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Appendicitis Mimicking Torsion of Left Testis
Girish D Bakhshi*, Yogesh S Puri**, Tarun Singhal**
 

Appendicitis within an Amyand’s hernia is rare; when it occurs it is often misdiagnosed as a strangulated inguinal hernia. This is more common on right side. Acute appendicitis is a rare cause of acute left inguinal pain in a cryptorchid patient with hernia. We present a case report of 23 year old male who presented to us with acute pain due to inflamed appendix in the left hernial sac mimicking torsion of testis.

Introduction
Claudius Amyand, surgeon to King George II,
performed the first recorded appendicectomy in 1736. The patient, an 11 year old boy, had a perforated appendix within an inguinal hernia.1 This was seen in right inguinal hernia. Thus the presence of an appendix in an inguinal hernia became known as ‘Amyand’s hernia’. The term Amyand’s hernia is used in varying situations. Authors have referred to Amyand’s hernia as the occurrence of an inflamed appendix within an inguinal hernia,2 as a perforated appendix within an inguinal hernia,1 or when a non-inflamed appendix is present within an irreducible inguinal hernia. The latter is similar to other herniae named according to the containing organ. Appendix in a hernial sac is mostly present in right side inguinal hernias, however, inflamed appendix present in left inguinal hernia is a rarity. Moreover a patient with bilateral undescended testis with inguinal hernia presenting as pain in hernia the diagnosis of strangulated hernia or torsion testis is considered.

We present a case of left inguinal hernia in a patient with bilateral undescended testes containing inflamed appendix mimicking torsion testis.

Case Report
A 23 year old male presented with bilateral inguinal swelling since childhood and acute pain in the left inguinal swelling since 1 day along with vomiting. Clinical examination revealed bilateral inguinal hernia with bilateral undescended testis and perineal hypospadias. Right inguinal hernia was reducible whereas left hernia was tender and partially reducible. Abdomen was soft. In view of acute pain and undescended testis diagnosis of torsion testis was made. Patient was explored through inguinal incision after taking consent of orchidectomy. Operative findings revealed inflamed appendix in the hernial sac along with omentum and small bowel (Fig. 1). Testis was present and was soft and small in size with no ischaemic changes.

Appendicectomy was done for appendicitis. As testis was atrophied and patient was 23 year old, hence, orchidectomy was done. Modified Bassini’s Herniorrhaphy was done. Post operative recovery was uneventful. Patient was discharged after suture removal on day 8. Barium study was done after six weeks for academic interest which showed mobile caecum and ruled out situs inversus or intestinal malrotation. Patient was later referred to urology for hypospadias correction.

Fig. 1 : Intra-operative findings showing inflamed appendix in the left hernial sac along with omentum, bowel and undescended testis with catheter in perineal hypospadias.

Discussion
Acute appendicitis is rarely included in the differential diagnosis of acute pain in left inguinal hernia. The incidence of appendicitis within an incarcerated hernia is indeed rare, being 0.13%.3 Amyand’s hernia is reported in infants4 even as young as six weeks. Majority of the times appendix is present in right side inguinal hernias. Clinical presentation is variable, and influenced by the presence of inflammation of the appendix and peritoneal contamination. It must be considered in an irreducible inguinal hernia as well as in the differential diagnosis of an acute scrotum. It may be mistaken for a strangulated hernia2 or torsion of the testis,4 and may present as a scrotal fistula or an abscess of the abdominal wall.3 Tenderness over McBurney’s point is likely to be absent. In our case there was no tenderness over McBurney's point. In our case in view of undescended testis, torsion testis was suspected. Appendicitis being a cause of pain with scrotal mass has been reported in infants5 but not in adults. Preoperative CT scans have been used to diagnose the condition,3 but data on the reliability of imaging are scant. Caecum and appendix present in the left inguinal hernia can be seen in situs inversus, intestinal malrotation or mobile caecum. Barium study in our case ruled out situs inversus and intestinal malrotation. Hence mobile caecum was the cause of appendix in left inguinal hernia in our case. Surgical procedure used depends on the pathology found. If the peritoneal cavity is uncontaminated it must be protected from contamination. Introducing a foreign material to a contaminated field has its dangers. It has been reccommended to repair without using synthetic mesh.2 In our case herniorrhaphy was done.

This case highlights that acute appendicitis in left inguinal hernia in presence of undescended testis can mimick torsion testis. Though, this is seen in infants,4,5 presentation in adults has not been reported. Our case also had hypospadias, hence in a patient with bilateral undescended testis and perineal hypospadias, there can be a mobile caecum with appendix in a hernial sac which should be kept as a differential diagnosis.

References

  1. Amyand C. Of an inguinal rupture, with a pin in the appendix caeci incrusted with stone; and some observation on wounds in the guts. Phil Trans R Soc Lond 1736; 39 : 329-42.
  2. Luchs JS, Halpern D, Katz DS. Amyand’s hernia : prospective CT diagnosis. J Computer Assisted Tomography 2000; 24 : 884-6.
  3. House MG, Goldin SB, Chen H. Perforated Amyand’s hernia. Southern Medical Journal 2001; 94 : 496-8.
  4. Ibrahim AHM, Al-Malki TA, Morad N. Scrotal appendicitis mimicking acute testicular torsion in a neonate http://www.kfshrc.edu.sa/annals/201/99-094.htm.
  5. Alvear DR, Rayfield MM. Acute appendicitis presenting as a scrotal mass. J Pediatr Surg 1976; 11 : 91-2.

TREATING LOW BACK PAIN

Despite a great deal of effort in the past decade, most of the treatments for low back pain have been ineffective or at best marginally effective. Most cases resolve regardless of the course of therapy, and some do not get better no matter what is done. Therein lies the problem for practitioners, patients, and policymakers.

“Brief pain management techniques delivered by appropriately trained clinicians offer an alternative to physiotherapy incorporating manual therapy, and could provide a more efficient first-line approach for management of non-specific subacute low back pain in primary care”.

Lancet, 2005; 365 : 1987-88.

ACUPUNCTURE CUTS DAYS WITH TENSION-TYPE HEADACHE

Acupuncture for tension-type headache is more effective than being on a waiting list, but no more effective than minimal acupuncture. People receiving acupuncture had significantly fewer days with a headache than those on the waiting list, but the difference compared with people receiving minimal acupuncture did not reach significance. Acupuncture was well tolerated, and improvements lasted several months after cessation of treatment.

BMJ, 2005; 331 : 376.

*Lecturer; **Resident, Department of Surgery, Grant Medical College and Sir JJ Group of Hospitals,
Mumbai 400 008.