Amyand's hernia

A 69-year-old male had past medical history of chronic obstructive pulmonary disease and left side renal stones presenting to the urban medical center emergency department (ED) with the chief complaint of pain in right groin and right flank area for 2 days. He denied of any trauma history recently, and no abdominal surgery history before. No fever, nausea, vomiting, diarrhea, constipation, gross hematuria, or dysuria were noted. Physical examination showed tenderness over the right inguinal area and right costovertebral angle. Blood tests revealed hemoglobin level (Hb) of 15.8 g/dL, white blood cell (WBC) count of 8000/μL, and C-reactive protein (CRP) of <0.02 mg/dL. The urine analysis revealed microscopic hematuria (red blood cell count: 12 cells/high power field). The abdominal radiograph that was obtained showed small radiopaque lesion superimposed on the left kidney, suggestive of left renal stone. The initial impression was nephrolithiasis cause of microscopic hematuria. However, the pain persisted after intramuscular injection of 25 mg diclofenac sodium. A whole abdominal computed tomography (CT) was performed and showed the vermiform appendix trapped within an inguinal hernia sac (Figure, white arrows; Fig. 1, target lesion, Fig. 2, tubular lesion). Amyand's hernia was diagnosed according to the CT findings. The patient chose to take oral analgesic and observe at home. We prescribed oral form diclofenac potassium 25 mg and magnesium oxide 250 mg three times daily. Five days later, the patient followed up at the outpatient department without fever nor abdominal tenderness.