We report the case of an 89-year-old man who came to the emergency department complaining of oliguria, nausea and localized pain in the right iliac fossa of 16 hours onset.
His personal history included adenocarcinoma of the prostate radiated 9 years ago, currently under treatment with monotherapy.
On examination, the abdomen was globulous, blade and presible, painful evidence of deep fixation in the right iliac fossa, with a positive Blumberg sign and pain in the right inguinal hernia.
The patient was afflicted with a blood pressure of 153 ppm and a heart rate of 101 ppm.
Blood analysis shows the following results: leukocytes, 15.780/ul; neutrophils, 92.2%; lymphocytes; glucose, 166 mg/dl; sodium, 133 mEq/l.
Chest and abdominal X-rays were normal.
Because of the clinical doubt, an abdominal ultrasound of the right iliac fossa with a high frequency probe is performed. The appendix is not clearly visualized, observing a liquid sheet of approximately 2 cm in size in the iliac vessels.
Since the ultrasound was inconclusive, a CAT scan was performed to identify the inguinal benign, observing in the right iliac fossa an evident alteration in the peritoneal fat, which shows an edematous and trabeculated appearance, with a similar fat duct.
Established by these findings, and the radiological diagnosis of probable acute colitis, with indirect inguinal herniation of the inflamed appendix, it was decided to perform an urgent surgical intervention, performing a right paramedian presence of the appendiceal povidone, right inguinal hernia septa.
Regulated cystectomy and parietal peritoneum closure were performed.
The anatomopathological diagnosis was acute meningitis.
She had a satisfactory postoperative evolution and was discharged nine days after the intervention.
1.
Comments and discussion
Amyand's hernia usually presents as a sensitive, tense and irreducible mass in the right inguinal region4, although it has also been described on the left side5,6, accompanied by varying degrees of abdominal pain and vomiting.
The presence of fever and leukocytosis is not constant.
In our case, the patient had pain in the right inguinal region with no evidence of herniation, was nauseous and had leukocytosis with neutrophilia, but was afflicted.
It is more common that the hernia is indirect and is present in men over 60 years of age, as in the case presented here, and has also been described in children.
Most Amyand's hernias are diagnosed during surgery, because it is indicated when a complicated inguinal hernia is suspected, and its preoperative diagnosis is exceptional.
CT is very useful for diagnosis in adults, as is ultrasound in children.
Amyand's syndrome has been defined and classified into four types according to a non-inflammated, inflamed, perforated appendix or a neoplasm or abdominal mass. It is proposed as concomitant abdominal hernia repair or herniation.
The best wound healing was achieved by laparotomy in order to perform the cystectomy in the conditions, ensuring good surgical field control and possible surgical abscess and minimizing surgical exposure.
We also chose to perform hernia repair by hernioplasty in a second time, in the absence of contamination of the abdominal wall.
