Differential Diagnosis for Perforated Appendix with Normal Appendix and Terminal Ileum Involvement

• Single Most Likely Diagnosis
  • Crohn’s Disease: This is the most likely diagnosis given the presentation of a thickened terminal ileum with greenish-white discharge and adhesions, which are characteristic findings of Crohn's disease, a type of inflammatory bowel disease (IBD) that can affect any part of the gastrointestinal tract but most commonly affects the terminal ileum.
• Other Likely Diagnoses
  • Tuberculosis (TB): TB can affect the gastrointestinal tract and present with similar symptoms, including thickening of the intestinal wall, discharge, and adhesions. The greenish-white discharge could be suggestive of caseous material seen in TB.
  • Actinomycosis: This is a rare chronic bacterial infection that can cause abdominal symptoms, including thickening of the intestinal wall and formation of sinus tracts, which could mimic the presentation described.
• Do Not Miss Diagnoses
  • Typhoid: Although less likely given the chronic nature of the findings (thickening and adhesions), typhoid fever can cause intestinal perforation and should be considered, especially in endemic areas, due to its potential for severe consequences if not treated promptly.
• Rare Diagnoses
  • Yersiniosis: A bacterial infection caused by Yersinia enterocolitica, which can mimic appendicitis and cause terminal ileitis, but it is less likely to cause the chronic changes described.
  • Intestinal Lymphoma: This could cause thickening of the intestinal wall and symptoms similar to those described, but it would be a less common cause of the acute presentation with perforation and greenish-white discharge.

Each of these diagnoses has a different approach to management, ranging from medical therapy for infections like TB and typhoid, to surgical intervention potentially combined with medical therapy for conditions like Crohn’s disease and actinomycosis. Accurate diagnosis is crucial for appropriate treatment.