Division
East Florida
Hospital
HCA Florida Lawnwood Hospital
Specialty
Transitional Year
Document Type
Poster
Publication Date
2025
Keywords
appendicitis, imaging
Disciplines
Diagnosis
Abstract
Introduction: Right lower quadrant pain is a common presentation of acute appendicitis, but presentations in elderly patients may be subtle. Appendiceal obstruction is frequently caused by fecaliths; however, not all radiopaque findings in the appendix represent fecaliths. Rarely, these obstructions can mimic metallic foreign bodies on imaging, complicating interpretation and management. This case highlights an unusual radiologic presentation of appendiceal obstruction with metallic appearance, underscoring the importance of careful image analysis in atypical cases of appendicitis.
Case Description: An elderly man presented to the emergency department with a three-day history of constant right lower quadrant abdominal pain. He denied associated gastrointestinal or urinary symptoms. On arrival, vital signs demonstrated a mild fever (38.3-38.6 C) and elevated blood pressure (>160/102 mmHg). Physical examination revealed localized right lower quadrant tenderness with mild guarding and a positive McBurney’s point, without other significant findings.
Laboratory evaluation showed leukocytosis with a WBC count of 15.4x103 / µL and neutrophilia (84.4%). Coagulation panel was unremarkable. Chemistry panel revealed mild hyponatremia (Na 133 mmol/L) and elevated total bilirubin (1.4 mg/dL). Urinalysis was notable for ketonuria and red blood cells, but without pyuria or leukocyte esterase.
CT of the abdomen and pelvis demonstrated a distended appendix with wall enhancement, peri-appendiceal fat stranding, and a radiopaque focus at the appendiceal ostium, initially concerning for a metallic foreign body. Abdominal X-ray confirmed a high-density object in the right lower quadrant.
Surgical consultation led to laparoscopic appendectomy. Intraoperative findings revealed a gangrenous appendix with localized peritonitis. The procedure was completed with minimal blood loss and no complications. The patient’s postoperative course was uncomplicated, with normalization of vital signs under hospitalist co-management with IV antibiotics and pain control.
Pathology confirmed acute perforated gangrenous appendicitis with severe peri appendiceal acute inflammation. The radiopaque object visualized on imaging was discarded intraoperatively and not included in the specimen submitted for pathological evaluation.
Discussion: The decision to proceed with surgical intervention was based on the patient’s clinical presentation, laboratory findings, and imaging studies. The persistent right lower quadrant pain, fever, and leukocytosis were consistent with acute appendicitis, while imaging demonstrated a radiopaque focus at the appendiceal base. Although the appearance initially raised suspicion for a metallic foreign body, the possibility of an obstructing fecalith was strongly considered, as both can present with high-density artifacts on CT and X-ray. Given the risk of perforation and peritonitis associated with fecalith-related appendicitis, prompt laparoscopic appendectomy was recommended.
This case highlights an important radiological pitfall: radiopaque appendiceal obstructions can mimic metallic foreign bodies, potentially leading to diagnostic confusion. Awareness of this overlap is essential, as misinterpretation could delay appropriate surgical consultation. Another important lesson is the value of specimen preservation for radiology-pathology correlation, as discarding the radiopaque object prevented definitive identification in this case. Ultimately, clinicians must integrate imaging findings with clinical context when evaluating appendicitis, particularly in elderly patients with atypical or subtle presentations. Early recognition and surgical management remain key to preventing complications such as gangrene or peritonitis.
Original Publisher
HCA Healthcare Graduate Medical Education
Recommended Citation
Cohen, Nathan and Padilla-Maldonado, Gary, "When Appendiceal Obstruction Looks Metallic: An Unusual Radiologic Presentation of Appendicitis" (2025). East Florida Division GME Research Day 2025. 18.
https://scholarlycommons.hcahealthcare.com/eastflorida2025/18
Abstract