Pneumobilia and hyperbilirubinemia associated with acute appendicitis: a case report
A thirty-year-old man presented to our emergency department with fever (39.9 °C) and orthostatic hypotension with lypothimia since the day before. He reported a single episode of epigastric pain and alimentary vomiting, three days before onset of fever. Pain and vomiting had promptly resolved with paracetamol and scopolamine. The patient also noticed his faeces were more fluid than usual, without increased bowel movement frequency. The patient denied consumption of illicit drugs, foreign travel or close contact with wild animals in recent months. He reported no medical disorders, he did not take any medication regularly. The patient was awake, alert and fully oriented, he felt tired and dizzy. Physical examination was unremarkable. He had no abdominal discomfort, pain or tenderness. Mc-Burney, Murphy, Rosving, Blumberg and psoas signs were all negative. Digital rectal examination and trans-rectal palpation of the prostate and Douglas pouch were negative. Systolic blood pressure was 90 mm Hg and heart frequency 100 beats per minute (sinus tachycardia at electrocardiography). Blood tests are shown in Table 1 and were normal except for moderate lymphocytopenia, mild thrombocytopenia, borderline increase of renal retention values, without loss of renal function. Inflammatory markers were raised. Bilirubin was increased, without concomitant increase in any other cholestatic parameters or hepatic enzymes. Focused abdominal and cardiac ultrasound scans were done. Cardiac ultrasound showed signs of hypovolaemia with hyperdynamic left ventricular function (visually assessed ejection fraction ca. 70%, reference range 55-65%), and a normal vena cava diameter (1.3 cm) with complete collapse upon inspiration. Abdominal ultrasound showed a small fluid collection in the Douglas pouch (Figure 1b) pneumobilia in the left liver lobe (Figure 1c), without any focal or diffuse changes in the liver parenchyma. Gallbladder, biliary ducts, and portal system were normal (Figure 1a). No signs of pneumoperitoneum, ileus, or bowel dilation were observed. Both kidneys appeared normal, showed no focal parenchymatous changes or hydronephrosis. The appendix was not visible. A diagnosis of severe sepsis was made. Intravenous fluids and empirical intra-venous broad-spectrum antibiotics (piperacillin-tazobactam) were initiated. Blood pressure and heart frequency promptly normalised. An abdominal focus was suspected: either a sonographically unrecognised gangrenous cholangitis or a bilio-enteric fistula. A CT-Scan of the abdomen was obtained. CT images showed: an enlarged inflamed appendix (length 15 cm), ascending retro-coecally and reaching into the epigastric region (Figure 2c), localised peritonitis with signs of paralytic ileus and free air along the ascending mesocolon (Figure 2a), as well as localised pneumobilia of the left liver lobe (Figure 2b). There were no signs of bilio-enteric or bilio-renal fistulae. No radiologic signs of intra-abdominal infection (other
Salient CT-Scan findings at admission: a.Free air in the abdomen (small circles). b.Pneumobilia in the left liver lobe (circle). c.Swollen, inflamed, ca. 15 cm long appendix ascending cranially and medially towards the liver containing an appendicolith (arrow) consistent with an acute perforated appendicitis.