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1.  Stump Appendicitis: An Uncompleted Surgery, a Rare but Important Entity with Potential Problems 
Case Reports in Surgery  2013;2013:972596.
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.
doi:10.1155/2013/972596
PMCID: PMC3638532  PMID: 23691424
2.  An unsuspected clinical condition: Appendicitis of appendicular residual, three cases report 
INTRODUCTION
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.
DISCUSSION
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.
CONCLUSION
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.
doi:10.1016/j.ijscr.2013.01.026
PMCID: PMC3605474  PMID: 23474976
Stump appendicitis; Appendicular remanent; Incomplete appendectomy
3.  A stump appendicitis in a child: a case report 
Background
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.
Case
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.
Conclusion
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.
doi:10.1186/1824-7288-35-35
PMCID: PMC2784782  PMID: 19919712
4.  A Case of Endoscopic Removal of a Giant Appendicolith Combined with Stump Appendicitis 
Clinical Endoscopy  2014;47(1):112-114.
Stump appendicitis is an acute inflammation of the residual appendix and is a rare complication after appendectomy. The physician should be aware of the possibility of stump appendicitis in patients with right lower abdominal pain after appendectomy so that delayed diagnosis and treatment can be prevented. Stump appendicitis is usually treated by surgical resection, and endoscopic treatment has not been reported previously. A 48-year-old man who had undergone appendectomy 35 years earlier presented to the hospital because of right lower quadrant discomfort. A computed tomography scan showed a large stone in the residual appendix. Colonoscopic findings revealed a large, smooth, protruding lesion at the cecum with a stone inside the appendiceal orifice. Endoscopic removal after incision of the appendiceal orifice was performed successfully.
doi:10.5946/ce.2014.47.1.112
PMCID: PMC3928483  PMID: 24570893
Appendicolith; Stump appendicitis; Endoscopic removal
5.  Clinical significance of de Garengeot's hernia: A case of acute appendicitis and review of the literature 
Introduction
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.
Discussion
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.
Conclusion
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.
doi:10.1016/j.ijscr.2011.12.003
PMCID: PMC3267278  PMID: 22288062
de Garengeot hernia; Appendicitis; Femoral hernia; Groin hernia
6.  Acute appendicitis in a duplicated appendix 
INTRODUCTION
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.
DISCUSSION
Double appendix represents a challenging clinical scenario in cases of right lower quadrant pain.
CONCLUSION
Life threatening consequences with legal extensions can arise from the incomplete removal of both stumps.
doi:10.1016/j.ijscr.2012.08.004
PMCID: PMC3437396  PMID: 22922359
Double appendix; Acute appendicitis; Appendectomy; Ultrasonography; Abdominal pain
7.  Stump appendicitis is a rare delayed complication of appendectomy: A case report 
Stump appendicitis is an acute inflammation of the residual appendix and one of the rare complications after appendectomy. Paying attention to the possibility of stump appendicitis in patients with right lower abdominal pain after appendectomy can prevent the delay of diagnosis and treatment. In patients with stump appendicitis, CT scan not only assists in making an accurate preoperative diagnosis but also excludes other etiologies. We report a 47-year old man with preoperatively diagnosed stump appendicitis by CT, who underwent an open appendectomy 20 years ago.
doi:10.3748/wjg.v12.i33.5401
PMCID: PMC4088215  PMID: 16981278
Stump appendicitis; Delayed complication; Preoperative diagnosis; Computed tomography; Incomplete appendectomy
8.  Appendiceal stump closure by metal endoclip in the management of complicated acute appendicitis 
Background
Closure of appendicular stump has been performed in different ways; however, the use of the metal endoclip in complicated grades of acute appendicitis, has not been evaluated yet in a prospective way.
Objective
To establish the effectiveness of appendiceal stump closure by metal endoclip for complicated appendicitis.
Method
From January 2009 to January 2011 were evaluated 131 consecutive patients who underwent a laparoscopic appendectomy for complicated acute appendicitis. From those, 118 underwent appendiceal stump closure by metal endoclip. The patient’s age ranged from 12 to 75 years old (31.7 ± 13.3) and 52.7% were male. Complicated appendicitis refers to gangrenous and/or perforated appendix, which may lead to abscess formation and degrees of peritonitis. The outcomes viability, operative time, infection complication, operative complications, and conversion rate were chosen to evaluate the procedure.
Results
The appendiceal stump closure by metal endoclip was used in 90% of cases. The presence of appendix base necrosis was the most important factor involved in failure of the procedure. Laparoscopic knot (1.5%), laparoscopic endo-suture (3.8%) and video assisted laparotomy (4.7%) were the alternatives used in difficult cases. The mean operative time was (67.54 ± 28.13 minutes). The wound and intra-abdominal infection rates were 2.54% and 5.08%, respectively. There were no operative complications and the conversion rate was 0.85%.
Conclusion
The appendiceal stump closure by metal endoclip, in complicated grades of acute appendicitis, is a safe and effective procedure. In patients with appendix base necrosis it should be avoided in favor of other alternatives.
doi:10.1186/1749-7922-8-35
PMCID: PMC3874646  PMID: 24047531
Complicated appendicitis; Appendectomy; Laparoscopy; Appendiceal stump
9.  Acute Appendicitis following Laparoscopic Live Donor Nephrectomy 
Acute abdominal pain following laparoscopic live donor nephrectomy (LLDN) might be a diagnostic dilemma, and prompt diagnosis and management is of paramount importance. Herein, we describe a case of acute appendicitis in a 62-year-old kidney donor who presented with acute abdominal pain 16 days following LLDN with features inconsistent with a diagnosis of acute appendicitis. An ultrasound scan suggested strangulated Spigelian hernia unrelated to the operative wound. Exploration of the wound and mini-laparotomy showed no evidence of wound dehiscence or a hernia, but revealed an inflamed appendix wrapped up with omentum. Appendectomy led to complete recovery of the patient. It is imperative to maintain a high index of suspicion for acute appendicitis in this situation to avoid septic complications that might adversely affect the residual renal function and cause negative impact on kidney donation. To the best of our knowledge, this is the first reported case of acute appendicitis following LLDN.
PMCID: PMC4089221  PMID: 25013574
Appendicitis; Laparoscopic donor nephrectomy; Kidney donor
10.  Appendectomy and Resection of the Terminal Ileum with Secondary Severe Necrotic Changes in Acute Perforated Appendicitis 
Patient: Female, 19
Final Diagnosis: Acute perforated appendicitis • appendiceal abscess • secondary necrosis of the ileal wall
Symptoms: Right lower quadrant abdominal pain • fever
Medication: —
Clinical Procedure: Diagnostic laparoscopy • open drainage of an appendiceal abscess • appendectomy • ileal resection
Specialty: Surgery
Objective:
Management of emergency care
Background:
Resectional procedures for advanced and complicated appendicitis are performed infrequently. Their extent can vary: cecal resection, ileocecectomy, and even right hemicolectomy. We present a very rare case of appendectomy that was combined with partial ileal resection for severe necrotic changes and small perforation of the ileum.
Case Report:
A 19-year-old female patient was hospitalized with right iliac fossa pain and fever 10 days after the onset of symptoms. On laparoscopy, a large mass in a right iliac fossa was found. The ultrasound-guided drainage of the suspected appendiceal abscess was unavailable. After conversion using McBurney’s incision, acute perforated appendicitis was diagnosed. It was characterized by extension of severe necrotic changes onto the ileal wall and complicated by right iliac fossa abscess. A mass was bluntly divided, and a large amount of pus with fecaliths was discharged and evacuated. Removal of necrotic tissues from the ileal wall led to the appearance of a small defect in the bowel. A standard closure of this defect was considered as very unsafe due to a high risk of suture leakage or bowel stenosis. We perform a resection of the involved ileum combined with appendectomy and drainage/tamponade of an abscess cavity. Postoperative recovery was uneventful. The patient was discharged on the 15th day.
Conclusions:
In advanced appendicitis, the involved bowel resection can prevent possible complications (e.g., ileus, intestinal fistula, peritonitis, and intra-abdominal abscess). Our case may be the first report of an appendectomy combined with an ileal resection for advanced and complicated appendicitis.
doi:10.12659/AJCR.892471
PMCID: PMC4307687  PMID: 25618525
Abdominal Abscess; Appendicitis; Intestine, Small
11.  Acute appendicitis secondary to Enterobius vermicularis infection in a middle-aged man: a case report 
Introduction
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.
Case presentation
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.
Conclusion
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.
doi:10.1186/1752-1947-5-559
PMCID: PMC3245485  PMID: 22128765
12.  The NOTA study: non-operative treatment for acute appendicitis: prospective study on the efficacy and safety of antibiotic treatment (amoxicillin and clavulanic acid) in patients with right sided lower abdominal pain 
BMJ Open  2011;1(1):e000006.
Background
Case control studies that randomly assign patients with diagnosis of acute appendicitis to either surgical or non-surgical treatment yield a relapse rate of approximately 14% at one year. It would be useful to know the relapse rate of patients who have, instead, been selected for a given treatment based on a thorough clinical evaluation, including physical examination and laboratory results (Alvarado Score) as well as radiological exams if needed or deemed helpful. If this clinical evaluation is useful, the investigators would expect patient selection to be better than chance, and relapse rate to be lower than 14%. Once the investigators have established the utility of this evaluation, the investigators can begin to identify those components that have predictive value (such as blood analysis, or US/CT findings). This is the first step toward developing an accurate diagnostic-therapeutic algorithm which will avoid risks and costs of needless surgery.
Methods/design
This will be a single-cohort prospective observational study. It will not interfere with the usual pathway, consisting of clinical examination in the Emergency Department (ED) and execution of the following exams at the physician's discretion: full blood count with differential, C reactive protein, abdominal ultrasound, abdominal CT. Patients admitted to an ED with lower abdominal pain and suspicion of acute appendicitis and not needing immediate surgery, are requested by informed consent to undergo observation and non operative treatment with antibiotic therapy (Amoxicillin and Clavulanic Acid). The patients by protocol should not have received any previous antibiotic treatment during the same clinical episode. Patients not undergoing surgery will be physically examined 5 days later. Further follow-up will be conducted at 7, 15 days, 6 months and 12 months. The study will conform to clinical practice guidelines and will follow the recommendations of the Declaration of Helsinki. The protocol was approved on November 2009 by Maggiore Hospital Ethical Review Board (ID CE09079).
Trial Registration
ClinicalTrials.gov identifier: NCT01096927.
Article summary
Article focus
Acute appendicitis can have severe complications including perforation and generalised peritonitis.
The appendix is found to be free of disease in 15–30% of appendectomies.
As surgery carries various risks, conservative non-surgical treatment with antibiotics for suspected appendix inflammation may avoid needless surgery, in particular as the relapse rate is low and the rate of complications is similar.
Key messages
Case control studies that randomly assign patients with acute appendicitis to either surgical or non-surgical treatment show a relapse rate of approximately 14% at 1 year.
The relapse rate of patients who are treated based on a thorough clinical evaluation should be below 14%.
Once factors predictive of outcome and/or the need of surgery are identified, an accurate diagnostic-therapeutic algorithm which will help avoid the risks and costs of needless surgery can be developed.
Strengths and limitations of this study
This non-randomised controlled study will evaluate the effectiveness and short and long term outcomes of non-operative antibiotic treatment of acute appendicitis.
Amoxicillin and clavulanic acid are common and easily managed low cost drugs, available both for intravenous and oral use.
Better analysis of clinical data might lead to better decision-making in patients with right iliac fossa pain and suspected acute appendicitis.
The study also aims to evaluate the Alvarado score, which is used to diagnose acute appendicitis and discriminate patients needing immediate surgery from patients who may safely undergo observation and antibiotic treatment.
A large sample of patients undergoing non-operative antibiotic treatment will allow a statistically powerful evaluation of safety, efficacy and cost.
An additional objective is to identify clinical, laboratory and imaging findings that are predictive of failure of conservative treatment and/or relapse of appendicitis and need for appendectomy within 1 year.
As efficacy can not be reliably determined in the absence of a control group, a case series observation determining ‘efficacy’ has limited value.
The Alvarado score is used to separate those with acute appendicitis from those with similar symptoms but no appendicitis and there is no evidence that this score can identify those who would benefit from antibiotic treatment.
doi:10.1136/bmjopen-2010-000006
PMCID: PMC3191386  PMID: 22021722
Lower abdominal Pain; right iliac fossa pain; acute appendicitis; antibiotic therapy; conservative Management; appendectomy; recurrence; length of hospital stay; sick leave time; short and long Term abdominal pain evaluation; study protocol; case control study
13.  Stump appendicitis: A rare clinical entity 
Stump appendicitis is one of the rare delayed complications after appendectomy with reported incidence of 1 in 50,000 cases. Stump appendicitis can present as a diagnostic dilemma if the treating clinician is unfamiliar with this rare clinical entity. We report an 18-year-old patient with Stump appendicitis, who underwent completion appendectomy laparoscopically.
doi:10.4103/0972-9941.118835
PMCID: PMC3830137  PMID: 24250064
Completion appendicectomy; laparoscopic appendectomy; stump appendicitis
14.  Barium Appendicitis 1 Month After a Barium Meal 
International Surgery  2012;97(4):296-298.
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.
doi:10.9738/CC160.1
PMCID: PMC3727263  PMID: 23294068
Appendicitis; Barium; Appendicolith
15.  Stump Appendicitis following Laparoscopic Appendectomy 
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.
PMCID: PMC3074687  PMID: 21509217
Appendicitis; Stump; Surgery; Case report; India
16.  Acute Myeloid Leukemia Presenting as Acute Appendicitis 
Case Reports in Hematology  2013;2013:815365.
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.
doi:10.1155/2013/815365
PMCID: PMC3693109  PMID: 23840984
17.  Stump Appendicitis: A Surgeon's Dilemma 
The authors make the point that completion appendectomy in cases of stump appendicitis should be performed laparoscopically when possible guided by CT scan findings.
Background:
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.
Database:
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.
Conclusion:
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.
doi:10.4293/108680811X13125733356954
PMCID: PMC3183543  PMID: 21985727
Appendicitis; Stump appendicitis; Laparoscopic appendectomy
18.  Metastasis from prostatic carcinoma causing acute appendicitis: Report of a case 
INTRODUCTION
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.
DISCUSSION
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.
CONCLUSION
Metastasis induced acute appendicitis should be considered as part of the differential diagnosis when a oncologic patient presents with signs of acute appendicitis.
doi:10.1016/j.ijscr.2013.01.011
PMCID: PMC3604713  PMID: 23500745
Appendix; Cancer; Metastasis; Prostate
19.  Left-sided appendicitis in a patient with situs inversus totalis 
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.
doi:10.4174/jkss.2012.83.3.175
PMCID: PMC3433555  PMID: 22977765
Situs inversus; Appendicitis; Laparoscopic; Appendectomy
20.  Successfully treated stump appendicitis diagnosed by CT and ultrasonography 
The Indian Journal of Surgery  2008;70(2):89-91.
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.
doi:10.1007/s12262-008-0024-x
PMCID: PMC3452401  PMID: 23133030
Stump appendicitis; CT; Ultrasonography
21.  Appendiceal diverticulum associated with chronic appendicitis 
Highlights
•We present a rare case of the association of an appendiceal diverticulum and chronic appendicitis in one patient.•The relevance of this case relies on the importance of the adequate knowledge of these pathologies, so we can approach them correctly.•We emphasize the importance of a surgical approach in both pathologies.
INTRODUCTION
Appendiceal diverticulosis is a rare entity, with a global incidence between 0.004% and 2.1% of all appendectomies. It has been related with an elevated risk of perforation in comparison to acute appendicitis, as well as an increased risk for synchronic appendicular cancer in 48% of the cases, and colonic cancer in 43%. The incidence of chronic appendicitis has been reported in 1.5% of all appendicitis cases.
PRESENTATION OF CASE
We present a 73-year-old female, with no relevant familial history, who presented due to a four-month-long oppressive, moderate pain in the lower right abdominal quadrant without irradiation or any other accompanying symptoms.
DISCUSSION
The documented incidence of appendiceal diverticula and chronic appendicitis by themselves is low; therefore the presence of both entities at the same time is extremely rare.
CONCLUSION
We present a case in which both diagnoses concurred in the same patient. The relevance of this case relies on the importance of the adequate knowledge of these pathologies, so we can approach them correctly. Although it does not represent an absolute surgical emergency, appendectomy represents the first therapeutic option.
doi:10.1016/j.ijscr.2014.10.066
PMCID: PMC4275807  PMID: 25460447
Appendiceal diverticulum; Chronic appendicitis; Chronic pain
22.  Scrotal abscess as a complication of perforated appendicitis: A case report and review of the literature 
Cases Journal  2008;1:165.
Introduction
Abscess formation following appendectomy is well known, especially when complicated by perforation. Infectious complications are the most common. Intraabdominal abscess formation, Pelvic abscess and wound infection are the most common sites of infection. Scrotal abscess following acute perforated appendicitis is very rare.
Cases presentation
We report two cases of scrotal abscess following perforated appendicitis, one was 1983 and the other in 1997. The first patient developed acute left hemiscrotum two weeks following correction of a tetralogy of Fallot that was diagnosed since infancy. Scrotal drainage as well as open appendectomy and abdominal drainage were followed by uneventful recovery. Six weeks later left groin exploration revealed patent processus vaginalis which was ligated. The second patient developed redness, swelling and pain in his left hemiscrotum 10 days after open appendectomy for perforated appendicitis. Groin exploration, ligation of a PPV and scrotal drainage was made. Recent reports on the subject, review of the literature, the rarity of the complication, and the possible association with recent introduction of laparoscopic appendectomy.
Conclusion
Acute scrotal swelling is frequently a surgical emergency. Developing in the post-operative period is no exception. Symptoms and signs may be hampered by analgesia, pain, and antibiotics, usually administered in this period. Reporting these rare complications following such a common procedure, especially now a day in the era of laparoscopic surgery. Only high degree of suspicion and vigilant intervention will accomplish a safe diagnosis and treatment. The appropriate time and approach to both abscess and PPV is still controversial. Until enough case reports treatment is to be individualized.
doi:10.1186/1757-1626-1-165
PMCID: PMC2562359  PMID: 18803815
23.  Imaging As An Aid To The Diagnosis Of Acute Appendicitis 
Acute appendicitis has been known as a disease entity for well over a century but a confident diagnosis before surgery in all patients suspected of the condition is still not possible. Timely diagnosis is essential to minimise morbidity due to possible perforation of the inflamed organ in the event treatment is delayed; so much so that surgeons often preferred to operate at the slightest suspicion of the diagnosis in the past. This resulted in the removal of many normal appendixes. When the diagnosis of appendicitis is clear from the history and clinical examination, then no further investigation is necessary and prompt surgical treatment is appropriate. Where there is doubt about the diagnosis however it is advisable to resort to imaging studies such as abdominal ultrasound or computed tomography to clear such suspicions before subjecting the patient to an appendicectomy. These studies would also help avoid delays in surgery in deserving patients.
PMCID: PMC4170352  PMID: 25606095
Appendicitis; diagnosis; computed tomography; ultrasound
24.  Diagnostic values of ultrasound and the Modified Alvarado Scoring System in acute appendicitis 
Background
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.
Methods
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.
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.
Conclusion
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.
doi:10.1186/1865-1380-5-26
PMCID: PMC3410771  PMID: 22673121
Appendicitis; Ultrasonography; Modified Alvarado Scoring System (MASS)
25.  Dengue fever mimicking acute appendicitis: A case report☆ 
INTRODUCTION
Dengue fever is an acute viral disease, which usually presents as a mild febrile illness. Patients with severe disease present with dengue haemorrhagic fever or dengue toxic shock syndrome. Rarely, it presents with abdominal symptoms mimicking acute appendicitis. We present a case of a male patient presenting with right iliac fossa pain and suspected acute appendicitis that was later diagnosed with dengue fever following a negative appendicectomy.
PRESENTATION OF CASE
A 13-year old male patient presented with fever, localized right-sided abdominal pain and vomiting. Abdominal ultrasound was not helpful and appendicectomy was performed due to worsening abdominal signs and an elevated temperature. A normal appendix with enlarged mesenteric nodes was found at surgery. Complete blood count showed thrombocytopenia with leucopenia. Dengue fever was now suspected and confirmed by IgM enzyme-linked immunosorbent assay against dengue virus.
DISCUSSION
This unusual presentation of dengue fever mimicking acute appendicitis should be suspected during viral outbreaks and in patients with atypical symptoms and cytopenias on blood evaluation in order to prevent unnecessary surgery.
CONCLUSION
This case highlights the occurrence of abdominal symptoms and complications that may accompany dengue fever. Early recognition of dengue fever mimicking acute appendicitis will avoid non-therapeutic operation and the diagnosis may be aided by blood investigations indicating a leucopenia, which is uncommon in patients with suppurative acute appendicitis.
doi:10.1016/j.ijscr.2013.08.017
PMCID: PMC3825978  PMID: 24096347
Dengue fever; Acute appendicitis; Acute abdomen; Leucopenia

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