presence alongside ischaemic heart disease, osteoarthritis and a degree of acute appendicitis within the Amyand’s hernia [1]. They can of congestive cardiac failure with poor exercise tolerance. be difficult to diagnose pre-operatively unless imaging is per- On further questioning he had noticed the lump for several formed. Hence intra-operative diagnosis is common. We present weeks but described no tenderness around the lump. Blood the case of a 90 year old male admitted with right hypochon- workup revealed c-reactive protein of 140 mg/L and white cell drium pain and raised inflammatory markers whose computed count of 15 × 10 . He had mildly deranged renal function at tomograph (CT) scan of the abdomen ultimately demonstrated baseline consistent with an element of chronic kidney disease. an Amyand’s hernia with acute appendicitis alongside acute Other blood tests were unremarkable. A diagnosis of acute cholecystitis. Given his co-morbidities and lack of symptoms cholecystitis was made with an incidental finding of right- in the inguinal region, the patient was managed conservatively sided inguinal hernia. He was commenced on intravenous with antibiotics with a good outcome. antibiotics and CT scan of the abdomen arranged to ensure no co-existent pathology given his age. CT scan revealed CASE REPORT the presence of a right-sided inguinal hernia containing a A 90 year old gentleman was admitted on the acute surgical thickened vermiform appendix with peripheral fat stranding take with right hypochondrium pain. On examination he was suggestive of acute appendicitis within an Amyand’s hernia Received: August 10, 2020. Accepted: October 6, 2020 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2020. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 1 Downloaded from https://academic.oup.com/jscr/article/2020/12/rjaa447/6035273 by DeepDyve user on 22 December 2020 2 A. O’Connor et al. Figure 1: Axial CT scan demonstrating right-sided inguinal hernia with vermi- Figure 2: Coronal CT scan demonstrating appendicitis located within the form appendix located within it, suggestive of Amyand’s hernia. inguinal canal. pressure from the abdominal wall leads to inflammation of the (Figs 1 and 2). Additionally, the scan did confirm the concurrent presence of acute uncomplicated cholecystitis. Senior surgical appendix [6]. There is no clear consensus into the optimal treatment of and anaesthetic discussions took place with regards to operating on this patient to treat his appendicitis and repair his hernia. Amyand’s hernia. Some surgeons advocate appendicectomy and hernia repair in all cases even in spite of no abdominal symp- It was universally agreed that the acute cholecystitis could be viably treated with intravenous antibiotics in the interim. toms, in order to prevent future complications from appen- dicitis. However surgeons opposing this point of view regard However, acute appendicitis, with its risk of complications, the appendix as useful in terms of paediatric immunity and in warranted further discussion. Following discussion with the adults, feel that risks of the procedure outweigh the benefits patient, consultant physicians, anaesthetists and surgeons, the given the low incidence of appendicitis in Amyand’s hernias [7]. decision was made to treat both conditions conservatively with Indeed in our case, the risk of any operation and subsequent antibiotics. The rationale for this was that the patient’s main general anaesthetic in a patient with cardiac co-morbidities and complaint was that of right upper quadrant pain. He did not anticoagulation would certainly outweigh the benefit given lack have any peritonism or tenderness to his right inguinal canal of right iliac fossa symptoms and a soft, non-tender hernia. that would suggest impending perforation or peritonitis. His co-morbidities and age undoubtedly made him a high-risk case Losanoff and Basson attempted to categorize Amyand’s her- nia and provide a treatment algorithm for it. Type 1 hernias for appendicectomy and hernia repair. Most importantly, the patient himself was very reluctant to undergo operation and involve a normal appendix within the hernia sac and warrant mesh repair with reduction of the appendix. Type 2 hernias had full capacity to make this decision, having been made well aware of the risks of not intervening. Ultimately, following a involve an acutely inflamed appendix but lack of abdominal sepsis, meriting appendicectomy with suture repair of the her- 12 day stay with intravenous antibiotics, physiotherapy input nia. Type 3 involves a perforated appendix and Type 4 appen- and input from the physicians, he was discharged and to date dicitis within the inguinal hernia and concurrent abdominal has suffered no complications of his hernia or gallstone disease. pathology. Types 3 and 4 are treated with suture repair of the hernia and appendicectomy, with investigation of the abdominal DISCUSSION pathology also warranted in Type 4 [8]. Our patient therefore Amyand first described his eponymous hernia in 1735 when had a Type 4 hernia. As mentioned, he was not acutely unwell operating on a paediatric patient with an inguinal hernia con- from an appendix perspective and therefore actually needed taining the vermiform appendix [1]. The incidence of Amyand’s broad-spectrum antibiotics to treat his concurrent cholecystitis. hernia is around 1% of all inguinal hernias, with this dropping to This case highlights that although such a classification is help- 0.1% if there is acute appendicitis present within the hernial sac ful, Amyand’s hernias presenting acutely should be clinically [2]. The majority of cases are right sided but case reports have assessed on an individual basis. described occurrence in the left side of the abdomen [3]. Their To conclude, Amyand’s hernias are rare and present in a clinical presentation is varied, ranging from asymptomatic as highly varied manner. Diagnostic vigilance is essential by ensur- in our case, through to presentation as an incarcerated inguinal ing examination of the hernial orifices in all patients presenting hernia [4]. Uncommonly, Amyand’s hernia can mimic acute scro- with an acute abdomen. Although classification systems exist, tal pathology such as torsion or abscess [5]. With regards to acute we propose assessing each case on its own merit based on the appendicitis occurring inside the sac, either primary appendici- patient’s co-morbidities. In our case, although appendicectomy tis can occur or prolonged incarceration of the appendix and and suture mesh repair would have been the ideal, management Downloaded from https://academic.oup.com/jscr/article/2020/12/rjaa447/6035273 by DeepDyve user on 22 December 2020 Acute appendicitis located within Amyand’s hernia 3 with intravenous antibiotics treated both conditions simultane- inguinal hernia (Amyand’s hernia): a systematic review of the ously and effectively. literature. Hernia 2020;24:951–9. 5. Omran A, Gawrieh BS, Abdo A, Ali Deeb M, Khalil MA, Shater W. Amyand hernia: scrotal pyocele, associated with per- REFERENCES forated vermiform appendix and complicated by testicular ischemia in neonate. JSurgCaseRep 2019;2019:rjz265. doi: 1. Singh K, Singh RR, Kaur S. Amyand’s hernia. J Indian Assoc 10.1093/jscr/rjz265. Pediatr Surg 2011;16:171–2. 6. Rajaguru K, Tan Ee Lee D. Amyand’s hernia with appendici- 2. Losanoff JE, Basson MD. Amyand hernia: what lies beneath– tis masquerading as Fournier’s gangrene: a case report and a proposed classification scheme to determine management. review of the literature. J Med Case Reports 2016;10:263. doi: Am Surg 2007;73:1288–90. 10.1186/s13256-016-1046-9. 3. Kovacic JL, Aitchison LP, Ip JCY. Case report: acute left- 7. Cigsar EB, Karadag CA, Dokucu AI. Amyand’s hernia: 11years sided Amyand’s hernia in an elderly patient. ANZ J Surg of experience. J Pediatr Surg 2016;51:1327–9. 2020;90:2101–3. 8. Losanoff JE, Basson MD. Amyand hernia: a classification to 4. Papaconstantinou D, Garoufalia Z, Kykalos S. Implications improve management. Hernia 2008;12:325–6. of the presence of the vermiform appendix inside an http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Acute appendicitis located within Amyand’s hernia—a complex case with concurrent acute cholecystitis

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Oxford University Press
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Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2020.
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Abstract

Amyand’s hernia is the presence of the vermiform appendix within an inguinal hernia sac. It is rare, and even rarer is the presence of acute appendicitis within the sac. It presents in a variety of different ways and often is only diagnosed intra- operatively. We present the case of a 90 year old male with extensive co-morbidities presenting with right upper quadrant pain, who on computed tomography scan of the abdomen, had acute cholecystitis alongside acute appendicitis within Amyand’s hernia. Ultimately given his co-morbidities, a conservative approach with prolonged antibiotic therapy was adopted, with a successful outcome. This case highlights that although classifications for treatment of Amyand’s hernia exist, careful clinical assessment is warranted in each case to ensure optimal outcome based upon individual circumstances. pyrexial, tachycardic markedly tender in the right upper INTRODUCTION quadrant of his abdomen. There was also a reducible non-tender Amyand’s hernias are rare subtypes of inguinal hernias whereby right-sided inguinal hernia present. His past medical history the vermiform appendix is present within the hernial sac. They included atrial fibrillation (anti-coagulated with apixaban) occur in just 1% of inguinal hernias. Even rarer is the presence alongside ischaemic heart disease, osteoarthritis and a degree of acute appendicitis within the Amyand’s hernia [1]. They can of congestive cardiac failure with poor exercise tolerance. be difficult to diagnose pre-operatively unless imaging is per- On further questioning he had noticed the lump for several formed. Hence intra-operative diagnosis is common. We present weeks but described no tenderness around the lump. Blood the case of a 90 year old male admitted with right hypochon- workup revealed c-reactive protein of 140 mg/L and white cell drium pain and raised inflammatory markers whose computed count of 15 × 10 . He had mildly deranged renal function at tomograph (CT) scan of the abdomen ultimately demonstrated baseline consistent with an element of chronic kidney disease. an Amyand’s hernia with acute appendicitis alongside acute Other blood tests were unremarkable. A diagnosis of acute cholecystitis. Given his co-morbidities and lack of symptoms cholecystitis was made with an incidental finding of right- in the inguinal region, the patient was managed conservatively sided inguinal hernia. He was commenced on intravenous with antibiotics with a good outcome. antibiotics and CT scan of the abdomen arranged to ensure no co-existent pathology given his age. CT scan revealed CASE REPORT the presence of a right-sided inguinal hernia containing a A 90 year old gentleman was admitted on the acute surgical thickened vermiform appendix with peripheral fat stranding take with right hypochondrium pain. On examination he was suggestive of acute appendicitis within an Amyand’s hernia Received: August 10, 2020. Accepted: October 6, 2020 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2020. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 1 Downloaded from https://academic.oup.com/jscr/article/2020/12/rjaa447/6035273 by DeepDyve user on 22 December 2020 2 A. O’Connor et al. Figure 1: Axial CT scan demonstrating right-sided inguinal hernia with vermi- Figure 2: Coronal CT scan demonstrating appendicitis located within the form appendix located within it, suggestive of Amyand’s hernia. inguinal canal. pressure from the abdominal wall leads to inflammation of the (Figs 1 and 2). Additionally, the scan did confirm the concurrent presence of acute uncomplicated cholecystitis. Senior surgical appendix [6]. There is no clear consensus into the optimal treatment of and anaesthetic discussions took place with regards to operating on this patient to treat his appendicitis and repair his hernia. Amyand’s hernia. Some surgeons advocate appendicectomy and hernia repair in all cases even in spite of no abdominal symp- It was universally agreed that the acute cholecystitis could be viably treated with intravenous antibiotics in the interim. toms, in order to prevent future complications from appen- dicitis. However surgeons opposing this point of view regard However, acute appendicitis, with its risk of complications, the appendix as useful in terms of paediatric immunity and in warranted further discussion. Following discussion with the adults, feel that risks of the procedure outweigh the benefits patient, consultant physicians, anaesthetists and surgeons, the given the low incidence of appendicitis in Amyand’s hernias [7]. decision was made to treat both conditions conservatively with Indeed in our case, the risk of any operation and subsequent antibiotics. The rationale for this was that the patient’s main general anaesthetic in a patient with cardiac co-morbidities and complaint was that of right upper quadrant pain. He did not anticoagulation would certainly outweigh the benefit given lack have any peritonism or tenderness to his right inguinal canal of right iliac fossa symptoms and a soft, non-tender hernia. that would suggest impending perforation or peritonitis. His co-morbidities and age undoubtedly made him a high-risk case Losanoff and Basson attempted to categorize Amyand’s her- nia and provide a treatment algorithm for it. Type 1 hernias for appendicectomy and hernia repair. Most importantly, the patient himself was very reluctant to undergo operation and involve a normal appendix within the hernia sac and warrant mesh repair with reduction of the appendix. Type 2 hernias had full capacity to make this decision, having been made well aware of the risks of not intervening. Ultimately, following a involve an acutely inflamed appendix but lack of abdominal sepsis, meriting appendicectomy with suture repair of the her- 12 day stay with intravenous antibiotics, physiotherapy input nia. Type 3 involves a perforated appendix and Type 4 appen- and input from the physicians, he was discharged and to date dicitis within the inguinal hernia and concurrent abdominal has suffered no complications of his hernia or gallstone disease. pathology. Types 3 and 4 are treated with suture repair of the hernia and appendicectomy, with investigation of the abdominal DISCUSSION pathology also warranted in Type 4 [8]. Our patient therefore Amyand first described his eponymous hernia in 1735 when had a Type 4 hernia. As mentioned, he was not acutely unwell operating on a paediatric patient with an inguinal hernia con- from an appendix perspective and therefore actually needed taining the vermiform appendix [1]. The incidence of Amyand’s broad-spectrum antibiotics to treat his concurrent cholecystitis. hernia is around 1% of all inguinal hernias, with this dropping to This case highlights that although such a classification is help- 0.1% if there is acute appendicitis present within the hernial sac ful, Amyand’s hernias presenting acutely should be clinically [2]. The majority of cases are right sided but case reports have assessed on an individual basis. described occurrence in the left side of the abdomen [3]. Their To conclude, Amyand’s hernias are rare and present in a clinical presentation is varied, ranging from asymptomatic as highly varied manner. Diagnostic vigilance is essential by ensur- in our case, through to presentation as an incarcerated inguinal ing examination of the hernial orifices in all patients presenting hernia [4]. Uncommonly, Amyand’s hernia can mimic acute scro- with an acute abdomen. Although classification systems exist, tal pathology such as torsion or abscess [5]. With regards to acute we propose assessing each case on its own merit based on the appendicitis occurring inside the sac, either primary appendici- patient’s co-morbidities. In our case, although appendicectomy tis can occur or prolonged incarceration of the appendix and and suture mesh repair would have been the ideal, management Downloaded from https://academic.oup.com/jscr/article/2020/12/rjaa447/6035273 by DeepDyve user on 22 December 2020 Acute appendicitis located within Amyand’s hernia 3 with intravenous antibiotics treated both conditions simultane- inguinal hernia (Amyand’s hernia): a systematic review of the ously and effectively. literature. Hernia 2020;24:951–9. 5. Omran A, Gawrieh BS, Abdo A, Ali Deeb M, Khalil MA, Shater W. Amyand hernia: scrotal pyocele, associated with per- REFERENCES forated vermiform appendix and complicated by testicular ischemia in neonate. JSurgCaseRep 2019;2019:rjz265. doi: 1. Singh K, Singh RR, Kaur S. Amyand’s hernia. J Indian Assoc 10.1093/jscr/rjz265. Pediatr Surg 2011;16:171–2. 6. Rajaguru K, Tan Ee Lee D. Amyand’s hernia with appendici- 2. Losanoff JE, Basson MD. Amyand hernia: what lies beneath– tis masquerading as Fournier’s gangrene: a case report and a proposed classification scheme to determine management. review of the literature. J Med Case Reports 2016;10:263. doi: Am Surg 2007;73:1288–90. 10.1186/s13256-016-1046-9. 3. Kovacic JL, Aitchison LP, Ip JCY. Case report: acute left- 7. Cigsar EB, Karadag CA, Dokucu AI. Amyand’s hernia: 11years sided Amyand’s hernia in an elderly patient. ANZ J Surg of experience. J Pediatr Surg 2016;51:1327–9. 2020;90:2101–3. 8. Losanoff JE, Basson MD. Amyand hernia: a classification to 4. Papaconstantinou D, Garoufalia Z, Kykalos S. Implications improve management. Hernia 2008;12:325–6. of the presence of the vermiform appendix inside an

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Published: Dec 1, 2020

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