Many patients have revisited emergency department because of abscesses caused by retained fecaliths which had been once appendicoliths according to some authors [1]. We reported herein a case of delayed acute abdomen of a far wandering appendicolith retained after laparoscopic appendectomy. One can find a wide variation in rates of appendicoliths during appendicitis. Since patients with appendicoliths are usually asymptomatic, appendicoliths are not pathognomonic in acute appendicitis. However, it is also true that appendicoliths can be found with perforation and abscess formation. In fact, appendicoliths are common, being present in 3% of general population and in nearly 10% cases of acute appendicitis. [2] [3].

A 24-year-old male patient, who had been operated on because of acute appendicitis in our emergency department 15 days ago, was readmitted to our general surgery department. According to his near medical history; laparoscopic appendectomy had been converted into open surgery because of perforated appendix and the patient had been discharged from the hospital on the second postoperative day without any complication. However, after two weeks; abdominal discomfort resulted in signs and symptoms of acute abdomen. Fever, abdominal guarding and rebound tenderness especially around umbilical region with acute abdomen resulted in re-hospitalization of the patient in our emergency department. Laboratory results were within normal ranges except for the levels of C-reactive protein and leukocyte count, were 95 mg/L and 17300/mm³, respectively. Direct abdominal X-ray (Figure 1), ultrasonography and computed tomography (Figure 2), detected a stoney structure of 2 cm surrounded by omentum and intestines at the right side of the vertebral column superior to umbilicus. Effused areas of small abscesses in addition air bubbles scattered around them throughout the abdomen were also reported. Right paramedian laparotomy exposed small islands of abscesses beginning at the abdominal wall. The stony fecalith of 2 cm was found under the leaflet of the transverse mesocolon (Figure 3) and it was surrounded by omentum and intestines creating a mass of almost 10 cm (Figure 4). The fecalith together with the surrounding and necrotizing omentum were resected (Figure 5). A Jackson-Pratt drain was placed. The patient was discharged from the hospital on the third postoperative day without any complication.

According to majority of the related studies, one cannot claim about a relationship between a gangrenous or perforated appendix and causative role of a fecalith. Fecaliths are usually described as incidental findings rather than being a primary cause of the disease [4] . Hence fecaliths are more dangerous when they leave appendix vermiformis. We think that insufflation of carbon dioxide used in the laparoscopy could have resulted in the far wandering of the fecalith during the initial surgical intervention in the present case. Appendiceal fecaliths may lead to right iliac fossa pain in the absence of obvious appendiceal inflammation. Therefore, even the routine removal of a normal-looking appendix at laparoscopy in the absence of any other obvious pathology may be an effective treatment for recurrent symptoms in cases with a fecalith according to some authors [5]. Working as a lymphoid organ or colonic reservoir may also contribute to acute appendicitis [6] [7] [8]. Interesting foreign bodies in the lumen of the appendix vermiformis [9] as well as eosinophilic appendicitis caused by Schistosoma japonicum [10] are all emphasizing that we still see only the tip of the iceberg of a very well-known disease. Acute appendicitis has always been among the most common cause of acute abdomen worldwide since antique times. Challenges in its diagnosis, variable combination of its clinical presentation especially altered by its retrocecal and/or subserosal locations, recommended scoring systems to decrease negative appendectomy rates, role and success of imaging modalities, non-operative treatment facilities, timing of appendectomy, in-hospital delay, appendicitis in pregnant patients, and its incidence which cannot be decreased along with its complications disguise continuous debates. Moreover; percutaneous drainage of a periappendicular abscess in the era of evolved radiological techniques has been another tool in its treatment during the last decades. One should always keep in mind, that a hidden cecal or appendiceal tumor could be an undesirable concomitant fact with a silent appendiceal phlegmon or mucocele which are very hard to diagnose even with colonoscopy especially in patients in whom physicians recommend interval appendectomy in cases who had been treated medically [11].

In conclusion, we shall keep in mind that retained appendicoliths might cause some complications which we could have avoided during the previous surgical intervention.

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