Trauma to the A
Report of
David A.
Appendix
Two Cases
Geer, MD; George Armanini, MD; James M. Guernsey, MD
Only two cases of trauma to the vermiform appendix are recorded English literature. This report adds two more cases: one due to a penetrating bullet wound of the abdomen where tangential laceration of the appendix was the only intra-abdominal injury, the other an avulsion of the appendix from the mesoappendix resulting from blunt abdominal trauma. Preoperative diagnosis of this specific lesion could not be made. Both patients were successfully managed by appendectomy. in the
to the appendix are exceedingly uncom¬ The purpose of this article is to report two cases of trauma to the appendix: one caused by a gunshot wound to the abdomen and the other by blunt abdominal
Injuries mon.
trauma.
REPORT OF CASES Case 1.—A 26-year-old man was admitted with a gunshot wound in the right lower quadrant of the abdomen. Examination of the abdomen revealed normal bowel sounds and only minimal guard¬ ing around a small entrance wound in the right lower quadrant. There was no muscle spasm, and results of a rectal examination were normal. The abdomen was explored through a midline inci¬ sion, and the only intra-abdominal injury found was a tangential
Accepted
for publication Nov 18, 1974. From the departments of surgery, Santa Clara Valley Medical Center, San Jose, Calif, and Stanford University School of Medicine, Stanford, Calif. Reprint requests to Department of Surgery, Santa Clara Valley Medical Center, 751 S Bascom Ave, San Jose, CA 95128 (Dr. Guernsey).
Appendix in patient 2. Note avulsion of sis of distal two thirds of appendix.
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mesoappendix and
necro¬
wound of the tip of the appendix. There was no contamination of the peritoneal cavity. An appendectomy was performed, and the
postoperative course was uncomplicated. Case 2.—A 39-year-old man sustained blunt trauma to the abdo¬ men in an automobile accident 24 hours prior to admission. He was seen immediately following the accident, complaining of mild ab¬ dominal pain and a laceration of the left knee. The laceration was sutured and his abdominal pain was considered to be due to ab¬ dominal wall contusion. He was discharged, but returned 24 hours later because of increasingly severe pain, mainly in the lower part of the abdomen. Pertinent findings were limited to the abdomen, which was diffusely tender with guarding in both lower quadrants. There was rebound tenderness in the right lower quadrant. Bowel sounds were absent. The preoperative diagnosis was intra-abdominal hemorrhage. At operation, the only findings were a small amount of blood in the peritoneal cavity, a 4-cm tear in the mesentery of the distal part of the ileum, and avulsion of the appendix from the mesoap¬ pendix. The distal two thirds of the appendix was necrotic (Fig¬ ure). The appendix was removed, the mesenteric defect repaired, and the patient's subsequent postoperative course was unremark¬ able. The microscopical examination of the appendix confirmed a diagnosis of hemorrhagic infarction.
appendiceal injuries may go unreported. Injury to the ap¬ pendix secondary to blunt abdominal trauma, however, must be very
rare indeed. Gate wood and Russum1 re¬ similar to our own in which a 39-year-old woman sustained blunt trauma to the abdomen and at laparotomy was found to have avulsed the distal three fourths of the appendix. Burgess2 reported the only other similar case that we could find in the English literature. He described a patient who developed abdominal pain af¬ ter using a pneumatic drill that rested on the right lower quadrant of his abdomen. At exploration, the patient was found to have avulsed the tip of the appendix. One can only speculate as to the mechanism of these ap¬ pendiceal injuries secondary to blunt trauma. In cases such as our second one and the one described by Gatewood and Russum, the patients sustained sudden decelerating injuries. The cecum is in a relatively fixed position in rela¬ tion to the appendix, and a sudden deceleration could cause avulsion of the mesoappendix with resulting is¬ chemia and necrosis of the distal part of the appendix.
ported
a case
COMMENT
Penetrating trauma to the abdomen involving the ap¬ pendix may be more common than can be appreciated from a review of the literature. It is likely that such cases are associated with other intra-abdominal injuries and the
References 1. Gatewood JW, Russum WJ: Injuries to the appendix seconto blunt trauma. Am J Surg 91:558-560, 1956. 2. Burgess CM: Traumatic appendicitis. JAMA 111:699-700, 1938.
dary
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/11/2015
Report of
David A.
Appendix
Two Cases
Geer, MD; George Armanini, MD; James M. Guernsey, MD
Only two cases of trauma to the vermiform appendix are recorded English literature. This report adds two more cases: one due to a penetrating bullet wound of the abdomen where tangential laceration of the appendix was the only intra-abdominal injury, the other an avulsion of the appendix from the mesoappendix resulting from blunt abdominal trauma. Preoperative diagnosis of this specific lesion could not be made. Both patients were successfully managed by appendectomy. in the
to the appendix are exceedingly uncom¬ The purpose of this article is to report two cases of trauma to the appendix: one caused by a gunshot wound to the abdomen and the other by blunt abdominal
Injuries mon.
trauma.
REPORT OF CASES Case 1.—A 26-year-old man was admitted with a gunshot wound in the right lower quadrant of the abdomen. Examination of the abdomen revealed normal bowel sounds and only minimal guard¬ ing around a small entrance wound in the right lower quadrant. There was no muscle spasm, and results of a rectal examination were normal. The abdomen was explored through a midline inci¬ sion, and the only intra-abdominal injury found was a tangential
Accepted
for publication Nov 18, 1974. From the departments of surgery, Santa Clara Valley Medical Center, San Jose, Calif, and Stanford University School of Medicine, Stanford, Calif. Reprint requests to Department of Surgery, Santa Clara Valley Medical Center, 751 S Bascom Ave, San Jose, CA 95128 (Dr. Guernsey).
Appendix in patient 2. Note avulsion of sis of distal two thirds of appendix.
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/11/2015
mesoappendix and
necro¬
wound of the tip of the appendix. There was no contamination of the peritoneal cavity. An appendectomy was performed, and the
postoperative course was uncomplicated. Case 2.—A 39-year-old man sustained blunt trauma to the abdo¬ men in an automobile accident 24 hours prior to admission. He was seen immediately following the accident, complaining of mild ab¬ dominal pain and a laceration of the left knee. The laceration was sutured and his abdominal pain was considered to be due to ab¬ dominal wall contusion. He was discharged, but returned 24 hours later because of increasingly severe pain, mainly in the lower part of the abdomen. Pertinent findings were limited to the abdomen, which was diffusely tender with guarding in both lower quadrants. There was rebound tenderness in the right lower quadrant. Bowel sounds were absent. The preoperative diagnosis was intra-abdominal hemorrhage. At operation, the only findings were a small amount of blood in the peritoneal cavity, a 4-cm tear in the mesentery of the distal part of the ileum, and avulsion of the appendix from the mesoap¬ pendix. The distal two thirds of the appendix was necrotic (Fig¬ ure). The appendix was removed, the mesenteric defect repaired, and the patient's subsequent postoperative course was unremark¬ able. The microscopical examination of the appendix confirmed a diagnosis of hemorrhagic infarction.
appendiceal injuries may go unreported. Injury to the ap¬ pendix secondary to blunt abdominal trauma, however, must be very
rare indeed. Gate wood and Russum1 re¬ similar to our own in which a 39-year-old woman sustained blunt trauma to the abdomen and at laparotomy was found to have avulsed the distal three fourths of the appendix. Burgess2 reported the only other similar case that we could find in the English literature. He described a patient who developed abdominal pain af¬ ter using a pneumatic drill that rested on the right lower quadrant of his abdomen. At exploration, the patient was found to have avulsed the tip of the appendix. One can only speculate as to the mechanism of these ap¬ pendiceal injuries secondary to blunt trauma. In cases such as our second one and the one described by Gatewood and Russum, the patients sustained sudden decelerating injuries. The cecum is in a relatively fixed position in rela¬ tion to the appendix, and a sudden deceleration could cause avulsion of the mesoappendix with resulting is¬ chemia and necrosis of the distal part of the appendix.
ported
a case
COMMENT
Penetrating trauma to the abdomen involving the ap¬ pendix may be more common than can be appreciated from a review of the literature. It is likely that such cases are associated with other intra-abdominal injuries and the
References 1. Gatewood JW, Russum WJ: Injuries to the appendix seconto blunt trauma. Am J Surg 91:558-560, 1956. 2. Burgess CM: Traumatic appendicitis. JAMA 111:699-700, 1938.
dary
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