Case Report

Complicated acute appendicitis? An unusual differential

Tropical Doctor 2015, Vol. 45(1) 49–51 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0049475514550064 tdo.sagepub.com

Shamir O Cawich1, Dale Hassranah2, Suresh Pooran2, Dilip Dan2 and Vijay Narayansingh3

Abstract Acute appendicitis is a common surgical diagnosis but several differential diagnoses exist and should be considered. Internal concealment is one such diagnosis. We present a case of a young man taken to the operating room with a preoperative diagnosis of complicated acute appendicitis. A ruptured caecum was encountered and several free-floating drug pellets were present. Attending doctors should consider this differential in the high prevalence areas and, whenever encountered, they should strongly consider early reporting.

Keywords Appendicitis, packer, drug, complicated, surgery

Introduction Acute appendicitis is a common surgical diagnosis across the globe. The lifetime risk to develop acute appendicitis is estimated to be 6.7% in women and 8.6% in men.1 Appendectomy remains the standard treatment for acute appendicitis2 but several differential diagnoses exist and should be considered. We present a case in which we encountered an unusual differential for complicated acute appendicitis.

Case Report A 28-year-old man complained of right lower quadrant abdominal pain and fever for 72 h duration. Upon examination he was mildly dehydrated and pyrexic at 37.7 C. Significant findings were limited to the abdomen that was mildly distended. There was tenderness with peritonitis at the right lower quadrant and suprapubic region. Blood results revealed a white cell count of 16  109/L, amylase levels at 33 IU/L and normal electrolyte levels. He was diagnosed with acute complicated appendicitis and taken to the operating room after a brief period of resuscitation. Due to the presence of peritonitis, he was prepared for laparotomy without further abdominal imaging. At operation, the abdomen was explored through a lower midline incision. A total of 150 mL of bilious

material and several foreign bodies were evacuated from the peritoneal cavity (Figure 1). The ileum was markedly distended and there was a 2 cm perforation noted at the ileum approximately 1 foot proximal to the ileo-caecal valve. Several more capsules were milked across the perforation and evacuated. The edges of the perforation were debrided and closed primarily. The abdomen was closed after peritoneal lavage. Owing to the unexpected findings, the authorities were only summoned after the operation. However, prior to their arrival a few hours later, the patient absconded from hospital. Further examination of the capsules revealed that they contained cannabis. The patient was never located.

1 Hepatobiliary Surgeon, Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad & Tobago 2 Consultant Surgeon, Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad & Tobago 3 Professor of Surgery, Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad & Tobago

Corresponding author: Shamir O Cawich, Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad & Tobago. Email: [email protected]

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Figure 1. An intraoperative photograph. The collecting dish contains foreign bodies unexpectedly encountered in the peritoneal cavity at laparotomy.

Discussion This man presented with a clinical picture suggestive of complicated acute appendicitis. He never divulged the history of internal concealment, even after consenting to an operation. Although we were surprised by the operative findings, in retrospect it is well known that these patients are deceptive historians.3 He was engaging in the practice of internal concealment, also called body packing. This refers to smugglers’ ingestion of illicit drugs for human transportation.4 Upon arrival at their destination, smugglers are usually given laxatives, cathartics or enemas in an attempt to expedite delivery of their cargo.3,4 International literature suggests that young single women are the most common perpetrators4–6 but the demographics in the Caribbean have changed, where more young men in their 30s are becoming smugglers.7 Although it is illegal in the Caribbean,8 the practice of body packing is relatively common because there is a large population of impoverished people and high unemployment rates.3,6,7 These smugglers can earn significant sums of money,3,4,6,7 with estimated rewards of up to US $10,000 for each successful trip.7 The most common drugs for smugglers to transport are heroin and cocaine.3–5 Cannabis body packing is less common because the profit margins are smaller9,10 and because many consider cannabis to be a ‘soft drug’ without significant harmful effects.8 This practice is potentially dangerous because systemic drug absorption may lead to acute toxicity and overdose.3–5 Toxicity occurs when the packages rupture, suddenly exposing large amounts of drug to the absorptive gut mucosa. In this era, however, we have been

encountering more robust packaging with industrialtype polymers being utilised. Since these packages are much less likely to rupture, acute toxicity has become a less common presentation. Close inspection of Figure 1 reveals the detail of typical second-generation packaging that has become commonplace in our clinical experience. More commonly, ingested packages become impacted causing mechanical bowel obstruction,3,4 followed by perforation, intra-abdominal sepsis and even death.10–12 East et al.6 previously reported that 65% of body packers in the Caribbean required operation for bowel obstruction, making it the commonest presentation. This occurs when pellets become impacted at the narrowest points in the gastrointestinal tract: the pylorus and ileo-caecal valve. Pellets that cannot pass the pylorus are retained in the gastric lumen that functions as a reservoir. But pellets unable to navigate the ileocaecal valve accumulate in the smaller-diameter ileum, potentially leading to contact-erosion through the wall. Additionally, constant peristaltic bombardment at the terminal ileum produces high intra-luminal pressures just proximal to the ileo-caecal valve. The high intraluminal pressure combined with the contact-erosion effect on relatively small-diameter terminal ileum sets the stage for perforation. This explains why 63% of perforations occur within the last few feet of the terminal ileum,6 as seen in this case. This patient had mechanical bowel obstruction with perforation that required an urgent laparotomy. As he met the threshold for exploration with peritonitis across the lower abdomen, no further preoperative imaging was pursued. In Western countries well-endowed with CT scanners, preoperative scans may have been requested but in many Caribbean countries where the practice of body packing is common, these advanced imaging modalities are not readily available in the public healthcare delivery systems. Furthermore, up to March 2014 there was no existing legislation in any Caribbean country to mandate the use of cross-sectional imaging in these cases. Most commonly, the diagnosis is made on plain radiography that reveals well-defined homogenous radio-dense packages in 80–90% of cases.3,13 Abdominal ultrasound may also be performed but is less sensitive than plain radiographs, correctly detecting 58% of proven packers who were asymptomatic on presentation.13 This patient required urgent laparotomy to control contamination and repair the perforation, but the diagnosis of internal concealment was unexpected. Therefore, law enforcement agents were not alerted preoperatively and this afforded the patient an opportunity to abscond from hospital early in the recovery period. Although the Health Insurance Portability and

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Accountability Act (Public Law 104-191) in the United States mandates reporting of these crimes to the authorities,14 there is no comparable legislation in Caribbean countries to mandate reporting.15 The decision to report to law enforcement is left to the attending medical teams.15 Admittedly, there was delay reporting this case to the authorities because the medical team was concerned that the patient was aware of their identity. This exposes the risk to the medical team when legislation to guide their actions is absent. On the other hand, there is also danger when cases go unreported because there is now the problem of handling the extracted drug. In some facilities hospital security officers confiscate the drug and they are handed to and disposed of by a pharmacist.6 Apart from the legal implications of handling drugs, there is also the danger of reprisal from the drug lords.3 This is not difficult to appreciate considering the enormous street value that these illegal drugs can fetch in developed countries.3,4,16

Conclusion Acute appendicitis is a common surgical diagnosis but there are several differential diagnoses that should be considered. Internal concealment is one such diagnosis. Attending doctors should consider this differential in the high prevalence areas and, whenever encountered, they should strongly consider early reporting. Declaration of conflicting interests None declared.

Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

References 1. Addiss DG, Shaffer N, Fowler BS and Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 1990; 132: 910–925. 2. Li X, Zhang J, Sang L, et al. Laparoscopic versus conventional appendectomy–a meta-analysis of randomized controlled trials. BMC Gastroenterol 2010; 10: 129.

3. Cawich SO, Williams EW, Evans NR and Johnson P. Occupational hazard: treating cocaine body packers in Caribbean countries. Int J Drug Policy 2008; 20: 377–380. 4. Traub S, Hoffman RS and Nelson LS. Body packing–the internal concealment of illicit drugs. N Engl J Med 2003; 26: 2519–2526. 5. Jill JR and Graham SM. Ten years of ‘‘body packers’’ in New York City: 50 deaths. J Forensic Sci 2002; 47: 843–846. 6. East JM. Surgical complications of cocaine body packing: A survey of Jamaican hospitals. West Ind Med J 2005; 54: 38–41. 7. Cawich SO, Valentine C, Evans NR, Harding HE and Crandon IW. The changing demographics of cocaine body packers in Jamaica. Int J Forensic Sci 2009; 3: 5. 8. Jefferson DA, Harding HE, Cawich SO and JacksonGibson A. Postoperative analgesia in the Jamaican cannabis user. J Psychoactive Drug 2013; 45: 227–232. 9. Soriano-Perez MJ, Serrano-Carrillo JL, Marin-Montin I and Cruz-Caballero A. Hashish body packing: a case report. Case Rep Med 2009; 712573: 1–3. 10. Cawich SO, Downes R, Martin AC, Evans NR, Mitchell DIG and Williams EW. Colonic perforation: a lethal consequence of cannabis body packing. J Legal Forensic Med 2010; 17: 269–271. 11. Barnett J and Codd G. Sudden, unexpected death of a cannabis body packer due to perforation of the rectum. J Clin Forensic Med 2002; 9: 82–84. 12. Hutchins KD, Pierre-Louis PJ, Zaretski L, Williams AW, Lin RL and Natarajan GA. Heroin body packing: three fatal cases of intestinal perforation. J Forensic Sci 2000; 45: 42–47. 13. Hierholzer J, Cordes M, Tantow H, Keske U, Maurer J and Felix R. Drug smuggling by ingested cocaine-filled packages: conventional X-ray and ultrasound. Abdominal Imaging 1995; 20: 333–338. 14. Kreismann E, Gang M and Goldfrank LR. The interface: Ethical decision making in medical toxicology and emergency medicine. Emerg Med Clin North Am 2006; 24: 769–784. 15. Cawich SO, Williams EW, Simpson LK, Evans NR and Johnson P. Treating cocaine body packers: The unspoken personal risks. J Forensic Legal Med 2008; 15: 231–234. 16. Khan FY. The cocaine ‘body packer’ syndrome: diagnosis and treatment. Ind J Med Sci 2005; 59: 457–458.

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Complicated acute appendicitis? An unusual differential.

Acute appendicitis is a common surgical diagnosis but several differential diagnoses exist and should be considered. Internal concealment is one such ...
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