Retroperitoneal leiomyosarcomas (RLMS) are a challenging clinical entity. The vast majority of patients are operated on when tumors are advanced. We report herein a case of RLMS, mimicking acute appendiceal disease and treated successfully via laparoscopy.
A 37-year-old woman, para 1, was admitted to our department for right lower quadrant abdominal pain, fever, and leukocytosis. She had no changes in gastrointestinal and urologic function. A physical examination revealed the presence of abdominal guarding, rebound, and a tender mass in the right lower quadrant. The abdominal ultrasound showed an inhomogeneous ovoid mass (6 cm in diameter) located below the cecum, with no definite margins, and consistent with an appendiceal abscess. The patient was referred for laparoscopy. The procedure was performed with the aid of 3 ports: a 12-mm trocar in the umbilicus (open technique), a 10-mm trocar in the left iliac fossa, and a 5-mm one in the suprapubic space. On inspection of the abdominal cavity, a retroperitoneal 6-cm mass was immediately found below the cecum and the appendix. Neither intraperitoneal seeding nor suspected lymph nodes were present. After dissection of the parietal peritoneum, the mass appeared to be encapsulated and well demarcated from all surrounding structures. It was eventually dissected and removed via a plastic bag. A standard appendectomy was also performed. The postoperative course was uneventful, and the patient was discharged on the 3rd day. The histology analysis of the resected specimen showed a totally excised G2 leiomyosarcoma. The appendix had no signs of inflammation. Postoperatively, the patient underwent a total-body CT-scan, which had no signs of residual or distant disease. No adjuvant therapy was necessary. At an 18-month follow-up, the patient was doing well and was disease free.
Surgery represents the main therapeutic option for resectable RLMS. Laparoscopy is a useful diagnostic tool that allows safe resection of incidentally discovered, small and well encapsulated RLMS.
Retroperitoneal leiomyosarcoma; Laparoscopy
Acute abdomen and acute appendicitis are unusual clinical presentations that occur in dengue infection–caused illness. Lymphoid hyperplasia and mesenteric adenitis are possible explanations, although vasculitis in the pathology of dengue infection has not been reported. Authors of previous case reports have described mimicking of acute appendicitis discovered upon surgical treatment. Dengue virus has not been proven to cause acute appendicitis.
We report a case of an 8-year-old Sinhalese boy who developed acute appendicitis during the acute phase of serologically confirmed dengue fever. Although abdominal pain, vomiting and right-sided tenderness were present at the time of admission, a diagnosis of acute appendicitis was considered only 18 hours later, when abdominal guarding and a well-defined mass in the right iliac fossa were detected clinically and ultrasonographically. Conservative management with intravenous antibiotics was successful.
In areas where dengue is endemic, awareness of dengue viral infection as a non-surgical cause of acute abdomen, as well as its ability to mimic acute appendicitis, is important because unnecessary surgery-related morbidity can be decreased. However, delaying or missing the diagnosis of acute appendicitis can result in serious complications. This message is particularly relevant to clinicians, especially pediatricians and surgeons, who encounter large numbers of patients during dengue epidemics and run the risk of missing the diagnosis of acute appendicitis. Likewise, delaying or missing the diagnosis of dengue hemorrhagic fever can lead to dengue shock syndrome and even death. This case highlights the need for careful evaluation of each patient who presents with acute abdomen and dengue infection.
Acute appendicitis; Dengue fever
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.
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.
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.
Dengue fever; Acute appendicitis; Acute abdomen; Leucopenia
Infarctions of the greater omentum and appendices epiploicae are uncommon, but well documented causes of acute abdominal pain. We present a rare case of torted fat on the parietal peritoneum over the anterior abdominal wall, mimicking clinical signs of acute appendicitis, which was diagnosed at laparoscopy. We are aware of only two other similar reported cases, both of which were diagnosed at the time of laparotomy.
A 41-year-old Caucasian woman presented with clinical signs of acute appendicitis. On diagnostic laparoscopy, a non-inflamed appendix was found. Further exploration revealed a necrotic torted appendage of fat overlying the parietal peritoneum of the right iliac fossa of the anterior abdominal wall.
Torted fatty appendages can be a diagnostic dilemma often mimicking more common causes of an acute abdomen. Laparoscopy is an excellent tool making the correct diagnosis in such cases.
Acute appendicitis is the most common cause of the right lower quadrant acute abdominal pain in children. Some other conditions including cecal epiploica appendix torsion, can simulate acute abdomen. Epiploica appendix torsion usually occurs in the sigmoid colon and rarely in the cecum of adult males. In children, this entity is extremely rare and may represent a diagnostic and therapeutic dilemma. We report a case of an 8-year-old Greek girl, presented with signs and symptoms mimicking acute abdomen. Our patient is the younger one among the other four with cecal epiploica appendix torsion that had been reported in the literature.
Female genital tuberculosis is a rare form of extrapulmonary tuberculosis. It is an asymptomatic disease usually diagnosed during the search for causes of infertility. However, it can present with a number of abdominopelvic symptoms. Herein we report a case of tubo-ovarian tuberculosis mimicking acute appendicitis.
A 17-year-old single Turkish woman presented to our hospital with complaints of right lower quadrant abdominal pain, nausea, and vomiting. Her physical examination findings, ultrasonogram, and leukocyte count were consistent with acute appendicitis. A cystic mass (15 cm × 6 cm) was detected on the right tubo-ovarian structure by laparotomy. The mass was excised while the tubo-ovarian structures were preserved and the need for an appendectomy was avoided. No microbiological evaluation was performed. The histopathological examination of the cystic mass revealed a granuloma with central caseating necrosis surrounded by epithelioid histiocytes. The patient was treated with anti-tuberculosis therapy for six months. No recurrence was observed during a 10-month follow-up period.
Genital tuberculosis should be considered in the differential diagnosis of right lower quadrant pain in women who live in tuberculosis-endemic regions.
Spontaneous non-occlusive ischemic colitis involving the cecum alone (isolated cecal necrosis) is a rare condition that is generally due to a low-flow state: shock. It presents with right lower quadrant abdominal pain and may resemble acute appendicitis. Little is known about postoperative ischemic necrosis of the remaining colon after surgical treatment of isolated cecal necrosis. We report four cases of isolated cecal necrosis mimicking acute appendicitis seen at our institution within a 4-year period.
The patients were two men and two women with a mean age at diagnosis of 59 years (range 46-68). The patients were of Turkish ethnic origin. All patients presented to the emergency room with acute abdominal pain and had symptoms of nausea and vomiting. The medical histories for three of the patients revealed end-stage renal failure requiring hemodialysis. The other patient had chronic obstructive pulmonary disease. Right hemicolectomy with anastomosis was performed in three patients and cecal resection with ileocolostomy was performed in the remaining one patient. All of the patients healed without complications. Median follow-up of patients was 24.5 (range: 17-37) months. There was no recurrence of ischemia in the remaining colon during the follow-up period of the patients.
Isolated cecal infarction should be included in the differential diagnosis of acute pain in the right lower quadrant of the abdomen, especially in those patients on chronic hemodialysis. While diffuse ischemic disease of the intestine has high morbidity, mortality and recurrence rates, patients with isolated cecal necrosis have a good prognosis with early diagnosis and surgical treatment compared to those with diffuse ischemic disease.
Vanek's tumour or Inflammatory Fibroid Polyp (IFP) are rare, benign localised lesions originating from the sub-mucosa of the gastrointestinal tract (GI) tract.1 They have been widely reported as occurring within the stomach, Duodenum, Jejunum and Ileum, more rarely (<1%) in the caecum or appendix.
Presentation of case
We present a case of a 28-year-old lady who presented with a 2-day history of right iliac fossa pain, nausea and low-grade fever. Subsequent, ultrasonography (USS) of the abdomen demonstrated an inflamed tubular structure originating from caecum with fluid in the pelvis mimicking an acute appendicitis. Next to normal appendix an inflammatory polypoid mass was identified and on histological examination confirmed to be an IFP (Vanek's tumour).
Right Iliac Fossa (RIF) pain with suspected appendicitis is one of the most common presentations in any acute surgical unit. In young women of childbearing age, the differential diagnosis can be varied and vast. The surgical management of IFP (Vanek's tumour) in such cases ranges from limited resection and caecectomy to limited right hemicolectomy.
To date, the exact histiogenesis of these tumours remains unclear and requires a high level of intra-operative suspicion. According to our search such presentation is not reported.
Vanek's tumour; Inflammatory fibroid polyp; Appendicitis; Caecal tumour
Right iliac fossa pain, nausea and vomiting in young adults are common symptoms that require careful surgical assessment with acute appendicitis being a common cause. Uncommonly, other conditions can mimic this presentation such as caecal diverticulitis. This condition is often misdiagnosed due to lack of characteristic features and the commonest method of detection is an intraoperative one. Hereby, we describe a rare case of right iliac fossa pain in a 34-year-old female which mimicked an acute appendicitis. The ability to recognize such condition is vital as its management is different and worse outcome can be prevented by earlier detection and proper management.
Hemangiomas are the most common benign neoplasms affecting the liver. They occur at all ages. Most cases are asymptomatic and do not require any treatment. Rarely, hemangiomas can be pedunculated. İf they undergo torsion and infarction, they become symptomatic. Herein; we report the case of a 31 year old male presenting with features of acute appendicitis: continuous right iliac fossa pain, rebound, guarding tenderness at McBurney' s point, nausea, anorexia, shifted white blood cell count and a Mantrels score of 6. At laparotomy a normal appendix was observed and a torsioned pedinculated liver hemangioma turned out to be the cause.
Gastrointestinal perforation due to a foreign body is not unknown. The foreign body often mimics another cause of acute abdomen and requires emergency surgical intervention. The majority of patients do not recall ingesting the foreign body. Perforations have been reported to occur in a pathologically abnormal colon.
We report an interesting case of a 47-year-old Caucasian man who had a perforation of the sigmoid colon caused by an ingested chicken bone mimicking acute appendicitis. Our patient presented with right iliac fossa pain and local tenderness. When a laparotomy was performed, a chicken bone was found protruding through the sigmoid colon, which was found to lie in the right iliac fossa, thus mimicking acute appendicitis. Our case is different from previously reported cases in that perforation occurred in a non-pathological colon.
Our case emphasises the fact that the operating surgeon has to be aware of various differential diagnostic possibilities which mimic acute appendicitis. This has implications on the training of junior surgeons who are often involved in performing these procedures, and may do so out of hours. Care needs to be taken while obtaining consent for the necessary operation.
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
Appendicitis epiploicae is described as a rare entity in an 8-year-old boy presented with the features of acute abdomen simulating acute appendicitis. Surgical exploration revealed a torsion of appendices epiploicae of the cecum. The excision of infarcted epiploicae with seromuscular inversion resulted in satisfactory recovery. Authors describe this uncommon cause of pediatric acute abdomen along with the review of pertinent literature.
Acute abdomen; appendicitis epiploicae; children
Meckel’s diverticulum is the commonest congenital abnormality of the gastrointestinal tract. Most of them are asymptomatic but can rarely present with forms of complications such as bleeding, obstruction, diverticulitis, intussusception and neoplasm. Patients with a perforation of Meckel’s diverticulum by a foreign body are rare and may present with right iliac fossa pain, which mimics acute appendicitis.
A 64-year-old Greek man presented with an eight-hour history of right iliac fossa pain. On examination, our patient had tenderness in his right iliac fossa. A provisional diagnosis of acute appendicitis was made. He was taken to theatre with the option of an appendicectomy. His appendix was found to have an about normal appearance. An inflamed Meckel’s diverticulum that had been perforated by a fish bone was found to be the cause of the abdominal pain. A Meckel’s diverticulectomy was performed. Our patient made an uneventful recovery and was discharged after two days.
Complications of Meckel’s diverticulum can be difficult to diagnose and early recognition and timely operative intervention must occur in order to provide the best outcome for these patients. This is an interesting and unusual case of perforation of Meckel’s diverticulum that highlights the importance of considering Meckel’s diverticulum as a differential diagnosis in every patient presenting with acute abdomen.
Meckel’s diverticulum; Perforation; Acute appendicitis
The literature is replete with articles of foreign-body appendicitis and periappendicitis, but to our knowledge there are only two reports of extraintestinal foreign bodies causing contact appendicitis.
A 47-year old woman presented to the emergency department with a 24-hour history of right iliac fossa pain, nausea and vomiting, high fever and palpable right iliac fossa mass. The patient had an anamnestic of systemic lupus erythematosus, that caused acute pericarditis with effusion, that was treated with pericardiotomy and a pericardial drain. The laboratory tests showed leukocytosis The plain abdomen film showed no radiologic signs corresponding to acute abdomen, while the computed tomography revealed a radio-opaque formation in the right iliac fossa, corresponding to the palpable mass. Exploratory laparotomy revealed a pericardial drain. The microbiologic analysis of the abscess revealed Salmonella. The postoperative course of the patient was uneventful.
Acute appendicitis due to a foreign body, without an anamnestic of either surgery or injury may cause a severe diagnostic dilemma. The computed tomography images may lead to logic riddles that have to be solved by an explorative laparotomy. Foreign bodies rarely cause acute abdomen, nevertheless the probability has to be considered when an interventional technique has been applied even if the location of the intervention is far from the abdominal cavity.
Patient: Female, 19
Final Diagnosis: Acute perforated appendicitis • appendiceal abscess • secondary necrosis of the ileal wall
Symptoms: Right lower quadrant abdominal pain • fever
Clinical Procedure: Diagnostic laparoscopy • open drainage of an appendiceal abscess • appendectomy • ileal resection
Management of emergency care
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.
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.
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.
Abdominal Abscess; Appendicitis; Intestine, Small
Acute appendicitis is a common condition seen in all surgical units. One rare condition that can mimic acute appendicitis is a nematode infection of the bowel. There have been few reported cases of nematode infection within the appendix and none that have been accompanied by intra-operative pictures.
PRESENTATION OF CASE
A 16-year-old female presented with a 12 h history of right iliac fossa pain and mild pyrexia. Bloods showed a neutrophilia and normal C-reactive protein. Laparoscopy was performed which revealed a non-inflamed appendix. The appendix was dissected and a live nematode was visualised exiting the base of the appendix. Anti-helminthics were given and the infection resolved.
Nematode infection is most commonly seen in Africa, Asia and South America. When seen within the United Kingdom (UK), it is seen most commonly within high-risk populations. Testing for these infections is not routine within the UK and when they are performed, the results take a considerable amount of time to return. These tests should be considered within high-risk populations so that unnecessary surgery can be avoided.
This case highlights the importance of considering rare causes of right iliac fossa pain including nematode infection in a young patient. The case highlights this by giving intra-operative pictures of live nematodes upon dissection of the appendix.
Appendicitis; Right iliac fossa pain; Nematode; Helminth; Laparoscopy
Right iliac fossa (RIF) pain is the most common presenting complaint in the general surgical ward. Though there are several causes for the RIF pain, acute appendicitis is the first and common diagnosis. Here we present one of the rare differential diagnoses of RIF pain in a young female patient with one month history of intermittent right lower abdominal pain. Patient’s symptoms and clinical findings indicated acute appendicitis, though ultrasonography didn’t show any significant abnormality. Through diagnostic laparoscopy we found that there was torsion of anterior abdominal wall parietal peritoneal pedunculated lipoma located in RIF region. The clinical presentation, examination, investigation, laparoscopic findings and further management is presented in this case report.
Diagnostic laparoscopy; Pedunculated lipoma; Right iliac fossa (RIF) pain; Torsion
Atypical presentations of appendix have been reported including backache, left lower quadrant pain and groin pain from a strangulated femoral hernia containing the appendix. We report a case presenting an epigastric pain that was diagnosed after computed tomography as a perforated appendicitis on intestinal malrotation.
PRESENTATION OF CASE
A 27-year-old man was admitted with a three-day history of epigastric pain. Physical examination revealed tenderness and defense on palpation of epigastric region. There was a left subcostal incision with the history of diaphragmatic hernia repair when the patient was 3 days old. He had an intestinal malrotation with the cecum fixed at the epigastric region and the inflamed appendix extending beside the left lobe of liver.
While appendicitis is the most common abdominal disease requiring surgical intervention seen in the emergency room setting, intestinal malrotation is relatively uncommon. When patients with asymptomatic undiagnosed gastrointestinal malrotation clinically present with abdominal pain, accurate diagnosis and definitive therapy may be delayed, possibly increasing the risk of morbidity and mortality.
Atypical presentations of acute appendicitis should be kept in mind in patients with abdominal pain in emergency room especially in patients with previous childhood operation for diaphragmatic hernia.
Perforated appendicitis; Unusual presentation; Laparoscopy; Epigastric; Malrotation; Diaphragmatic hernia
Although in most cases the diagnosis of acute appendicitis is straightforward, not all patients experience typical symptoms and other conditions may mimic appendicitis. In fact, 15–25% of appendectomies involve the removal of a normal appendix. To date, there is no literature evidence that herniation pit (HP) may mimic acute appendicitis. We report a case of a 30 year old woman admitted to the Emergency Department for severe, acute pain developing a few hours earlier in the lower right fossa, with irradiaton to the right thigh. She did not present any fever, nausea or vomiting, Blumberg’s sign was absent but the psoas sign and obturator sign were both positive. WBC count was 16,000/mm3 and the Alvarado score was 4. Biochemistry profile was normal. US was unclear and transvaginal ultrasound did not show any gynecological disease. CT scan showed only an herniation pit of the right femoral neck. The patient was admitted to an orthopedic ward and treated with anti-inflammatory therapy. She was discharged after 2 days without any pain and in good conditions. Our case demonstrates that herniation pits of the right femoral neck should be considered a potential cause of right lower abdominal pain mimicking acute appendicitis, particularly if the psoas sign and obturator sign are positive and the patient is physically active.
Femoral neck; Herniation pit; Acute appendicitis; Abdominal pain
A 78-years-old man presented with right lower quadrant pain for 2 months. Computed tomography revealed an irregular and multicystic mass near the cecum like as appedeceal mucocle. The lesion was diagnosed xanthogranulomatous appendicitis by histopathological findings of surgical specimen. Xanthogranuloma is uncommon disease, especially in the appendix. We report an interesting case of xanthogranulomatous appendicitis mimicking appendiceal mucocele in radiological images.
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.
Appendicolith; Stump appendicitis; Endoscopic removal
Despite reported poor sensitivity and specificity, plain abdominal radiographs have a role in the investigation of suspected appendicitis.
PRESENTATION OF CASE
We report a case of a previously healthy 47 year old man, who presented with sudden onset abdominal pain associated with a raised temperature. He gave a short history of pain around the umbilicus, which radiated to his right iliac fossa over a period of hours. On examination his abdomen was soft with rebound tenderness in the right iliac fossa. Investigations revealed white cell count 11.2 × 109/L, CRP 4 mg/L and normal haemoglobin, renal and liver function tests. An inflamed appendix was visible with thickened walls on a plain abdominal radiograph and was confirmed during laparoscopic appendectomy and subsequent histology. He made good recovery and was discharged.
Prominent appendiceal wall and air in the appendix has been described in the literature as a CT finding that can distinguish appendicitis from other differential diagnoses and here we present a case of diagnosis of appendicitis on a plain abdominal radiograph showing this sign which to the best of our knowledge is rarely seen on abdominal films.
Careful assessment of plain abdominal films in suspected appendicitis is encouraged not just for exclusion of other causes of pain but also in the possible detection of an inflamed appendix.
Abdominal; Radiograph; Diagnosis; Appendicitis; Prominent; Wall
Endometriosis is a common disease generally, but appendiceal endometriosis causing acute appendicitis is a very uncommon clinical phenomenon and a few cases have been reported. The authors aim to highlight the rarity of such clinical entity in Nigeria. A 29 year old nulliparous woman presented with severe right iliac fossa pains, tenderness and rebound tenderness on her second day of menstruation. She subsequently had appendicectomy and a histopathological diagnosis of appendiceal endometriosis causing acute appendicitis. Appendiceal endometriosis causing acute appendicitis is rare, and definitive diagnosis is performed through histopathological evaluation. Post-operative gynaecological follow-up is highly recommended.
Appendix; Endometriosis; Appendicitis
A 61-year-old male was admitted to our hospital due to right lower abdominal pain and watery diarrhea for 3 d. Beginning 3 wk before he arrived in our hospital, he took 3rd-generation cephalosporin (cefixime) for
2 wk due to chronic left ear otitis media. Colonoscopic examination revealed yellowish patches of ulcerations and swelling covered with thick serosanguineous exudate in the cecum and ascending colon. After 7 d of oral metronidazole treatment, his symptoms completely disappeared. We report a case of localized pseudomembranous colitis in the cecum and ascending colon mimicking acute appendicitis associated with cefixime.
Enterocolitis; Pseudomembranous; Appendicitis; Abdomen; Acute; Diarrhea; Cefixime