P2335 - A Rare Case of Amyand’s Hernia Presenting as Acute Uncomplicated Appendicitis

Award: Presidential Poster Award

Award: Presidential Poster Award

Samuel C. Purkey, DO, Jacob DePolo, MD, Mark Anderson, MD
University of Tennessee Medical Center, Knoxville, TN

Introduction: Inguinal hernias account for approximately 75% of abdominal hernias. Amyand’s hernias, inguinal hernias with the vermiform appendix within the hernia sac, are exceedingly uncommon at 1% of reported inguinal hernia cases. We present a rare case of an Amyand’s hernia presenting as acute uncomplicated appendicitis.

Case Description/Methods: We present a 68-year-old male with complaints of back and abdominal pain. He noted weakness and tarry stools. On exam, there was moderate abdominal discomfort with a right inguinal hernia. Labs revealed a leukocytosis of 17.9K/uL, hemoglobin of 7.0g/dL, and hematocrit of 19%. Computed tomographic imaging of the abdomen revealed diverticulosis without diverticulitis. The appendix extended into a right inguinal hernia with mild fat stranding and fluid at the base of the hernia raising concern for early acute appendicitis (Image 1,2,3,4). He was admitted and initiated on empiric cefepime, proton pump inhibitors, and fluids with 2 units of packed red blood cells.

General surgery evaluated the patient, and the hernia was reduced at bedside. The patient’s pain and leukocytosis improved. Given the improved clinical picture, he was a candidate for outpatient follow-up to discuss repair of his symptomatic Amyand’s hernia with resolving uncomplicated appendicitis. Gastroenterology performed upper and lower endoscopies revealing no stigmata of recent bleeding to explain his anemia and melena. The appendiceal orifice was visualized without significant findings of complicated appendicitis (Image 5). He was discharged with plans to follow-up with general surgery and gastroenterology.

Discussion: The incidence of Amyand’s hernia in literature has ranged from 0.19-1.7% of reported inguinal hernias. Rarer, the incidence of associated appendicitis is estimated at 0.07–0.13%. Patients can present asymptomatic or with pain, nausea, and a palpable mass in the groin. Complications include appendicitis, perforation, and abscess formation. With a reported mortality rate up to 14-30%, sepsis remains the leading cause of death in complicated cases. No consensus has been made on the optimal approach to management. Surgery remains the mainstay of therapy. The Losanoff and Basson classification was developed to guide management (Table 1). Although the incidence is low, it remains an important differential, as patients may experience life-threatening complications if not identified and treated appropriately with early intervention and consideration for surgical correction.


Figure: Image 1: Sagittal CT image demonstrates and indirect right inguinal hernia containing the vermiform appendix with adjacent inflammatory straining. Additionally, a small amount of free fluid can be seen at the base of the hernia sac.
Image 2: Coronal CT image demonstrates an indirect right inguinal hernia containing the vermiform appendix with mild adjacent inflammatory stranding.
Image 3: Axial CT image demonstrates free fluid at the base of the hernia sac just inferior to the base of the appendix (outside of the field of view).
Image 4: Axial CT image demonstrates an indirect right inguinal hernia containing the vermiform appendix with mild adjacent inflammatory stranding.
Image 5: Endoscopic evaluation and visualization of the appendiceal orifice.

Losanoff and Basson Classification	Management
Type 1: Normal appendix within the inguinal hernia	Reduction of the inguinal hernia +/- mesh repair
Type 2: Acute appendicitis without associated complications	Appendectomy with primary repair of hernia without mesh
Type 3: Acute appendicitis with associated complications	Laparotomy, appendectomy, and primary repair without mesh
Type 4: Acute appendicitis with other associated abdominal pathology	Managed as a type 2 or 3 while investigating the associated abdominal pathology

Table: Losanoff and Basson classification of Amyand's Hernia


Disclosures:
Samuel Purkey indicated no relevant financial relationships.
Jacob DePolo indicated no relevant financial relationships.
Mark Anderson indicated no relevant financial relationships.


Samuel C. Purkey, DO, Jacob DePolo, MD, Mark Anderson, MD. P2335 - A Rare Case of Amyand’s Hernia Presenting as Acute Uncomplicated Appendicitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.