# Appendicitis Secondary to Trauma following a Camel Kick: Case Report and Review of Literature

Authors: Ali Toffaha; Omer Al-Yahri; Zainab Hijawi; Saif Al-Mudares; Mohannad Al-Tarakji; Fakhar Shahid; Syed Muhammad Ali
Journal: Case Reports in Surgery
 (2021)

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## Abstract

Introduction. Independently, trauma and appendicitis are two of the most common conditions in surgical practice. Rarely, both conditions may coexist, which raises the controversy whether it is merely a coincidence or trauma may lead to acute appendicitis. Presentation of Case. We report a case of acute appendicitis after blunt abdominal trauma caused by a camel hoof kick to the abdomen in a young man and discuss the potential underlying pathophysiologic mechanisms with review of the pertinent literature. Conclusions. Blunt abdominal trauma caused by a camel kick to the abdomen requires a close observation of the patients. A camel kick may increase intra-abdominal pressure and cause internal organ injury including the appendix. Therefore, acute appendicitis should be considered in differential diagnosis in any patient with abdominal pain resembling appendicitis following blunt abdominal trauma.


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## Body

## 1. Introduction

Appendicitis is one of the most common surgical conditions affecting about 7% of people during their lifetime [1]. The etiology of acute appendicitis is multifactorial, with luminal obstruction being considered the major cause [1]. Blunt abdominal trauma (BAT) has been infrequently reported as a possible cause for acute appendicitis; however, most of the reported cases were in pediatric age group (Table 1). Herein, we report a rare case of acute appendicitis after blunt abdominal trauma caused by a camel hoof kick to the abdomen.Table 1
Summary of the case reports with publication year showing the cases of acute appendicitis secondary to traumatic abdominal injuries.
Study∗SexAgePHMOIPresentationDExaminationLabsXRUSCTSurgeryIntraopHistoHSCurrent studyQatarM35 yURCamel kickRLQ pain few hours after the kick, anorexia, V2 dVit: Nr, RLQ bruise, tendernessWBC: 15.5, CRP: 90.5, bilirubin: 29.1NRNRAp 16 mm, wall enhancement, periappendiceal fat strandingL AppyAAAA12 hZvizdic2019Bosnia & HerzegovinaCc[2]M7 yURHorse kickSudden, progressive pain in RLQ, V10 hBP: 95/55, P: 110, T: 38.3, RR: 18. Abrasions, swelling tenderness and guarding RLQWBC: 11.5, Hb: 13.2, Plt: 280NRPericecal free fluid, extending to pouch of DouglasSmall focus of free peritoneal air, free pelvic fluidLap, AppyPerf AA with localized peritonitisPerf AA, full thickness inflammation of Ap wall6 d postopCobb2017U.S[6]M17 yADMVCDiffuse progressive Abd pain 24 h after MVC, V 10 timesNRVit: Nr, tender in both LQ’s (Lt>Rt) and Lt upper quadrantWBC: 10.8, Hb: 15.8, Plt: 243Abd XR: abnormal bowel loop RLQNRDilated Ap 1.3 cm surrounding fluid in RLQ and pelvisL Ex, Lap, AppyInflamed Ap, dark fluid in RLQ concerning for viscus injuryAA10 d postopAhmed2014India[4]M12 yURHit disk’s cornerPeriumbilical Abd pain 1 d after trauma, fever1 dP: 114, BP: 90/56, minimal Abd movement with resp, bruise RLQ, rigid diffusely tender abdomenWBC: 17, Hb: 10.5Abd XR: air under diaphragmPelvic free fluidNREx Lap, AppyPus in pelvis, Perf AA at tipAA>4 dPaschos2012Greece[7]F17 yURBicycle accidentAbd pain 12 h after trauma, discharged and came back with pain, anorexia, N&V1 dVit: Nr, ecchymosis and tenderness RLQWBC: 9.1, on readmission: 12.7, Hb: 1.95 mmol/LNRAbd free fluidNRLap, AppyFree fluid, AA, contusion cecal baseAA2 dTorres-Grau2012UK[3]M15URFall from bicycleAbd pain 30 m after fall6 hBP: 105/47, P: 57, T: 36.7, RLQ tendernessWBC: 16.2, Neu: 13.6, Hb: 14.4, CRP: 1 AmyNRFree fluid in the peritoneumNRL Ex, AppyNecrotic, non-Perf ApAANRAtalla2010Australia[8]M53 yURFall on edge of car doorAbd pain 7 h after fall7 hP: ↑, BP: ↓, RLQ tenderness and guardingWBC: ↑NRURThickened Ap (10 mm) with fat strandingL Ex, AppyAAAA1 d postopToumi2010UK[1]M11 yURInjury by elbow to RLQAbd pain after trauma, N&V, anorexia, fever3 dT: ↑, P: ↑, RLQ tendernessUA: trace blood; Inf m: ↑NRNRAA with adjacent collectionAppyAAAA serositis4 d postopEtensel2005Turkey[9]M9 yNRFallPolytrauma1 hBP: 80/50, P: 86, T: 36.7, confused, resp dist, head and Lt chest abrasions, ↓ breath sounds Lt chestHb: 11.2, WBC: 17.2Chest and Abd XR: Lt lung contusion, free peritoneal airFree airHead CT: brain edema, Lt parietal bone fx; Abd CT: free airLap, AppyAA, no bowel PerfAA10 dHoury2001Colarado[10].M5 yURFallAbd pain1 hBP: 114/75, P: 149, RR:32, T: 37.7, Abd tenderness and guarding more in RLQNNFree fluid in pouch of DouglasPelvic free fluid, AAEx Lap, AppyAA, Perf at the baseAANRSerour1996Israel[11]M11 yURPunchRLQ pain, N&V18 hBP: 115/60, P: 100, T: 37, looked ill, RLQ tendernessHb: 13.7, WBC: 4.5NRNRCalcified appendicolith, prerectal fluidLap. AppyGangrenous ApGangrenous appendicitis with periappendicitisNRSerour1996Israel[11]M8 yURFallAbd pain, N and fever3 hBP: 95/55, P: 96, T: 38.2, ecchymosis over right side of the face, RLQ tenderness, guarding, and reboundHb: 12.5, WBC: 20.1NRNRNRAppyAAPhlegmonous appendicitis with periappendicitisNRSerour1996Israel[11]M7 yURFightAbd pain, fever, VFew dT: 40, acute AbdNRNRNRAbscess in RLQAppy, drainage of abscessGangrenous Perf ApGangrenous Perf appendicitisNRCiftci1996Turkey[12]M8NRMVCAbd pain2 hNRNRNRNRNRAppyPerf ApAAAverage hospital stay 6.4 dCiftci1996Turkey[12]F5NRFallAbd pain6 hNRNRNRNRNRAppyAAAACiftci1996Turkey[12]F13NRBallN12 hNRNRNRNRNRAppyAAAACiftci1996Turkey[12]M14NRMVCAbd pain4 hNRNRNRNRDilated bowel loops, free fluidAppyPerf ApAACiftci1996Turkey[12]M7NRAssaultAbd pain12 hNRNRNRNRDilated bowel loops, free fluidAppyAAAA∗For space considerations, only the first author is cited; AA: acute appendicitis; Abd: abdomen/al; AD: atopic dermatitis; Ap: appendix/appendiceal; Appy: appendectomy; BP: blood pressure in mmHg; CRP: C-reactive protein; D: duration of symptoms; d: days; diaph: diaphragm/atic; Ex: exploratory/ion; fx: fracture; h: hour/s; Hb: hemoglobin g/dL; Hem: hematoma; Histo: histology; HS: hospital stay postoperatively; Intraop: intraoperative findings; Inf m: inflammatory markers; I.O: intestinal obstruction; L: laparoscopic; Lap: laparotomy; LQ: lower quadrant; Lt: left; M: male; m: month/s; min: minute/s; McB: McBurney’s point; MOI: mechanism of injury; MVC: motor vehicle collision; N: nausea; Neu: neutrophils; NR: not reported; Nr: normal; P: pulse in beats per minute; Perf: perforation; PH: past history; pneumomed: pneumomediastinum; Plt: platelets K/μL; postop: postoperative; resp: respiration; Retro: retroperitoneal; resp dist: respiratory distress; RLQ: right lower quadrant; RR: respiratory rate; Rt: right; T: temperature °C; UA: urine analysis; UR: unremarkable; V: vomiting; Vit: vital signs; WBC: white blood cell count K/μL; y: year/s; ↑: high; ↓: low.


## 2. Case Presentation

A 35-year-old Bangladeshi man presented to the emergency department at Hamad Medical Corporation, Doha, Qatar, with two-day history of progressive right lower abdominal pain, associated with four times vomiting and loss of appetite. He was doing completely well but developed these symptoms few hours after a strong direct camel kick on his right abdomen. He did not have any urological symptoms, nor any comorbidities, and his systemic review was unremarkable.The patient was conscious and had normal vital signs. Generally, was looking well, abdominal examination showed a right lower abdominal bruise, tenderness, rebound tenderness, and involuntary guarding in the right iliac fossa. Head to toe examination showed no other signs of trauma. Laboratory tests showed high inflammatory markers (white blood cell count (WBC) 15.5 K/μL, hemoglobin 15.3 g/dL, platelets 207 K/μL, CRP: 90.5, and bilirubin: 29.1). CT abdomen with IV and oral contrast was done and showed a dilated appendix in the right iliac fossa (16 mm in diameter), with wall enhancement and periappendiceal fat stranding (Figure 1). The patient was diagnosed with acute appendicitis, and an emergency laparoscopic appendectomy was performed. Intraoperative findings showed grossly inflamed appendix with fibrinous exudate with no collection or perforation (Figure 2), and the inspected other intra-abdominal solid and hollow organs were normal. Postoperatively, the patient recovered well and was discharged one day after surgery. On follow-up 2 weeks in the clinic, he was completely healthy, wounds were healed, and histopathology confirmed the diagnosis of acute appendicitis.Figure 1
Abdomen CT scan with IV and oral contrast showing dilated appendicular tip (∗∗) and base (∗), with periappendiceal fat stranding (arrow) and enhancing wall.Figure 2
Intraoperative findings showing acutely inflamed appendix with fibrinous exudate.


## 3. Discussion

The most commonly identified cause of acute appendicitis is the luminal obstruction leading to inflammation and complications of the appendix [2]. One of the earliest well-documented reports that linked blunt abdominal trauma (BAT) with traumatic appendicitis (TA) was the Hungarian stunt performer, Harry Houdini, who used to voluntarily hit his abdomen as a show of strength, subsequently developed peritonitis due to perforated appendix and died [3]. Despite the reports on the possible relationship between BAT and appendicitis are limited (Table 1), however, many theories support this relationship [4]. Some speculated that BAT might cause inflammation by the direct impact and appendiceal injury, and others attributed it to the indirect effect, leading to increased intraluminal pressure followed by burst or intraluminal pressure induced mucosal injury resulting in hematoma/edema that will cause luminal narrowing followed by obstruction and inflammation [4].Looking at the demographic characteristics of patients who develop TA, most of the reported cases (including ours) showed male predominance, similar to nontraumatic appendicitis; however, in former, more male predominance is expected as blunt trauma is more frequent among males [5], mostly seen in pediatric age group in contrast to our case who was an adult (Table 1). A possible explanation underlying pediatric patients’ predominance is the smaller abdominal cavity, softer, and less muscular abdominal wall as compared with adults, where the transmission of energy following trauma is more significant leading to greater increase in intra-abdominal pressure, causing increased appendicular luminal pressure and thus appendicitis. Older children may represent the most sensitive age group due to the fact that they are more independent to participate in risky outdoor activities than their younger counterparts [1].Patients usually present as the classical picture of acute appendicitis with a difference of preceding trauma, developing abdominal pain within 6-48 hours following the severe blunt abdominal injury. This can be associated with other typical symptoms of acute appendicitis including nausea, vomiting, and anorexia (Table1). Our patient had abdominal pain that started few hours after the BAT, in agreement with most of other reported cases in literature.As for investigations, similar to that of nontraumatic appendicitis, blood tests usually show raised inflammatory markers and peculiar clinical signs and imaging, specifically CT scan of the abdomen, if required will confirm the diagnosis (Table1), as our patient showed leukocytosis and had features of acute appendicitis on abdominal CT scan.Diagnostic criteria for TA were postulated by Shutkin and Wetzler as follows:(1)
Absolute freedom from abdominal symptoms, including pain, nausea, vomiting, and tenderness, before the trauma(2)
Direct trauma must be severe and forcible, involving the abdominal wall and specially in the right half(3)
Indirect trauma must be violent, acute, and unexpected(4)
Symptoms must appear immediately after the trauma(5)
Symptoms must be persistent and progressive, assuming the symptoms and signs of acute appendicitis(6)
The pathologic findings must indicate a suppurative, destructive, or necrotic process [3]Our patient fulfilled all the mentioned criteria, so we regarded it as TA.As for the management, TA does not differ than nontraumatic appendicitis, with mainstay of treatment being surgical appendectomy (Table1).In terms of postoperative recovery, we noticed that patients treated for TA have relatively longer hospital stay than those with nontraumatic cause (Table1). This might be because of the accompanied injuries; in fact, some of these patients presented with polytrauma, and TA was just a part of their multisystem involvement.


## 4. Conclusions

Blunt abdominal trauma caused by a camel kick to the abdomen requires a close observation of the patients. A camel kick may increase intra-abdominal pressure and cause indirect injury to internal organs including the appendix. Therefore, abdominal pain in these patients should not be regarded as being caused solely by abdominal wall contusion, and acute appendicitis should be considered in the differential diagnosis in any patient with abdominal pain following blunt abdominal trauma.



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*Source: 6667873-2021-01-07.xml*