Vol.3, No.2, 116-1 17 (2011) Health
doi:10.4236/health.2011.32021
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Delayed treatment of appendectomy that causes
systemıc inflammatory response syndrome: a rare
complication
Ayten Saracoglu1, Kemal Tolga Saracoglu1*, Belkis Aylu2, Vural Fidan3
1Department of Anesthesiology and Reanimation, Central Education and Research Hospital, Erzurum, Turkey;
*Corresponding Author:
2Department of General Surgery, Central Education and Research Hospital, Erzurum, Turkey;
3Department of Ear Nose Throat, Central Education and Research Hospital, Erzurum, Turkey.
Received 30 November 2010; revised 23 January 2011; accepted 25 January 2011.
ABSTRACT
When acute appendicitis is present and lately
treated, further complications will occur against
patients. This case report describes an unusual
presentation of acute appendicitis in a young
patient and demonstrates a unique late compli-
cation of perforated appendicitis. A 15 year old
female acute appendicitis patient had lapara-
tomy accompanied systemic inflammatory re-
sponse syndrome (SIRS) symptoms. After treat-
ment of 6 days in the intensive care unit (ICU),
the patient was healed. We emphasize the im-
portance of early treatment for acute appen-
dicitis and septic complications.
Keywords: Sepsis; SIRS, Apendectomy; Apses;
Complication
1. INTRODUCTION
Acute appendicitis may become life threatening if it is
complicated by retroperitoneal abscess. The mortality
rate is 16.7% and deaths are mostly caused by profound
sepsis [1]. The initial leakage of endogenous gastrointes-
tinal microflora into the peritoneal cavity results in peri-
tonitis and secondary septicemia, which often results in a
localized intraabdominal abscess [2]. The American
College of Chest Physicians defined the criterias of SIRS
in the consensus conference for sepsis and organ failure.
Patients present with two or more of the following crite-
rias [3]:
1) Body temperature (T) > 38.3˚C or < 36˚C
2) Heart rate > 90 beats/minute
3) Frequency of breathing > 20/min or PaCO2 < 32
mm Hg
4) Leukocyte count or immature-to-total (I/T) ratio >
12.000/mm3 or < 4.000/mm3, > 10% immature (band)
cells
We report a case in which the patient was wrongly
diagnosed and SIRS came into existance.
2. CASE REPORT
A 15 year old female patient applied to the village
clinic with symptoms of diarrhea and tummyache. Her
medical history was unremarkable. She was diagnosed
as urinary tract infection and gastroenteritis and was told
to take nidazolam tablet and nonsteroidal antiinflamma-
tory drug in her prescription. At the end of 7th day, she
came back to the same clinic with again tummyache
together with nausea and vomiting. Abdominal disten-
tion and fever of 38.4˚C were determined in her physical
examination. Later, the patient was admitted to the
emergency clinic of Central Education and Research
Hospital. She was hospitalized in internal medicine ser-
vice. Because the evidences of abdominal distention,
nausea and vomiting, diarrhea and weight loss of 5 kg
did not regressed, she was examined by general surgery
in the 3rd day. In physical examination, the patient was
apathetic, uncooperative, disoriented, her Glasgow
Coma Scale was 9, temperature (T) 39.8˚C, heart rate
(HR) 150 beat/min, arterial tension (TA) 60/30 mmHg,
dry and crusty oral mucosa, sinus tachycardia in elec-
trocardiogram, tachypnea, respiratory rate (RR) 40/min,
41.5% hematocrit value and white blood cell (WBC)
value was 31700. She was accepted to the operation
room urgently under the prediagnosis of mechanical
intestinal obstruction by malignant tumour. After median
incision, edematous intestines with patchy cohesive-
nesses were watched over. The purulent volume of 2000
cc was aspired from the abdominal cavity. As median
perforation of appendicitis was determined, appendec-
tomy was applicated. The operation took 2 hours time.

K. C. Chou et al. / Health 3 (2011) 116-117
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
117117
Due to the central venous pressure (CVP) measurements,
liquid replacement was administered by colloid and
christalloid solutions. She was accepted to the ICU with
the diagnosis of SIRS postoperatively. The postoperative
values were: TA:80/60 mmHg, HR:147 beat/min, oxy-
gen saturation (SpO2): 91%, Sodium: 128 mEq/L, Po-
tassium:2.7 mEq/L, Glucose: 222 mg/dL, ıonized cal-
cium: 0.59 mmol/L, Albumin: 1.5 g/dL, Direct bilirubin:
0.38 mg/dL, Total protein:3.2 g/dL, Hb: 12.8 g/dL,
Platelet: 465000/microL WBC: 34800/microL, T: 38.2˚C.
The patient was in respiratory distress with RR of 32/
min and Forced vital capacity: 55%, Forced expiratory
volume in 1st minute: 58%. The blood gase: pH: 7.38,
Partial pressure of carbon dioxide (pCO2): 26.1 mmHg,
Partial pressure of oxygen (pO2): 70.3 mmHg Bicarbon-
ate (HCO3): 15.5 mEq/l Base excess (BE): -7.6 Lactate:
1.2 mg/dL SpO2: 93.8%. She had oxygene support with
8 lt/min by facemask. Hyponatremia and hypocalemia
treatment, antibioteraphy, colloid and cristalloid re-
placement, total parenteral nutrition, cristallysed insuline
theraphy was put in order. Non-invasive mechanical
ventilation was provided by using facemask. On the
second postoperative day, the haemodynamic parameters
did not differ but pCO2 was 28.7 mmHg, pO2 was 101.2
mmHg and CVP was +2 mmH20. The abdominal Com-
puterized Tomography (CT) findings were normal in the
4th day and she was dramatically healed during the fol-
lowing days. Orally feeding was started in the 5th day
and at the end of the 6th day the patient was discharged
from the ICU. WBC value in 8th day was 22800/microL
and in 12th day it was 15700/microL.
3. DISCUSSION
A significant number of complications for acute ap-
pendicitis develop due to delayed or even missed diag-
nosis. Complicated appendicitis includes perforation of
the appendix, empyema or abscess formation [4]. As
Nozoe et al. attracted attention on SIRS score to deter-
mine the surgical indication for acute appendicitis, this
score could be useful as objective and auxiliary informa-
tion [5]. On the other side, unnecessary appendectomy
carries long-term risks for the patient [6]. The impor-
tance of complex therapy should be considered. Both
surgical and postoperative intensive cares are consider-
able. Additionally, collaboration between surgeons and
anesthesiologists is remarkable [7]. Septic pylephlebitis
or wound infection has been also reported after perfo-
rated retrocecal appendicitis [8,9]. CT might be an ad-
vantage for physicians in preoperative evaluation [10].
The patient that we report in this case did not need en-
dotracheal intubation. Non-invasive mechanical ventila-
tion by facemask was enough so, the patient was not
face to face for the complications of invasive ventilation
therapy. This result occured as a benefit of early reha-
bilitation in the ICU. Acute apendicitis must be diag-
nosed by talented physicians without wasting time.
Lateness in operation decision combines the rudiments
of pathway that extends from perforation to septic in-
tramural abcesses [11].
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