Nematode as a Cause of Appendicular–Cutaneous Fistula

Abstract

In the operation, we found that expanded appendix was perforated from its distal part and was stulized to the right lateral abdominal wall. The complications of postoperative was intestinal stula.
Colonoscopy was performed revealing some nematode around the appendiceal ori ce. The development of stula after bowel resection and anastomosis can be devastating. Immediate drainage and establishment of enteral nutrition can lead to spontaneous healing of stula.

Conclusions
Testing for nematode infection in a patient with suspected appendicitis is not routine, it still stands as a challenge in clinical practice. In view of this situation, killing parasites is necessary, otherwise it is di cult to cure.

Main Text
The patient was a 75-year-old man whose chief complaint was right lower quadrant intermittent dull pain for one year, drainage of purulent secretion through a ori cium stula in right regio abdominalis lateralis for one month before admission. His medical history was unremarkable. Abdominal magnetic resonance scan was performed and revealed abnormal signal from the iliac fossa to the right regio abdominalis lateralis in Figure 1A.Therefore, a presumptive diagnosis of appendicitis with cutaneous stula was made. During exploration, expanded appendix was seen, which was perforated from its distal part and was stulized to regio abdominalis lateralis. Open appendectomy was performed and the stump was buried routinely. Appendicular-cutaneous stula was resected and then the area was left open for secondary healing. A stump drain was put in the appendectomy eld. The histological examination of the removed appendix and stula showed chronic in ammation. There were no nematodes identi ed at that stage.On the third postoperative day,a small amount of fecal material and gas was drawn out through the drainage with no abdominal pain and fever. A emergency colonoscopy was performed revealing some nematode around the appendiceal ori ce shown in Figure 1B surprizingly. Due to the local action of nematodes on the stump, the closure of appendix stump failed, partial resection of the intestinal and the insertion of mebendazole into lumen were performed.The patient was discharged with a course of antihelminthics and recoveried uneventfully.Appendectomy is amongst the most common general surgical procedures performed. One critical part of this procedure is effective closure of the appendix stump to prevent catastrophic intra-abdominal complications from a fecal leak into the abdominal cavity. The formation of a post-appendicectomy stula is rare but devastating. Major etiological factors include leakage from the appendiceal stump, neoplasm of the appendix or cecum,infection, in ammatory bowel disease, and distal obstruction. The management of enterocutaneous stula involves enteral nutrition, drainage, antibiotic coverage, as well as surgical excision and segmental resection of the involved bowel.
Prolonged intrabdominal infection can lead to enterocutaneous stula, chronic bowel obstruction, sepsis, and even death [1]. Some refractory stulas may need surgical repairment [2]. Cutaneous stula may develop spontaneously as a complication of an perforating appendicitis [3]. However, intestinal stula caused by parasites is a rare report.The development of stula after bowel resection and anastomosis can be devastating. Immediate drainage and establishment of enteral nutrition can lead to spontaneous healing of stula [4].Testing for nematode infection in a patient with suspected appendicitis is not routine, it still stands as a challenge in clinical practice. In view of this situation, killing parasites is necessary, otherwise it is di cult to cure.

Declarations
Ethics approval and consent to participate The datas in terms of ethics approval and patient informed consent are in compliance with the relevant provisions of the Medical Ethics Committee.

Consent for publication
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editors-in-Chief of this journal.
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