Year : 2017 | Volume
: 11 | Issue : 2 | Page : 89--91
Acute appendicitis following renal transplant: A case report and review of literature
Jacob Mathew, Ramesh Rajan
Department of Surgical Gastroenterology, Government Medical College, Trivandrum, Kerala, India
Department of Surgical Gastroenterology, Government Medical College, Trivandrum, Kerala
Only a few cases of acute appendicitis (AA) have been reported in renal transplant recipients. The presentation may be delayed or non-specific due to the masking of inflammatory signs in the immunosuppressed patient. It is essential to differentiate this condition from acute rejection, which may present in the same manner. The management of AA in the setting of a transplanted patient is not clear. A case report and review of literature is presented.
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Mathew J, Rajan R. Acute appendicitis following renal transplant: A case report and review of literature.Indian J Transplant 2017;11:89-91
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Mathew J, Rajan R. Acute appendicitis following renal transplant: A case report and review of literature. Indian J Transplant [serial online] 2017 [cited 2019 Oct 19 ];11:89-91
Available from: http://www.ijtonline.in/text.asp?2017/11/2/89/214388
Gastrointestinal complications are reported in up to 50% of renal transplant recipients. Around 10% of these patients present with acute abdominal pain. The most common conditions include cholecystitis, gastric and duodenal ulcer complications, diverticulitis, and pancreatitis. Only a few cases of acute appendicitis (AA) have been reported in renal transplant recipients. The symptoms and signs of AA may be delayed or nonspecific due to the masking of inflammatory signs in the immunosuppressed patient. It is essential to differentiate this condition from acute rejection, which may present in the same manner. The management of AA in the setting of a transplanted patient is not clear. We present a case report and a review of the existing published literature.
A 27-year-old male presented 2 months after living-related renal transplant for end-stage renal disease (chronic glomerulonephritis) with complaints of right iliac fossa (RIF) pain and vomiting of 1-day duration. He did not complain of any urinary symptoms or decrease in urine output. His postoperative course after transplant was unremarkable and he was on prednisolone, mycophenolate mofetil, and tacrolimus. On examination, he was afebrile with no tachycardia and normal blood pressure. The graft kidney could be felt in the RIF and there was rebound tenderness. Bowel sounds were present and per rectal examination was normal. Laboratory values including total and differential counts and amylase and lipase were within normal limits. Blood urea was 45 mg/dl and serum creatinine was 1.6 mg/dl. His urine output was adequate.
A Doppler ultrasonography (USG) of the graft kidney showed normal blood flow and echotexture and probe tenderness in the RIF. The appendix could not be visualized. A plain computed tomography (CT) of the abdomen showed a dilated thick-walled appendix with surrounding inflammation. There was no evidence of perforation, phlegmon, or abscess formation. A diagnosis of uncomplicated AA was made.
The patient was kept nil per oral (except for immunosuppression) and was started on antibiotics (piperacillin + tazobactam 4.5 g intravenous [iv] q8 h, metronidazole 500 mg iv q8 h) and iv fluids. Tramadol was given for pain relief. The patient elected to undergo conservative management after explaining the risks of nonoperative management. He agreed to undergo surgery should his condition worsen or any complications occur.
He underwent serial clinical examination, daily total and differential counts, blood urea and serum creatinine, and bedside ultrasound. Oral immunosuppression was continued at the previous dosage.
He improved symptomatically and was started on clear fluid by the 5th day of hospital admission and gradually advanced to a soft diet. He was discharged on the 10th day on normal diet and serum creatinine (1.1 mg/dl).
He was taken up for interval laparoscopic appendectomy 6 weeks later. Standard port placements (umbilical 10 mm port, suprapubic 5 mm port, and RIF 5 mm port) were used with pneumoperitoneum set at 12 mmHg. The postoperative period was uneventful. Immunosuppressants were continued in the perioperative period. He was kept for observation and discharged on the 4th postoperative day on normal diet.
The incidence of AA in transplant recipients is quite low in literature. In a retrospective review of nearly 8000 solid organ transplant recipients between 1989 and 2002, Savar et al. reported 17 patients who underwent surgery for AA of which three were renal transplant recipients. Bardaxoglou et al. reported two cases of AA following renal transplant in their series of 416 cases. In another large series of 2340 renal transplant recipients, Benjamin et al. reported two cases of AA. There are also several case reports and small series in literature.,,
AA may occur at any time following transplantation. In the series by Savar et al., mean time from transplantation to appendectomy was 1064 days (16–2977 days).
AA may be confused with a number of conditions in renal transplant recipients including acute rejection or gastroenteritis. Atypical or delayed presentations may lead to a delay in diagnosis. This may in turn lead to increased incidence of septic complications or even mortality., USG is usually the first imaging modality to be used in acute abdomen. A definitive diagnosis can be made in most cases. It can be combined with a Doppler study to assess the graft kidney. However, it is heavily operator dependent. A CT scan overcomes this limitation and may also help to rule out other differential diagnoses such as bowel perforation. It is also more sensitive in picking up local complications. However, the optimum CT protocol is still controversial. In the series by Savar et al., CT was done in 16/17 patients and was diagnostic in 15 patients. We feel that an early CT should be done where a diagnosis cannot be made confidently on USG.
Conservative management of AA with antibiotics in transplant recipients must be considered with hesitation due to the high incidence of complications (24%) when compared to nontransplant recipients. However, it must be noted that most of these complications occurred due to delay in diagnosis.,, Appendicectomy (open/laparoscopic) is considered the gold standard treatment for AA. Multiple randomized controlled trials have recently shown the safety of antibiotics as primary treatment for uncomplicated AA. However, there was a high incidence of recurrence and subsequent surgical management within 1 year in some of these trials. A randomized controlled trial is not possible in transplant recipients due to the low number of cases and also due to ethical considerations. We recommend immediate surgery though conservative management under close observation may be possible in selected patients or where consent for surgery is not given.
Pneumoperitoneum leads to a reduction in renal blood flow and transient oliguria. This can be avoided by keeping intra-abdominal pressure at a minimum and by preloading the patient with fluids. Renal dysfunction due to pneumoperitoneum has been shown to be transient in animal models. However, the effects on the denervated graft kidney have not been well studied. Laparoscopy has been used in renal transplant recipients for a variety of conditions including drainage of lymphoceles and cholecystectomy without any adverse effects. This shows the safety and feasibility of laparoscopy in renal transplant recipients. There are several advantages to a laparoscopic approach in these patients. It helps to differentiate from other acute abdominal conditions. A smaller incision leads to faster wound healing and reduced incidence of wound infection and incisional hernias as many of these patients may be on steroids. Oral diet can be started earlier, thereby leading to earlier resumption of immunosuppression. Hospital stay is reduced making the patient less likely to pick up a hospital-acquired infection.
Appendicitis is rare following renal transplantation. Presentation may be delayed and symptoms may be atypical. Delay in diagnosis is associated with increased morbidity and mortality. Hence, a high index of suspicion should be maintained and early CT scan is recommended. Laparoscopic appendicectomy is the treatment of choice. Early surgery is recommended, but conservative management with antibiotics under close monitoring may have a role in selected patients where surgery is not feasible. Such patients should undergo surgery at a later date due to a high rate of recurrence.
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Conflicts of interest
There are no conflicts of interest.
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