Mock appendicitis: small bowel perforation secondary to lung cancer metastasis.

A 60-year-old male smoker with a history of angina pectoris presented to the emergency department with progressive abdominal pain and fever during the previous 48 hours. The patient described a pain that was periumbilical at first and then migrated to the right lower quadrant. There was no nausea or vomit ing, and his vital signs were normal. Physical examination revealed a right lower quadrant pain with guarding. The pulmonary and nodal exam results were normal. The patient’s leukocyte count was 12 × 109/L. A computed tomography (CT) scan with contrast and ultrasound evaluation showed some inflammation in the right lower quadrant with dilated small bowel and an inflammatory mass measuring 2.5 × 4.5 cm. We could not see the appendix clearly. There was no free air and no abscess. These exam results were compatible with acute appendicitis. We scheduled the patient for a laparoscopic appendectomy. At surgery, we found a normal appendix and 2 ileal lesions, one at the terminal ileum and the other on the jejunum. The liver was normal. The lesion on the terminal ileum was perforated and sealed by an adjacent bowel loop (Fig. 1). After thorough lavage of the operative site, we exteriorized the 2 loops of bowel through a 6-cm midline incision. We conducted 2 segmental resections with end-to-end anastomosis. The patient’s postoperative course was uneventful, and he was discharged on the fifth postoperative day. Pathology revealed a poorly differentiated metastatic neoplasm involving the small bowel, consistent with a primary lung cancer (antibody test results for cytokeratin 7 were positive, cytokeratin 20 negative and thyroid transcription factor-1 positive. A CT scan of his chest further revealed a 4-cm mass in the right upper lobe and a 3-cm mass in the left lower lobe involving the pleura (Fig. 2). We did not perform biopsies; rather, we administered a course of palliative postoperative chemotherapy. The patient died 10 months after surgery.