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AMYAND'S HERNIA AS A RARE CAUSE OF ABDOMINAL PAIN WITH EARLY APPENDICITIS AND DIVERTICULITIS
Austin Mahajan^*1, Suresh Mahajan^2
1Ohio University Heritage College of Osteopathic Medicine, Athens, OH; ²Southwest General Health Center, Middleburgh Heights, OH

Case Overview
A 57 year old Caucasian male with a history of sigmoid diverticulosis presented to the ER with a two day history of severe bilateral lower abdominal pain. Patient complained of severe pain with movement and a bulge in his right groin. Laboratory results revealed leukocytosis (15.3 K/?L). On exam, patient was afebrile but tachycardic. Cardiovascular and lung exams were normal. Abdomen had diffuse pain with guarding and no rebound tenderness. Bowel sounds were normal. Right groin had a 2 cm reduceable painful lump with no overlying erythema. Abdominal CT showed acute sigmoid diverticulitis with bowel wall thickening and fat stranding. Bilateral inguinal hernias with a mildly inflamed appendix herniating into the right inguinal canal (Amyand’s Hernia - Figure 1A). Patient started on IV ciprofloxacin and metronidazole. Surgical consult was obtained. Patient’s abdominal pain and leukocytosis resolved after four days. He completed the 14-day outpatient antibiotic treatment for diverticulitis. Elective outpatient bilateral herniorrhaphy was performed without appendectomy.

Discussion
Amyand’s hernia is characterized by the presence of the appendix within the inguinal hernia sac (Figure 2). It is a rare condition, accounting for 1% of all inguinal hernias. Acute appendicitis within the hernia sac is extremely rare, with a reported incidence of 0.1%. Males account for 91% of Amyand’s hernia cases, and it is three times more common in children due to the patency of the processus vaginalis. Amyand’s hernia can become incarcerated which constitutes a medical emergency requiring surgical intervention to prevent bowel ischemia, obstruction, or perforation. Conservative treatment of acute appendicitis with antibiotics has been shown to be non-inferior to appendectomy in the past decade. Concurrent diagnosis of sigmoid diverticulitis posed an elevated risk of surgical complications. Following treatment with IV antibiotics, the patient’s WBC normalized, and bilateral abdominal pain resolved. The patient subsequently returned for elective bilateral herniorrhaphy with mesh repair.

Conclusion
This case demonstrates the successful management of Amyand’s hernia complicated by diverticulitis using a conservative approach with IV antibiotics and careful monitoring. This strategy reduced the risk of incarcerated Amyand’s hernia with acute appendicitis, while allowing for elective repair to prevent recurrence.

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