Background Acute appendicitis is a common condition that classically occurs with periumbilical pain that radiates to the right lower quadrant, accompanied by nausea, vomiting, fever, and decreased oral intake. But in patients with complex abdominal surgical history, anatomical defects can lead to atypical presentations. Here, we have acute appendicitis in an 82-year-old male with a prior Whipple procedure and cholecystectomy, who presented without "typical" appendicitis symptoms.

Case Presentation An 82-year-old man with a history of pancreatic cancer (status post-Whipple procedure), prostate cancer, and cholecystectomy was seen from a referral hospital with five days of fevers and progressively worsening intake. He complained of no abdominal pain aside from a chronic, years-long, postoperative gassy distress. Leukocytosis (WBC 20,000) and positive blood cultures for Klebsiella were found upon initial presentation to our hospital. His abdominal ultrasound was normal as well. However, CT imaging, which was only ordered once he got to VAMC, found a dilated appendix that was suspicious for an acute appendicitis. Due to his surgical history, the appendix was possibly seen to be in an ectopic location, posterior to his liver. It was deemed he was not an optimal candidate for surgery due to his age and history of prior abdominal operations. Nonoperative treatment with IV antibiotics was initiated subsequently. Over the course of a week, he came with clinical improvement with resolution of leukocytosis and was discharged in stable condition.

Discussion This case illustrates the diagnostic challenge of appendicitis in patients with altered surgical anatomy. Classic migratory pain to the right lower quadrant is a reliable predictor of appendicitis, but this patient lacked this presentation due to post-surgical anatomical change, as well as his abdominal pain presenting as a years-long, chronic, non-specific bloating pain. As a learning point, one must have a high index of suspicion for appendicitis in elderly patients with extensive surgical history with ambiguous systemic symptoms, and manage appropriately. Initial imaging is crucial to avoid delayed diagnosis and appropriate guiding treatment.