Appendicitis Secondary to Trauma following a Camel Kick: Case Report and Review of Literature

Introduction Independently, trauma and appendicitis are two of the most common conditions in surgical practice. Rarely, both conditions may coexist, which raises the controversy whether it is merely a coincidence or trauma may lead to acute appendicitis. Presentation of Case. We report a case of acute appendicitis after blunt abdominal trauma caused by a camel hoof kick to the abdomen in a young man and discuss the potential underlying pathophysiologic mechanisms with review of the pertinent literature. Conclusions Blunt abdominal trauma caused by a camel kick to the abdomen requires a close observation of the patients. A camel kick may increase intra-abdominal pressure and cause internal organ injury including the appendix. Therefore, acute appendicitis should be considered in differential diagnosis in any patient with abdominal pain resembling appendicitis following blunt abdominal trauma.


Introduction
Appendicitis is one of the most common surgical conditions affecting about 7% of people during their lifetime [1]. The etiology of acute appendicitis is multifactorial, with luminal obstruction being considered the major cause [1]. Blunt abdominal trauma (BAT) has been infrequently reported as a possible cause for acute appendicitis; however, most of the reported cases were in pediatric age group (Table 1). Herein, we report a rare case of acute appendicitis after blunt abdominal trauma caused by a camel hoof kick to the abdomen.

Case Presentation
A 35-year-old Bangladeshi man presented to the emergency department at Hamad Medical Corporation, Doha, Qatar, with two-day history of progressive right lower abdominal pain, associated with four times vomiting and loss of appetite. He was doing completely well but developed these symptoms few hours after a strong direct camel kick on his right abdo-men. He did not have any urological symptoms, nor any comorbidities, and his systemic review was unremarkable.
The patient was conscious and had normal vital signs. Generally, was looking well, abdominal examination showed a right lower abdominal bruise, tenderness, rebound tenderness, and involuntary guarding in the right iliac fossa. Head to toe examination showed no other signs of trauma. Laboratory tests showed high inflammatory markers (white blood cell count (WBC) 15.5 K/μL, hemoglobin 15.3 g/dL, platelets 207 K/μL, CRP: 90.5, and bilirubin: 29.1). CT abdomen with IV and oral contrast was done and showed a dilated appendix in the right iliac fossa (16 mm in diameter), with wall enhancement and periappendiceal fat stranding ( Figure 1). The patient was diagnosed with acute appendicitis, and an emergency laparoscopic appendectomy was performed. Intraoperative findings showed grossly inflamed appendix with fibrinous exudate with no collection or perforation (Figure 2), and the inspected other intra-abdominal solid and hollow organs were normal. Postoperatively, the patient recovered well and was discharged one day after surgery. On follow-up 2 weeks in the clinic, he was completely healthy,

Discussion
The most commonly identified cause of acute appendicitis is the luminal obstruction leading to inflammation and complications of the appendix [2]. One of the earliest welldocumented reports that linked blunt abdominal trauma (BAT) with traumatic appendicitis (TA) was the Hungarian stunt performer, Harry Houdini, who used to voluntarily hit his abdomen as a show of strength, subsequently developed peritonitis due to perforated appendix and died [3]. Despite the reports on the possible relationship between BAT and appendicitis are limited (Table 1), however, many theories support this relationship [4]. Some speculated that BAT might cause inflammation by the direct impact and appendiceal injury, and others attributed it to the indirect effect, leading to increased intraluminal pressure followed by burst or intraluminal pressure induced mucosal injury resulting in hematoma/edema that will cause luminal narrowing followed by obstruction and inflammation [4]. Looking at the demographic characteristics of patients who develop TA, most of the reported cases (including ours) showed male predominance, similar to nontraumatic appendicitis; however, in former, more male predominance is expected as blunt trauma is more frequent among males [5], mostly seen in pediatric age group in contrast to our case who was an adult (Table 1). A possible explanation underlying pediatric patients' predominance is the smaller abdominal cavity, softer, and less muscular abdominal wall as compared with adults, where the transmission of energy following trauma is more significant leading to greater increase in intra-abdominal pressure, causing increased appendicular luminal pressure and thus appendicitis. Older children may represent the most sensitive age group due to the fact that they are more independent to participate in risky outdoor activities than their younger counterparts [1].
Patients usually present as the classical picture of acute appendicitis with a difference of preceding trauma, developing abdominal pain within 6-48 hours following the severe blunt abdominal injury. This can be associated with other typical symptoms of acute appendicitis including nausea, vomiting, and anorexia (Table 1). Our patient had abdominal pain that started few hours after the BAT, in agreement with most of other reported cases in literature.
As for investigations, similar to that of nontraumatic appendicitis, blood tests usually show raised inflammatory markers and peculiar clinical signs and imaging, specifically CT scan of the abdomen, if required will confirm the diagnosis (Table 1), as our patient showed leukocytosis and had features of acute appendicitis on abdominal CT scan.
Diagnostic criteria for TA were postulated by Shutkin and Wetzler as follows: (1) Absolute freedom from abdominal symptoms, including pain, nausea, vomiting, and tenderness, before the trauma (2) Direct trauma must be severe and forcible, involving the abdominal wall and specially in the right half (3) Indirect trauma must be violent, acute, and unexpected (4) Symptoms must appear immediately after the trauma (5) Symptoms must be persistent and progressive, assuming the symptoms and signs of acute appendicitis (6) The pathologic findings must indicate a suppurative, destructive, or necrotic process [3] Our patient fulfilled all the mentioned criteria, so we regarded it as TA.
As for the management, TA does not differ than nontraumatic appendicitis, with mainstay of treatment being surgical appendectomy (Table 1).
In terms of postoperative recovery, we noticed that patients treated for TA have relatively longer hospital stay than those with nontraumatic cause (Table 1). This might be because of the accompanied injuries; in fact, some of these patients presented with polytrauma, and TA was just a part of their multisystem involvement.

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Case Reports in Surgery may increase intra-abdominal pressure and cause indirect injury to internal organs including the appendix. Therefore, abdominal pain in these patients should not be regarded as being caused solely by abdominal wall contusion, and acute appendicitis should be considered in the differential diagnosis in any patient with abdominal pain following blunt abdominal trauma.

Data Availability
The data used to support the findings of this study are included in the article.

Ethical Approval
As all the information was given retrospectively from the chart review and the patient was deidentified, this case report was exempted and waiver of consent was obtained and approved by medical research center, Hamad Medical Corporation, reference number (MRC-04-20-811).

Consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available on request.