Introduction

Appendicitis is a disease frequently encountered in

surgical practice. Complications such as perforation,
abscess formation and peritonitis are not uncommon.
Most of the time, diagnosis and treatment are straight-
forward. On the other hand, a delayed diagnosis can lead
to rare, but sometimes serious, complications. We
present a rare but fatal case of retroperitoneal perforated
appendicitis with subsequent extensive retroperitoneal
abscess formation and subcutaneous emphysema
resulting in severe sepsis, multiple organ failure and
death.
Case report
A 76-year-old man presented at our emergency depart-
ment with progressive abdominal pain and loss of
appetite that had persisted for five days. The patients
medical history showed non-insulin dependent diabetes
mellitus and hypertension. Physical examination showed
a slightly ill-looking man with a temperature of 37.5C,
a blood pressure of 90/45 mmHg and a pulse rate of
117/min. The abdomen was adipose and tender in the
lower half and right flank without clinical signs of peri-
tonitis. Abnormal laboratory data included leukocytosis
(30.3 10
9
/L), anaemia (Hb 6.6 mmol/L) and disturbed
renal function (creatinine of 289 mol/L and urea of
23.3 mmol/L). Urinalysis showed 2-5 leucocytes per
field, 2-5 erythrocytes per field and no bacteria. Ultra-
sound examination of the abdomen showed a stone in the
right pyelum, without signs of obstruction. On suspicion
of suffering from urosepsis, the patient was treated with
intravenous antibiotics, followed by a quick recovery
with disappearance of leucocytosis. After four days he
was discharged with oral antibiotics.
Five days later the patient returned to our hospital
because of persistent abdominal pain, mainly on the right
side. His blood pressure was 85/45 mmHg ; pulse and
body temperature were normal. On physical examination
a red and tender mass was palpable in the right upper
abdominal quadrant. Laboratory tests showed leukocyto-
sis (22 10
9
/L), anaemia (6.5 mmol/L), thrombocytosis
(631 10
9
/L), progressively disturbed renal function
(creatinine of 408 mol/L and urea of 49 mmol/L) and
increased C-reactive protein levels (326 mg/L). Ultra-
sonography demonstrated an abscess in the right abdom-
inal wall with culture of a subsequent puncture showing
candida glabrata, candida tropicalis, gram-positive flora
and anaerobe flora. Subsequently, the patient was treated
with intravenous fluconazole, ciprofloxacin, amoxicillin
and metronidazole. With abdominal computed tomogra-
phy (CT) abscesses in the retroperitoneum and subcuta-
neous emphysema at the right side and in the right
abdominal wall were seen, extending into the left
abdominal wall down to the pelvis (Fig. 1). Emphysema
in the left perirenal space with stones in the left kidney
and bladder were also seen. Additional workup with CT-
IVP (intravenous pyelogram) and contrast x-ray of the
colon (for colonic perforation) showed no abnormalities.
At this moment a urologic origin seemed the most likely
cause. The patient was clinically stable and repeated lab-
oratory tests did show some improvement (leucocytes of
10.1 10
9
/L, C-reactive protein levels of 304 mg/L, cre-
atinine of 168 mol/L and urea of 31.5 mmol/L) during
conservative treatment with intravenous antibiotics.
Acta Chir Belg, 2008, 108, 457-459
Retroperitoneal Abscess and Extensive Subcutaneous Emphysema in Perforated
Appendicitis : a Case Report
N. B. Tomasoa*, J. M. Ultee, B. C. Vrouenraets
Department of Surgery, Sint Lucas Andreas Hospital, Amsterdam, the Netherlands.
*At present : Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands.
Key words. Perforated appendicitis ; retroperitoneal abscess ; subcutaneous emphysema.
Abstract. Most of the time, the diagnosis and treatment of appendicitis are straightforward. However, a missed diagno-
sis can sometimes lead to life-threatening complications. A fatal case of appendicitis in a 76-year-old man who present-
ed with progressive abdominal pain, retroperitoneal abscesses and extensive subcutaneous emphysema, is described.
Eventually, laparotomy showed appendicitis perforated into the retroperitoneum without any signs of peritonitis. Despite
multiple operations the patient died two months after admission due to multiple organ failure.
However, on day nine, surgical drainage of retro- and
preperitoneal abscesses took place. At laparotomy,
exploration showed an appendicitis perforated into the
retroperitoneum without any signs of peritonitis.
Appendectomy was performed and several drains were
left in the abscesses. Post-operatively, the patients con-
dition deteriorated and despite multiple operations for
persistent abscess formation and sepsis, he died due to
multiple organ failure two months after admission.
Discussion
Worldwide, acute appendicitis is a disease commonly
encountered in everyday practice, with a lifetime risk of
approximately 7% (1). Proper diagnosis and treatment
are essential to prevent morbidity and mortality (2, 3).
Occasionally, serious and sometimes life-threatening
complications of perforated appendicitis do occur. Four
other cases of retroperitoneal perforated appendicitis
with formation of retroperitoneal abscesses and subcuta-
neous emphysema have been described (4-7). Among
these, several similarities are described : the patients
presentation is unusual, a retroperitoneal ruptured appen-
dicitis can cause serious complications and CT is the
diagnostic tool of choice.
Although a frequently encountered disease, the diag-
nosis of appendicitis may be missed. Because of its posi-
tion, a retroperitoneal perforated appendicitis can cause
atypical and confusing physical findings (5). Infection
and air can extend to communicating compartments,
resulting in emphysema and abscesses in unexpected
anatomical sites. Other cases have been described with
extension to the abdominal wall, thigh, and perinephric
space (4-7).
458 N. B. Tomasoa et al.
Since the location of infection in our patient was
retroperitoneal, typical peritoneal signs were absent and
treatment for a presumed urosepsis was installed. Prompt
surgery and source control, especially during the first
admission, would most likely have altered the unfortu-
nate outcome of our patient. An early appendectomy
could have prevented this extensive spreading of appen-
dicitis.
For a definite diagnosis of acute appendicitis, CT scan
of the abdomen is considered to be the imaging study
with the highest accuracy and efficiency (8-10). Not only
can it be of great help in diagnosis, but also in evaluating
the extension of involvement. Furthermore, an approach
for drainage of abscesses can be made on CT results.
Only on CT scanning, emphysema and abscessing of the
right flank were seen. As described by ISHIGAMI et al. the
superior and inferior lumbar triangles, two sites of
anatomical weakness in the flank abdominal wall, allow
spreading to the abdominal wall (7). Nonetheless, in our
case, CT findings were not sufficient for the diagnosis
and the cause of abscess and emphysema formation was
unclear until laparotomy.
In summary, a case of a retroperitoneal perforated
acute appendicitis causing formation of retro- and
preperitoneal abscesses with extensive subcutaneous
emphysema was presented : a rare but life-threatening
complication. Physicians should have in mind that occa-
sionally disease extension to unexpected anatomical sites
does occur, causing unusual clinical pictures. CT scans
of the abdomen should be made freely. However, some-
times an exploratory laparotomy is necessary to reveal
the cause. This case re-emphasizes the importance of
early management for such a common disease.
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Retroperitoneal Perforated Appendicitis 459
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Dr. B. C. Vrouenraets, surgeon
Department of Surgery, Sint Lucas Andreas Hospital
Postbus 9243
1006 AE Amsterdam
Tel. : +31 20 5108770
Fax : +31 20 6838771
E-mail : bc.vrouenraets@slaz.nl