Melena Post-laparoscopic Appendicectomy—One of a Kind: A Rare Case Report

INTRODUCTION

Appendicectomy can be done by open or laparoscopical approach, and is the commonest surgery performed with a very minimal complication rate.¹

The postoperative complications are quite rare, with a mean rate of 4.6 and 3.3%, respectively, which are intra-abdominal abscesses, stump leakage, stump appendicitis, surgical site infections, seromas, wound rupture, intestinal damage, medical complications, small-bowel obstruction due to the formation of adhesions, and paralytic ileus.²

Though cases with rectal bleeding post appendicectomy had been reported in the literature, melena post appendicectomy is one kind of complication as melena as a cause of lower intestinal bleed is itself a rare complication.³

In this article, we had discussed about melena that occurred post laparoscopic appendicectomy in a young male patient and its management.

CASE DESCRIPTION

A 28-year-old male with no known comorbidities or past surgical history, came to the surgical outpatient department with complaints of right lower abdominal pain, pricking type of pain, intermittent, and no aggravating or relieving factors. He also complained of 2 episodes of vomiting containing food particles, non-bilious, and non-blood-tinged. History of fever, 1 episode, low grade, not associated with chills or rigors, resolved spontaneously. On examination, the abdomen was soft, tenderness present over the right iliac fossa, with rebound tenderness, bowel sounds heard, and hernial orifices free. No significant findings in per-rectal examination following which ultrasound abdomen was suggestive of acute appendicitis. After routine investigations, the patient was taken up for laparoscopic appendicectomy under general anesthesia. Intraoperative inflamed appendix was found in the right iliac fossa. Histopathology of the specimen shows an appendix with mucosal ulceration. Lamina propria shows dense inflammatory composed predominantly of lymphocytes and eosinophils extending up to the muscularis propria. Serosa shows congested blood vessels (Fig. 1).

The patient on postoperative second day complained of pain, black-colored stools suggestive of melena following which UGI scope showed normal study and CECT abdomen was taken, which showed postoperative inflammatory changes in the form of mild bowel-wall enhancement, mesenteric fat stranding, and minimal interbowel-free fluid at the ileocecal junction in the right iliac fossa. No obvious arterial bleed or pseudoaneurysms were noted. Mild post-op arterial phase blush near the post-op region was seen which might be suggestive of source of melena (Fig. 2).

Melena post appendicectomy is one of the rarest complications. Only a handful number of cases have been reported about lower GI bleed post appendicectomy as mentioned by Koimtzis et al.,⁴ but melena post appendicectomy had never been reported in literature. In our case, upper gastrointestinal bleeding was ruled out as the cause of melena by upper GI endoscope. CECT abdomen ruled out any active bleed in the abdomen or peritoneal collection, which would have caused melena. As other causes are ruled out, the probable cause of melena in our case would be stump bleed where the patient was closely monitored, where the symptoms resolved spontaneously after 5 days. Colonoscopy can also be considered if the patient develops the complication at a later stage.

CONCLUSION

In summary, we have presented a very unusual case of melena post appendicectomy. Although this type of complication is rarest, but if it is left unattended, the patient might end up with serious complications, also, unnecessary intervention may result in serious morbidity for the patient.

REFERENCES

1. Kirby A, Hobson RP, Burke D, et al. Appendicectomy for suspected uncomplicated appendicitis is associated with fewer complications than conservative antibiotic management: a meta-analysis of post-intervention complications. J Infect 2015;70(2):105–110. DOI: 10.1016/j.jinf.2014.08.009.

2. Andersson RE. Short-term complications and long-term morbidity of laparoscopic and open appendicectomy in a national cohort. Br J Surg 2014;101(9):1135–1142. DOI: 10.1002/bjs.9552.

3. Vo N, Hall FM. Severe post appendectomy bleeding. Am Surg 1983;49(10):560–562. PMID: 6331778.

4. Koimtzis G, Sapalidis K, Koletsa T, et al. Massive endoluminal bleeding from the invaginated appendiceal stump after appendectomy: a unique case of gastrointestinal bleeding. ProClinS Surgery and Procedures 2018;1(1):1–5.