A case of retroperitoneal abscess in crohn’s disease patient due to acute appendicitis

Acute appendicitis is a common and well-recognized condition that is overly easily managed. However, at times it can become significantly complicated and thus life-threatening. Acute appendicitis can present atypically with findings such as peritonitis and even abdominal abscesses. Crohn’s disease is a chronic inflammatory disease that may occur in the alimentary tract and has various clinical courses. It is characterized by several complications, including bowel strictures, bowel obstruction, fistulas, abscesses, and hydronephrosis. However, these two conditions when affecting the same person can be easily misinterpreted in favor of Cron`s disease and lead to life-threatening events. We present a case of a 62-year-old female patient previously diagnosed with Crohn's disease, who was hospitalized due to a clinical presentation of acute abdomen, diffuse lower abdominal pain, back pain, pain in the right femoral region, urge to vomit and elevated body temperature for the last 3 days. Laboratory results revealed leukocytosis and an elevated C-reactive protein level. The abdominal ultrasound and CT scan revealed liquid collections in right paracolic space and Douglas`s pouch. Surgical treatment with an urgent exploratory laparotomy followed by appendectomy was performed. The retroperitoneal abscess was drained through fistulous communication in the inguinal region, followed by generous lavage of the abscess cavity in the following days. On the thirteenth postoperative day, the patient condition worsened with findings of pneumoperitoneum and liquid collection in the abdomen, on the control abdominal CT scan аnd a re-operation was performed. The intraoperative findings were perforations of the ceco-ascending part of the colon and distal part of the ileum. A right hemicolectomy with temporary ileostomy was performed followed by improved and stabile postoperative follow-up. After 1 month, the patient was discharged in good general condition. This is a complex surgical case where the patient on one side suffers the Crohn’s disease, which histologically is characterized by transmural inflammation of the gut with high risk for fistula and abscess formation. On the other side, even though the appendicular involvement in Crohn's disease is a relatively frequent event (21%), the clinician's focus solely on Crohn`s disease rather than on acute inflammation of the appendix. This case should raise the surgeon`s awareness in patients with Crohn`s disease in the setting of retroperitoneal and inguinal abscesses to avoid delayed treatment with life threatening complications. The diagnostic tool of choice is abdominal CT scan, with rapid evaluation followed by adequate treatment as the key to the survival of the patient.