A young man with concurrent acute appendicitis and incarcerated right indirect inguinal hernia.

Dear editor

We read with great interest the expert opinion of Ditsatham et al1 on an extremely interesting case. Ditsatham describes a patient who presented with both appendicitis and an indirect inguinal hernia. There is very little known on the subject of concurrent appendicitis and hernia throughout the literature. There were some aspects to the history that stood out.

The past medical history was particularly revealing. The patient had presented with pectus excavatum, which had been repaired by Nuss procedure. There is little information in the literature on the etiology of pectus excavatum; however, a link between the condition and connective tissue disorders has been made.2 One can infer from Redlinger et al2 that if pectus excavatum is exhibited in over two-thirds of Marfan syndrome patients, it may be linked to the connective tissue, specifically collagen. The presence of a collagen abnormality, even one that may not be synonymous with a diagnosis, can still pose certain health problems.

Klinge et al3 present the link between collagen abnormalities and an increased risk of recurrent abdominal hernia. Parallels can be drawn to our patient who presented with a reducible inguinal mass 4 years prior to his described presentation. The risk of such a rare concurrent event may be increased if linked with a connective tissue disorder. Further research should be undertaken in this field to look for a causative relationship.

Conditions with unusual presentation of appendicitis have been described; this paper made reference to a rare condition, Amyand hernia, named after an English surgeon. This is relevant since Amyand hernias are often misdiagnosed as a strangulated hernia, and so, the incidence of possible concurrent appendicitis and hernia is higher than reported.4

Concurrent appendicitis and other acute abdomen conditions have also been reported. Eggleston and Afzal5 describe a case of concurrent appendicitis and cecal bascule. In the case reported by Ditsatham, interest diverts to link the two conditions. Could the strangulation of appendix secondary to the traction of omentum in the hernia sac cause appendicitis? The rare presentation of these two conditions makes the viability of an observational study difficult.

To conclude, it can be said that this young man may have had a mild underlying collagen abnormality that has led to an increased risk of hernia, thus increasing his 0.0009% risk of developing a concurrent appendicitis and inguinal hernia. The systemic effects of connective tissue disease need to be further explored, with particular attention being paid to the manifestations in the bowel. An important learning point highlighted by this case is that you should always be thorough with your examination and never rule out the possibility of concurrent pathology.