Stump appendicitis is a delayed complication of appendectomy. It is rare and few cases reported in the paediatric literature. The authors report on another case in a child and focus on the diagnostic peculiarities of this entity.
A 9-year-old boy with previous history of open appendectomy was admitted for a right lower quadrant pain with bilious vomiting and fever. Physical examination demonstrated tenderness in the right lower quadrant and guarding over the appendectomy scar. The white blood cell count was 23.500 cells/mm3. Plain abdominal radiograph and ultrasonography revealed fecalith localized in the right iliac fossa. The diagnosis of stump appendicitis was advocated and confirmed at laparotomy. A gangrenous and perforated appendiceal stump was found and completely removed. The post-operative course was uneventful after 18 months follow-up period.
Stump appendicitis is rare and should be considered in any patient with right lower quadrant pain even if there is a history of appendectomy. Complete removal of the appendix is the only mean to prevent the occurrence of this complication.
Appendicectomy for appendicitis is one of the commonest surgical procedures performed worldwide. The residual appendiceal stump left after an initial appendectomy risks the development of stump appendicitis. Stump appendicitis is a real recognized entity but not often considered when evaluating patients with right lower quadrant abdominal pain, especially those with past history of appendectomy. It remains a clinical challenge with the result that its diagnosis and effective treatment are often delayed with possible attendant morbidity or mortality. Stump appendicitis results from obstruction of the lumen of the remaining appendix stump, usually by a faecolith. This increases intraluminal pressure, impairing venous drainage and allowing subsequent bacterial infection. We present the case of a twenty-five (25)-year-old female who underwent laparoscopic appendicectomy and presented four and half (4(1/2)) months later with fever, right lower quadrant abdominal pain, and tenderness associated with repeated vomiting. Exploratory laparotomy was carried out after clinical and imaging studies which revealed big inflammatory mass with abscess at the right iliac fossa and recurrent appendicitis of the appendiceal stump. Surgical treatment is easy but recognition of this important entity but potentially dangerous condition should always be borne in mind in order to avoid delay in its diagnosis and treatment.
Stump appendicitis is a rare complication of appendectomy unusually included in the differential diagnosis. This is found in appendectomized patients with similar symptoms to those of a previous appendicitis.
PRESENTATION OF CASE
We present three cases, two women and a man of 67, 30 and 24 years old, respectively. They underwent surgery at our centre and their appendectomies presented technical difficulties: problems when identifying the appendicular base or the complete appendicular structure. In the first case, diagnosis and therapy were performed with laparoscopy. The second case was diagnosed by an abdominal ultrasound (US) which revealed a tubular structure with thickened walls. An abscess was observed in the computed tomography (CT) scan for the third case and a laparotomy revealed the retained appendix.
Although there are several factors that can contribute to this rare pathology, the main cause of stump appendicitis is the persistence of a large appendicular remnant. CT and US are very useful diagnosis tools. Treatment consists to a completion appendectomy of the stump which can be carried out by an open or a laparoscopic approach.
In this rare pathology a prior history of appendicectomy can delay the diagnosis and increase its associated morbidity and even mortality. In patients with abdominal pain in the right lower quadrant and previous appendectomy, it is important to include this pathology in the differential diagnosis, in order to not delay the treatment and thus avoid complications.
Stump appendicitis; Appendicular remanent; Incomplete appendectomy
Acute appendicitis due to Enterobius vermicularis is very rare, affecting mostly children. Whether pinworms cause inflammation of the appendix or just appendiceal colic has been a matter of controversy.
A Caucasian 52-year-old man was referred to our Emergency Department with acute abdominal pain in his right lower quadrant. The physical and laboratory examination revealed right iliac fossa tenderness and leukocytosis with neutrophilia. An open appendectomy was performed. The pathological examination showed the lumen containing pinworms. Two oral doses of mebendazole were administered postoperatively. The follow-up to date was without incident and he was free of symptoms one year after the operation.
The finding of E. vermicularis in appendectomy pathological specimens is infrequent. Parasitic infections rarely cause acute appendicitis, especially in adults.
One should keep in mind that the clinical signs of intestinal parasite infection may mimic acute appendicitis, although rare. A careful evaluation of symptoms such as pruritus ani, or eosinophilia on laboratory examination, could prevent unnecessary appendectomies.
Stump appendicitis (SA) is a rare clinicopathologic entity characterised by inflammation of the appendiceal remnant after incomplete appendectomy. The diagnosis is not routinely suspected in patients who have previously undergone appendectomy. We report a case of SA in an adolescent boy who had previously undergone laparoscopic appendectomy. The case necessitated surgical completion of the appendectomy.
Appendicitis; Stump; Surgery; Case report; India
Because barium sulfate (BaSO4) is not harmful to the mucosa, it is widely used for gastrointestinal imaging. Barium appendicitis is a very rare complication of barium meals and barium enema. We report a case of acute appendicitis associated with retained appendiceal barium. A 47-year-old man presented with right lower abdominal pain after upper gastrointestinal imaging was performed using barium 1 month earlier. The abdominal plain roentgenogram showed an area of retained barium in the right lower quadrant. Multiplanar reconstruction of computed tomography scans showed barium retention in the appendix. Emergency appendectomy was performed. A cross section of the specimen revealed the barium mass. Barium-associated appendicitis is a very rare clinical entity but we should be cautious of this uncommon disease when we encounter barium deposits in the appendix after barium examination. This report is significant because barium was identified both macroscopically and microscopically.
Appendicitis; Barium; Appendicolith
Metastasis induced acute appendicitis is extremely rare.
PRESENTATION OF CASE
We present a 72-year-old man who presented with typical signs of acute appendicitis. He underwent appendectomy and was successfully discharged without any complication. Histopathological examination diagnosed the metastasis to appendix from prostatic cancer.
Cancers of the appendix are rare and usually diagnosed incidentally in approximately 1% of all appendectomies. The rate of perforation was found to be higher in metastasis induced acute appendicitis in comparison with simple acute appendicitis in the literature. Tumors other than primary appendix tumors when present in the appendix are easily recognized as metastatic, requiring immunohistochemical studies.
Metastasis induced acute appendicitis should be considered as part of the differential diagnosis when a oncologic patient presents with signs of acute appendicitis.
Appendix; Cancer; Metastasis; Prostate
Although rare, inflammation of the appendiceal stump can occur and is still an important clinical entity. There has been a recent increase in interest in stump appendicitis. In this study a case of right lower quadrant pain in an 18-year-old man who underwent an appendicectomy 7 months previously is presented. Recurrent appendicitis was noted in an appendiceal stump during surgery which previously diagnosed by CT and ultrasonography.
Stump appendicitis; CT; Ultrasonography
Situs inversus totalis is a rare inherent disease in which the thoracic and abdominal organs are transposed. Symptoms of appendicitis in situs inversus (SI) may appear in the left lower quadrant, and the diagnosis of appendicitis is very difficult. We report a case of left-sided appendicitis diagnosed preoperatively after dextrocardia that was detected by chest X-ray, although the chief complaint of the patient was left lower-quadrant pain. The patient underwent an emergent laparoscopic appendectomy under the diagnosis of appendicitis after abdominal computed tomography (CT). In patients with left lower quadrant pain, if the chest X-ray shows dextrocardia, one should suspect left-sided appendicitis. A strong suspicion of appendicitis and an emergency laparoscopic operation after confirmation of the diagnosis by imaging modalities including abdominal CT or sonography can reduce the likelihood of misdiagnosis and complications including perforation and abscess. Laparoscopic appendectomy in SI was technically more challenging because of the mirror nature of the anatomy.
Situs inversus; Appendicitis; Laparoscopic; Appendectomy
Acute appendicitis is a rare complication of colonoscopy that has been reported only 12 times in the English-language literature and is usually associated with obstruction of the appendiceal lumen with fecal matter during colonoscopy. None of the previous reports have described findings of perforation of the appendix within 24 hours of colonoscopy.
We present the case report of a patient who underwent urgent laparotomy within 16 hours of colonos-copy for findings of free intraabdominal air and peritonitis from acute perforated appendicitis.
Laparoscopy confirmed 2 perforations of the appendix and diffuse peritonitis. Laparotomy was necessary to perform appendectomy, exclude a right colonic injury, and control intraabdominal sepsis.
In patients with abdominal pain who have had a recent colonoscopy, a high index of suspicion is necessary for accurate diagnosis of perforated appendicitis. Perforation can occur hours after colonoscopy even when a biopsy is not performed.
Perforated appendicitis; Colonoscopy
Appendiceal mucocele is an infrequent but well recognized entity that can present with a variety of clinical syndromes or can be asymptomatic and discovered incidentally. A 55 years old patient was admitted in the emergency department for acute right lower quadrant pain. A diagnosis of appendicitis was made. At operation an appendiceal mucocele was found. An appendectomy was performed. The diagnosis of appendiceal mucocele is an important one in that it can be associated with malignancies and other serious gastrointestinal, ovarian, and urological complications.
Abdominal pain; appendicitis; mucocele; complication; malignancy; Morocco
The authors make the point that completion appendectomy in cases of stump appendicitis should be performed laparoscopically when possible guided by CT scan findings.
Stump appendicitis is defined by the recurrent inflammation of the residual appendix after the appendix has been only partially removed during an appendectomy for appendicitis. Forty-eight cases of stump appendicitis were identified in the English literature.
The institutional CPT codes were evaluated for multiple hits of the appendectomy code, yielding a total of 3 patients. After appropriate approval from an internal review board, a retrospective chart review was completed and all available data extracted. All 3 patients were diagnosed with stump appendicitis, ranging from 2 months to 20 years after the initial procedure. Two patients underwent a laparoscopic and the one an open completion appendectomy. All patients did well and were discharged home in good condition.
Surgeons need a heightened awareness of the possibility of stump appendicitis. Correct identification and removal of the appendiceal base without leaving an appendiceal stump minimizes the risk of stump appendicitis. If a CT scan has been obtained, it enables exquisite delineation of the surrounding anatomy, including the length of the appendiceal remnant. Thus, we propose that unless there are other mitigating circumstances, the completion appendectomy in cases of stump appendicitis should also be performed laparoscopically guided by the CT findings.
Appendicitis; Stump appendicitis; Laparoscopic appendectomy
Double appendix represents an extremely rare and commonly “missed” diagnosis, often with life threatening consequences.
PRESENTATION OF CASE
In this case report we present an interesting case of operative treatment of acute appendicitis in a doubled vermiform appendix stemming operative pitfalls. A 23-year-old female was admitted to the emergency room department complaining of diffuse abdominal pain, nausea, and vomiting over the past 36 h. As soon as the diagnosis of acute appendicitis was established a laparotomy via a McBurney incision was decided. Intraoperative findings included the presence of mild quantity of free fluid and surprisingly a thin non-inflamed appendiceal process. It was the preoperative ultrasound findings suggestive of acute appendicitis that dictated a more thorough investigation of the lower abdomen that led to the discovery of a second retrocecal inflamed appendix. Formal appendectomy was then performed for both processes. The patient had an uneventful recovery and was discharged on the fourth postoperative day.
Double appendix represents a challenging clinical scenario in cases of right lower quadrant pain.
Life threatening consequences with legal extensions can arise from the incomplete removal of both stumps.
Double appendix; Acute appendicitis; Appendectomy; Ultrasonography; Abdominal pain
Intestinal schistosomiasis as unusual aetiology for acute appendicitis, nowadays a rising disease in western countries. Recent changes in global migration has led to an immigration growth in our scenario, upsurging people coming from endemic areas of schistosomiasis. Schistosomal appendicitis, seldom reported in developed countries, is now an expected incrising entity in our hospitals during the near future. Due to this circumstances, we believe that schistosomiasis should be consider as a rising source for acute appendicitis in western countries. In order to illustrate this point, we present a case of a 45-years-old black man, from Africa, was admitted via A&E because of acute abdominal pain, located in right lower quadrant. Acute appendicitis was suspected, and he underwent laparotomy and appendectomy. Pathological study by microscope revealed a gangrenous appendix with abscesses and parasitic ova into the submucosal layer of the appendix, suggesting Schistosomiasis.
Hernia appendicitis is a rare occurrence often described in association with groin hernias. We present a rare case of hernia appendicitis through a Pfannenstiel incision. Laparoscopy was performed with the intention to perform an appendectomy. An acutely inflamed appendix was visualized with the tip incarcerated into a 2 cm segment of the right most portion of a previous Pfannenstiel incision. Laparoscopic trans-hernial appendectomy with immediate laparoscopic suture herniorraphy was performed.
Early recognition of appendiceal hernias can be managed with appendectomy and suture herniorraphy omitting prosthetics. In cases with advanced pathology, approach should mimic that for emergent management of strangulated bowel and should be left to the surgeon’s discretion.
Appendicitis in leukemic patients is uncommon but associated with increased mortality. Additionally, leukemic cell infiltration of the appendix is extremely rare. While appendectomy is the treatment of choice for these patients, diagnosis and management of leukemia have a greater impact on remission and survival. A 59-year-old Caucasian female was admitted to the surgical service with acute right lower quadrant pain, nausea, and anorexia. She was noted to have leukocytosis, anemia, and thrombocytopenia. Abdominal imaging demonstrated appendicitis with retroperitoneal and mesenteric lymphadenopathy for which she underwent laparoscopic appendectomy. Peripheral smear, bone marrow biopsy, and surgical pathology of the appendix demonstrated acute myeloid leukemia (AML) with nonsuppurative appendicitis. In the setting of AML, prior cases described the development of appendicitis with active chemotherapy. Of these cases, less than ten patients had leukemic infiltration of the appendix, leading to leukostasis and nonsuppurative appendicitis. Acute appendicitis with leukemic infiltration as the initial manifestation of AML has only been described in two other cases in the literature with an average associated morbidity of 32.6 days. The prompt management in this case of appendicitis and AML resulted in an overall survival of 185 days.
Making the diagnosis of acute appendicitis is difficult, and is important for preventing perforation of the appendix and negative appendectomy results. Ultrasound and clinical scoring systems are very helpful in making the diagnosis. Ultrasound is non-invasive, available and cost-effective, and can accomplish more than CT scans. However, there is no certainty about its effect on the clinical outcomes of patients, and it is operator dependent. Counting the neutrophils as a parameter of the Alvarado Scale is not routine in many laboratories, so we decided to evaluate the diagnostic value of the Modified Alvarado Scaling System (MASS) by omitting the neutrophil count and ultrasonography.
After ethical approval of methodology in Tehran University of Medical Sciences ethical committee, we collected the data. During 9 months, 75 patients with right lower quadrant pain were enrolled in the study, and underwent abdominal ultrasonography and appendectomy, with pathological evaluation of the appendix. The MASS score was calculated for these patients and compared with pathology results.
Fifty-five male and 20 female patients were assessed. Of these patients 89.3% had acute appendicitis. The sensitivity, specificity, PPV, NPV and accuracy rate of ultrasonography was 71.2%, 83.3%, 97.4%, 25% and 72.4%, respectively. By taking a cutoff point of 7 for the MASS score, a sensitivity of 65.7%, specificity of 37.5%, PPV of 89.8%, NPV of 11.5% and accuracy of 62.7% were calculated. Using the cutoff point of 6, a sensitivity of 85.1%, specificity of 25%, PPV of 90.5%, NPV of 16.7% and accuracy of 78.7% were obtained.
Ultrasound provides reliable findings for helping to diagnose acute appendicitis in our hospital. A cutoff point of 6 for the MASS score will yield more sensitivity and a better diagnosis of appendicitis, though with an increase in negative appendectomy.
Appendicitis; Ultrasonography; Modified Alvarado Scoring System (MASS)
Gastrointestinal tuberculosis is quite rare, representing only 3% of all extrapulmonary cases. Involvement of the appendix is rare, only occurring in about 1% of cases. It is usually secondary to tuberculosis elsewhere in the abdomen. A prompt diagnosis depends on a high index of suspicion as clinical signs may be nonspecific and microbiological confirmation is difficult. Histopathologic examination is often the only way to reach a diagnosis and to establish specific antibiotic therapy. In these cases, due to the absence of specific symptoms and signs, the diagnosis is delayed until after surgery.
Acute appendicitis; peritoneal tuberculosis; tuberculosis; peritonitis; appendectomy
Tuberculosis primarily affecting the appendix is extremely rare and the diagnosis is difficult. Here, we report the case of a 14-year-old healthy boy presenting with right lower quadrant abdominal pain. On computed tomography, the distended appendix with 3.3 × 2.7 cm mass located at the right side of the right iliac artery was detected. There was neither bowel wall thickening nor active lung lesion. After laparoscopic appendectomy with mass excision, histopathological examination revealed chronic granulomatous inflammation, with caseous necrosis of the appendix. We made a diagnosis of primary tuberculosis of appendix and administrated anti-tuberculosis medication.
Tuberculosis; Appendicitis; Mesenteric lymphadenitis
Acute acalculous cholecystitis is traditionally associated with elderly or critically ill patients.
We present the case of an otherwise healthy 23-year-old Caucasian man who presented with acute right-sided abdominal pain. An ultrasound examination revealed evidence of acute acalculous cholecystitis. A laparoscopy was undertaken and the dual pathologies of acute acalculous cholecystitis and acute appendicitis were discovered and a laparoscopic cholecystectomy and appendectomy were performed.
Acute acalculous cholecystitis is a rare clinical entity in young, healthy patients and this report describes the unusual association of acute acalculous cholecystitis and appendicitis. A single stage combined laparoscopic appendectomy and cholecystectomy is an effective treatment modality.
A 48-year-old woman who was without any abnormal past medical history underwent colonoscopy as a screening procedure for colorectal disease. The procedure was uneventful and there was no sign of inflammation around the appendicular orifice or the luminal surface of the cecum. The patient did not complain of pain or significant discomfort throughout the procedure. She then developed pain in the right lower quadrant of the abdomen that evening and this persisted for four days. She visited the outpatient department and underwent abdominal ultrasonography, which showed a swollen appendix with a collection of pericecal fluid. Surgical exploration and appendectomy were performed; the final diagnosis was acute suppurative appendicitis. Colonoscopists should be aware of this rare complication and consider it when making the differential diagnosis of post-colonoscopy abdominal pain.
Acute appendicitis, as well as intestinal obstruction, is a common surgical emergencies. Both the conditions can present as an acute abdomen, however the diagnosis of acute appendicitis can be overlooked when it presents as a small bowel obstruction. Difficulties in correctly identifying the cause of pain can be hazardous to the patient and care needs to be taken in obtaining a prompt and accurate diagnosis enabling the most appropriate management. Appendiceal duplication although rare and difficult to diagnose preoperatively, should be checked while operating for appendicular pathology in order to avoid serious clinical and medicolegal implications.
We hereby report a case of appendiceal duplication presenting as small bowel obstruction with one appendix having acute appendicitis and the other one perforated in the middle third.
The presence of the appendix in a femoral hernia sac is known as de Garengeot's hernia. We report a rare case of an elderly woman with femoral hernia appendicitis and discuss the surgical pitfalls and considerations through a literature review.
Presentation of case
An 83-year-old woman presented with fever and right lower quadrant abdominal pain. Clinical examination revealed a femoral hernia. Ultrasonography confirmed bowel was present in the hernia sac. In the operation room, an acutely inflamed appendix was recognized within the sac. The patient underwent appendectomy and hernia repair with sutures.
Acute appendicitis within a femoral hernia is rare and multiple dilemmas exist regarding its treatment. An incision below the inguinal ligament is a reasonable choice in order to access the hernia sac. A mesh should be placed in non-infectious appendectomy while herniorrhaphy is preferred in cases of appendicitis.
The presence of the vermiform appendix in a femoral hernia sac is rare but the surgeon should be aware of this clinical entity. Prompt diagnosis and appropriate surgical treatment is the key to avoid complications.
de Garengeot hernia; Appendicitis; Femoral hernia; Groin hernia
Appendicitis in femoral hernia is a rare condition, which raises diagnostic challenge.
A 40-year-old man presented with painful right-sided groin swelling of 1-week duration. The area was explored, with presumpted diagnosis of inguinal abscess. At exploration a femoral hernia was found which contained a mildly inflammed appendix. Appendicectomy and hernia repair was done. Post surgical course was uneventful. We present this case with brief summary of literature pertaining to such lesions.
The rare occurrence of femoral hernia containing appendix may be explained by different degrees of intestinal rotation during development or variation in its attachment to the caecum. Inflammation is due to tight femoral ring. Preoperative diagnosis is difficult. Management options are diverse.
We present this case because of rarity. Early surgery prevents complications.
A 71-year-old man was diagnosed with an aggressive mantle cell lymphoma and was started on six cycles of R-CHOP chemotherapy. Approximately two weeks after starting his first cycle of chemotherapy, he complained of severe right lower quadrant abdominal pain, and an abdominal CT scan demonstrated an enlarged appendix with evidence of contained perforation. The man underwent open appendectomy for acute appendicitis and recovered. The appendectomy specimen was submitted for routine pathological analysis. There was histologic evidence of perforation in association with an inflammatory infiltrate with fibrin adhered to the serosal surface; scattered small lymphoid aggregates were present on the mucosal surface. Although the lymphoid aggregates in the submucosa and lamina propria were rather unremarkable by routine histologic examination, immunohistochemistry revealed the lymphocytes to be predominantly Cyclin D1-overexpressing B cells. To our knowledge, this is the first reported case of acute appendicitis in association with appendiceal involvement by mantle cell lymphoma.