Synchronous presentation of acute cholecystitis and acute appendicitis successful treatment in one step laparoscopic procedure. A case series and literature review

Abstract

Introduction Hundreds of thousands of cholecystectomies and appendectomies are performed in the United States annually. Due to the prevalence of cholecystitis and appendicitis, a subset of patients will require both operations. The limited literature describing these patients supports a laparoscopic approach over open surgery; consistent with the advantages of laparotomy over open surgery in the treatment of each condition individually. Case presentation We report two cases where a patient presented with cholecystitis and appendicitis simultaneously. An abdominal computer tomography (CT) scan revealed the presence of the two diagnoses, which was then confirmed by an abdominal ultrasound. A four-access port was utilized for simultaneous appendectomy and cholecystectomy. Discussion A review of the literature indicates that simultaneous infection with appendicitis and cholecystitis is rare, and thus clinical presentation, lab work, and imaging studies are all needed to support such a diagnosis. Potential findings on imaging in these patients may include distended gallbladder with thickened wall and fluid-filled dilated appendix with mural enhancement. In the event that both clinical presentation and further work-up indicate both pathologies, laparoscopic intervention is suitable. A four-access port is deemed the conservative approach to dealing with such cases. Conclusion Finding a single diagnosis responsible for a patient's illness is a high priority in an acute care setting, a concept known as diagnostic parsimony. However, it is inevitable that very common illnesses will be comorbid in a subset of patients, and physicians should be prepared to consider contemporaneous illness in the isolated circumstances it is warranted.

Synchronous Acute Appendicitis and Acute Cholecystitis

“…Each pathology has characteristic findings on the physical examination; for example, McBurney’s, Rovsing’s, and Blumberg’s signs are regularly present in acute appendicitis as Murphy’s sign is in acute cholecystitis. However, their absence does not exclude the diagnosis, especially when pain limits eliciting these signs as in our patient [ 3 , 6 ].…”

“…According to the literature, patients with those two simultaneous conditions are difficult to evaluate in the emergency room. They generally present with right upper quadrant pain and right-sided or diffuse abdominal tenderness, so it can be challenging to reach a high level of suspicion based on the clinical picture alone [ 3 , 5 ]. Each pathology has characteristic findings on the physical examination; for example, McBurney’s, Rovsing’s, and Blumberg’s signs are regularly present in acute appendicitis as Murphy’s sign is in acute cholecystitis.…”

“…Abdominal CT scan has led to reduce false negatives for appendicitis and decrease misdiagnoses. In terms of cholecystitis, a sonogram is preferred over CT as approximately 8% of gallstones are isodense to the surrounding bile [ 3 ]. Still, ultrasonography is operator-dependent.…”

“…Both are among the most common pathologies in general surgical practice, although their synchronous presentation in a single patient is rare. It is important to consider the possibility of this double diagnosis, especially in patients who present with acute abdominal pain that is ambiguous, and when the anamnesis and physical examination suggest a mixed picture [ 3 ].…”