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Case 58: Right iliac fossa pain and a mass

A 62 year old woman refused to see a doctor for more than a week despite abdominal pain. What began as central abdominal cramp then settled in her right lower quadrant.

1.Whats wrong with this picture?

There is a large inflammatory mass in the right iliac fossa containing fluid and gas locules. This would be consistent with a locally perforated appendix.

2.Treatment options?

If seen early operative intervention, after more than a week a percutaneous drain is often successful at settling the septic process (presuming the intra-peritoneal sepsis is localised to the right iliac fossa)

3.What procedure has been performed?

A radiologically inserted percutaneous drainage catheter. This catheter used here was a wide bore catheter which also had an irrigation lumen.

4.Name the radiological investigation performed here?

Fluoroscopic tubogram.

5.Possible explanations for this appearance?

An appendicoel base which has necrosed causing free communication between the collection and the caecum, or the radilogically placed catheter has been inadvertently placed through the right colon. In either case leaving the catheter until a controlled fistula track is establised then removing the catheter and allowing the track to close is probably the best course of action.

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