AIMS: To expose a case of acute abdomen due to appendicitis whose diagnosis was difficult and complicated because of the patient's profile and his comorbidities. CASE DESCRIPTION: Male patient, 52 years old, superobese, smoker and with chronic liver disease, complaining of acute abdominal pain in the right hypochondrium, vomiting and low diuresis. Initially with no signs of peritoneal irritation, the patient was medically managed, but presented worsening of clinical status, progressing to shock and cardiac arrest. The investigation by laparotomy found acute appendicitis, collateral circulation and liver cirrhosis. CONCLUSIONS: Acute abdomen has great impact on emergency care and, since it comprises several clinical situations, knowing and suspecting its main causes and its atypical presentations becomes essential, mainly in cases of difficult diagnosis.

The detectability, vascularization and size of the normal and inflamed appendix were investigated in the study. 148 patients under suspicion of appendicitis or with lower right abdominal pain were studied over a period of five months beginning in January 1998. An ultrasound-transducer was employed at a wave length of 3.5 MHz to 10 MHz. Vascularization was measured using 'Duplex' and 'Color Angio'. The results were compared with operative evidence, histology and patient history. The appendix was detected in about 30% of the cases (47/148). But of the presumably normal appendices only 12% (13/109) were detected. 27 appendices sonographically diagnosed as acutely inflamed were confirmed by operation and phlegmonic. The acute appendicitis was sonographically diagnosed with a sensitivity of 82% and a specificity of 95%. The diameter of the normal appendices was an average of 5.5 mm, that of the acute was 12.2 mm whereby 21 of 25 organs were at least 9 mm. The measurement of the organ size seems to be more helpful than the detection of vascularization. Both methods alone cannot detect the acute phlegmonic appendicitis. The normal appendix was less frequently detected than described in current literature. Patients with pain present difficulties in ultra-sound examination because both the cooperation and the time for the correct diagnosis are limited.

Hérnia interna de delgado em pós-operatório de sigmoidectomia a Hartmann Enteric internal hernia in postoperative period of Hartmann's sigmoidectomy