PMC5131238_01
Abdominal X-ray on admission. Normal findings.
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The blood laboratory tests showed results within normal limits (WBC: 8.01 K/muL, with 76.3% neutrophils) and imaging control through abdominal X-ray (Figure 1) and ultrasound did not reveal any abnormalities.
Imaging through colonoscopy. No signs of inflammation until the point of 10 cm proximally to the ileocecal valve.
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The procedure was uneventful and examination up to 10 cm proximally to the ileocecal valve did not lead to any pathologic findings (Figure 2).
Abdominal X-ray after colonoscopy and clinical deterioration. Presence of free abdominal gas.
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A new abdominal X-ray was performed, presenting free abdominal gas (Figures 3(a) and 3(b)).
Abdominal CT scan. Perihepatic collection with free abdominal gas.
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The abdominal CT scan revealed diffuse inflammation not only in the area of the appendix and free gas in the peritoneal cavity, but also in the retroperitoneal space (Figure 4).
Intraoperative findings. Acute appendicitis with peritonitis. Presence of a fecalith.
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Based on the condition and the imaging findings, an exploratory laparotomy was performed, during which perforated appendicitis with peritonitis was revealed (Figures 5(a) and 5(b)).