Duplicate appendix with acute ruptured appendicitis: a case report.

Duplication of the appendix is a rare congenital anomaly that, in adults, is most often found incidentally during surgery for other reasons. Appendicitis in the duplicated appendix is very rare and has been reported less than 10 times in the medical literature. We describe a 33-year-old woman with worsening periumbilical pain, nausea, vomiting, and fever. Physical examination showed localized peritonitis in the right lower quadrant. She had an elevated white blood cell count with neutrophilia. Computed tomography showed acute ruptured appendicitis. Diagnostic laparoscopy showed 2 appendices attached via separate bases to a single cecum with no other concurrent anomalies. Both appendices were removed laparoscopically. Histopathology confirmed normal appendiceal tissue in one and severe acute transmural appendicitis in the other. Awareness of appendiceal duplication and a thorough intraoperative inspection are critical to assess the presence of significant associated anomalies and avoid life-threatening complications.

Surgical and nonsurgical management of gallstones.

Cholelithiasis, or gallstones, is one of the most common and costly of all the gastrointestinal diseases. The incidence of gallstones increases with age. At-risk populations include persons with diabetes mellitus, persons who are obese, women, rapid weight cyclers, and patients on hormone therapy or taking oral contraceptives. Most patients are asymptomatic; gallstones are discovered incidentally during ultrasonography or other imaging of the abdomen. Asymptomatic patients have a low annual rate of developing symptoms (about 2% per year). Once symptoms appear, the usual presentation of uncomplicated gallstones is biliary colic, caused by the intermittent obstruction of the cystic duct by a stone. The pain is characteristically steady, is usually moderate to severe in intensity, is located in the epigastrium or right upper quadrant of the abdomen, lasts one to five hours, and gradually subsides. If pain persists with the onset of fever or high white blood cell count, it should raise suspicion for complications such as acute cholecystitis, gallstone pancreatitis, and ascending cholangitis. Ultrasonography is the best initial imaging study for most patients, although additional imaging studies may be indicated. The management of acute biliary colic mainly involves pain control with nonsteroidal anti-inflammatory drugs or narcotic pain relievers. Oral dissolution therapy is usually minimally successful and used only if the patient cannot undergo surgery. Laparoscopic cholecystectomy remains the surgical choice for symptomatic and complicated gallstones, with a shorter hospital stay and shorter convalescence period than open cholecystectomy. Percutaneous cholecystostomy is an alternative for patients who are critically ill with gallbladder empyema and sepsis.