Hot Rock Syndrome: Acute Appendicitis Presenting as Small Bowel Obstruction

Author(s):
Peter Kim; Michael Jureller

Background:

All general surgeons learn that small intestinal obstruction can be caused by a plethora of intra-abdominal processes. Acute appendicitis as the primary cause of small bowel obstruction is only rarely reported in the literature. In 1894, Dr. Francis Markoe, as presented to the New York Surgical Society, where he described a perforated appendix laying across the cecum and adherant to the terminal ileum.

Hypothesis:

Since then, this pathology of appendicitis with small bowel obstruction is seen rarely in the literature, and only as case reports.  Curiously, no identified source in the literature reports this pathology to be associated with an appendicolith.  Thus, we propose the term “Hot Rock Syndrome,” which we define as a presentation of small bowel obstruction due to acute appendicitis with impacted stone of feces as an inflammatory source of extrinsic bowel obstruction and likely associated ileus.

Methods:

We present a 26-year old male without past surgical history who arrived in sepsis due to acute appendicitis with a large fecalith (Figure 1a). Small bowel was grossly dilated with the transition point pinpointed to the inflamed appendix (Figure 1b). The patient was treated successfully with laparotomy and appendectomy. This case report, along with a review of the literature, leads our group to the conclusion that laparotomy is a safe and effective primary treatment modality to address patients suffering with Hot Rock Syndrome.

Results:

The patient was treated successfully with laparotomy and appendectomy. This case report, along with a review of the literature, leads our group to the conclusion that laparotomy is a safe and effective primary treatment modality to address patients suffering with Hot Rock Syndrome.

Conclusions:

Appendicitis should be considered in the differential diagnosis for patients that don’t resolve their small bowel obstruction with non-operative therapy.