What’s in the sac?

These are abdominal computed tomography scans of a man in his 70s who presented with fever and right lower quadrant abdominal pain (fig 1, coronal view left, sagittal view right). On examination, he had a bulge in his right groin that displayed rebound tenderness, and his inflammatory markers were raised. Subsequent imaging showed a thick walled appendix with mural hyperenhancement and intraluminal appendicoliths within the right inguinal sac (white arrows), extending through the inguinal canal towards the scrotum.

Fig 1

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Amyand’s hernia with appendicitis was diagnosed. Amyand’s hernia is a rare form of inguinal hernia in which the appendix is contained within the hernia sac. This type of hernia can result in an atypical presentation of acute appendicitis, which may be mistakenly diagnosed as an incarcerated inguinal hernia and inappropriately managed.12 This patient underwent an appendectomy with primary hernia repair, and at six month follow-up the hernia had not recurred.