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Snapshot diagnosis - why has this surgical wound not healed?

A full wound drainage bag was hardly what the patient wanted, but was it surgical failure or something else? Dr Mike Wyndham describes another unusual case

A full wound drainage bag was hardly what the patient wanted, but was it surgical failure or something else? Dr Mike Wyndham describes another unusual case

The patient

He was certainly pretty disenchanted with the outcome and I could hardly blame him.

A bag regularly filling up with fluid was not the planned outcome to an appendicectomy carried out three weeks earlier. The wound had never healed properly and had then started to discharge in two places. The patient also wasn't feeling that well, with intermittent shivery episodes.

His appetite had not returned to normal.

First instinct

A wound infection seemed a reasonable suspicion until the copious amounts of fluid appeared. A connection to the bowel seemed the likeliest answer. The question was, what was the cause?

Differential diagnosis

• Failure to remove the appendix properly

• The appendix stump had split

• Crohn's disease

Getting on the right track

Clearly, the operation had not produced the intended result. Surgical failure was a possibility, with either inadequate removal of the appendix or the base of the operation site blowing apart. Could IBD be the cause, particularly as a fistulous connection had developed?

The hidden clue

A return visit to the hospital resulted in an MRI scan. The result showed changes in the ileum compatible with Crohn's disease.

Outcome

An ileo-colonoscopy confirmed the presence of Crohn's disease and after treatment with azathioprine, surgery was carried out to remove the fistula and affected bowel.

Dr Mike Wyndham is a GP in Edgware, north London

Snapshot diagnosis - why has this surgical wound not healed?

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