description
68 year old male presents with a 3 day history of severe right-sided abdominal pain radiating down into his right scrotum. He has had associated vomiting on 3 occasions and his wife reports that the bedsheets and pillow case were drenched with sweat last night. On examination, his vitals are: 38.6 degrees, 130bpm, 100/60mmHg, 24 breaths/min, 97% sats on room air. His peripheries are warm and vasodilated. Chest is clear. Abdomen demonstrates localised peritonism in the right lower quadrant. Testes are non-tender. His urine dipstick is negative for blood, leukocytes or nitrites. Labs demonstrate a white cell count 18 and CRP 280. Renal function is normal. Blood cultures are collected which quickly grow Clostridium. A CT Abdomen and Pelvis is performed with IV contrast. Review the scan and identify the primary pathology which explains the patient's presentation. ANSWER: There is a small right indirect inguinal hernia containing an enlarged 9.5mm inflamed appendix with associated fat stranding and minimal fluid. This finding of acute appendicitis contained within an inguinal hernia is consistent with Amyand's hernia. There are no features of small or large bowel obstruction. There is no free fluid or gas within the abdomen. There is no definite intraabdominal lymphadenopathy. Incidentally, there are numerous other findings in this scan, including cholelithiasis without features of cholecystitis; multiple simple liver cysts; bilateral renal cortical cysts; a large hiatal hernia; a 12mm short-axis elongated lesion in the right para-aortic region posterior to the crus of the diaphragm, which may represent a lymph node. Additionally, there is subcutaneous emphysema involving the lower abdominal wall. Amyand's hernia is a rare form of inguinal hernia in which the vermiform appendix becomes incarcerated within the hernia. Its incidence is less than 1%. The condition is named after Claudius Amyand, an English surgeon, who is attributed with performing the first successful appendicectomy on a young boy who had appendicitis contained within an inguinal hernia.