Case Report

A 30-year-old female patient with a height of 1.62 m and weight of 110 kg (BMI 41.91) having pain in the lower abdomen was admitted to the emergency department. The previous day, symptoms started with pain in the epigastrium. As time went on, the pain was located around the navel and finally settled in the right iliac fossa. The patient did not report having nausea, episodes of vomiting, or fever at home. The patient’s bowel habits were unaltered, and she reported loss of appetite the previous two days.
The physical examination raised the suspicion of appendicitis since a positive McBurney’s sign was found - right lower abdominal quadrant pain - and rebound tenderness, indicating peritoneum irritation. The blood test results revealed leucocytosis, with WBC 12.730/mm3 (66.4% Neut, 23.6% Lym, 8.1% Mono) and increased levels of the C-reactive protein (2.06). Our patient had an Alvarado score 9 [1]. Additionally, neither the urine analysis nor the abdominal X-ray revealed any findings.
Afterward, an examination of the abdomen was performed with an ultrasound. The coarse examination revealed no particular findings. The graded compression technique was then performed using the 8 MHz probe set above the position of maximum sensitivity with gradually increasing pressure exerted to displace the normal supernatant gas. The appendix was identified (Figure 1) with the blind end of the appendix arising from the base of the caecum. The appendix was dilated (diameter 1.5cm) in target appearance (axial section) [a], was non-compressible when compression was applied [b] and had hyperechoic appendicolith with posterior acoustic shadowing and periappendiceal fluid collection (white arrow) [c]. After the application of the coloured Doppler, it showed intense vascularization of the wall as an image of mural hyperaemia [d].
The patient was hemodynamically stable but, during admittance, presented with a low-grade fever (37.5 oC). After reviewing the test results, a decision was made to perform an open appendectomy via a McBurney’s incision.
Intraoperative findings included a mild quantity of free fluid in the right iliac fossa and an inflamed appendix. Surprisingly, another thin, mildly inflamed appendix was found when the appendectomy was completed (Figure 2).
Both the appendices could be separated at the bases and were ligated individually. Our case presented a B2 type appendiceal duplication [2]. An inspection of the small bowel for the presence of Meckel’s diverticulum followed, which was negative. Histopathological examination of the surgical specimen confirmed the clinical findings. Both specimens showed identical features: appendiceal mucosa with extensive transmural chronic, active inflammation associated with suppurative peritonitis (Figure 3a,b). The patient had an uneventful recovery and was discharged on the sixth postoperative day.