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Acute appendicitis: an unusual cause
  1. S K Clark,
  2. T Qureshi,
  3. M Sen
  1. Department of Surgery, Crawley Hospital, Crawley, West Sussex, UK
  1. Miss S K Clark, 25 Kelso Place, London W8 5QG, UK

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Answers on p 130.

A 52 year old woman presented with a two day history of worsening central abdominal pain, with nausea, and vomiting. Over the previous month she had been treated for a flare up of rheumatoid arthritis. Her only medication was methotrexate 10 mg/week and buprenorphine 200 μg three times a day. On examination she looked unwell and had a pyrexia of 37.4°C. Her pulse was 110 beats/min and her blood pressure was 110/54 mm Hg. Her abdomen was distended and she had generalised peritonism; bowel sounds were absent. She had a mild leucocytosis of 11.2 × 109/l but her full blood count and serum electrolytes were otherwise normal. Plain abdominal radiography revealed multiple central loops of small bowel which were not dilated.

At laparotomy there was free pus in the pelvis, and a pelvic appendix was inflamed and perforated distally; the only other abnormalities were a 10 cm nodular cyst of the right ovary and inflammation of the omentum. Appendicectomy, right salpingo-oophorectomy, and omentectomy were performed. These organs were non-adherent and were therefore removed separately.


Describe the histological features (see p 131).
What further treatment is indicated?

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