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.
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 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.
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.
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.
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.
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
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
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
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
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.
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.
Acute appendicitis is one of the most common causes of right lower quadrant acute abdominal pain in adults. Some other conditions, including appendicitis epiploicae, can simulate an acute abdomen. Appendicitis epiploicae or epiploic appendicitis usually originates in the sigmoid colon and rarely from other parts of colon. We report a case of a 20-year-old man with appendicitis epiploicae of the caecum, who underwent surgery for acute appendicitis. Analysis of this uncommon condition, together with a review of the pertinent literature, are presented.
Interval appendicectomy is not routinely indicated after successful resolution of an appendix mass. Whether this policy can also be applied to patients with appendicular foreign body presenting with an appendix mass remains a matter of debate. We report here a patient who presented with recurrent symptoms following conservative management of an appendicular mass associated with a foreign body in the appendix. We also review the available literature briefly.
A 70 year old gentleman was admitted with right iliac fossa pain, tenderness, and raised inflammatory markers. A computed tomography scan of his abdomen showed an appendix mass with a small abscess and a linear opaque foreign body. His symptoms resolved completely on conservative management with intravenous antibiotics. A colonoscopy few weeks later was unremarkable. He presented with recurrent symptoms a few months later. A repeat computed tomography scan showed persistent appendicular abscess with the same foreign body in it. A laparotomy with appendicectomy, abscess drainage and removal of the foreign body was carried out with satisfactory outcome.
Surgeons should be aware of appendicular foreign body as a cause of persistent/recurrent symptoms after conservative management of appendicular mass. These patients require prompt surgery and formal appendicectomy. Interval appendicectomy should be considered.
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.
Common complications of Henoch-Schönlein purpura (HSP) that lead to surgical intervention include intussusception, perforation, necrosis, and massive gastrointestinal bleeding. Acute appendicitis is rarely seen as a complication of HSP. A seven-year-old boy was admitted for arthralgia, abdominal pain, hematochezia, melena, and purpuric rash on the lower extremities. On admission day abdominal ultrasonography was normal, but on day 5, he became pyrexial and developed right iliac fossa pain and tenderness with guarding. Ultrasonography showed distended appendix surrounded by hyperechoic inflamed fat. On exploration an acutely inflamed, necrotic appendix was removed and grossly there was an appendiceal perforation in the appendiceal tip. Microscopically some of the small blood vessels in the submucosa showed fibrinoid necrosis with neutrophilic infiltrations. The authors report the case of a child who developed acute perforative appendicitis requiring appendectomy while on treatment for HSP.
Purpura, Henoch-Schoenlein; Appendicitis; complications
Solitary caecal diverticulum is an uncommon entity and therefore difficult to diagnose except at surgery. Caecal diverticulitis is an infrequent cause of acute abdomen and usually presents in a manner similar to acute appendicitis. It is extremely difficult to differentiate it preoperative from acute appendicitis and such distinction is usually made in the operating room. The optimal management of this clinical condition is still controversial, ranging from conservative treatment with antibiotics to aggressive surgical resections.
We report a case of a 61 year old Caucasian who presented with acute onset right iliac fossa pain indistinguishable from acute appendicitis. The true diagnosis of a perforated acute caecal diverticulitis with an abscess mass was only made at operation in the presence of a macroscopically normal appendix. We reviewed the literature to highlight the difficulty of a preoperative diagnosis and the need for a high index of suspicion especially in the older age group presenting in manner similar to acute appendicitis.
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 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.
A 22-year-old pregnant woman presented at the twenty-seventh week of gestation in the Emergency Department with acute abdominal pain and right iliac fossa tenderness. Urgent MRI was done and was suggestive of acute appendicitis. A laparoscopy was performed that confirmed an inflamed and purulent appendix that was removed. The technique used is described in detail. The histopathologic findings were those of acute appendicitis, carcinoid, and endometriosis of the appendix. We report the first case of this extremely rare triad presented in pregnancy.
Acute appendicitis is the most common presentation of the acute abdomen in the UK. Although in most cases this is an easily reached diagnosis, presentation is not always typical and there are certain other conditions which may mimic appendicitis. Diagnostic adjuncts usually provide the additional information required to make a confident diagnosis; however, in some circumstances, the safest and most reliable course of action is appropriate surgical intervention. A case report is presented of a 43-year-old woman who presented with history of peri-umbilical pain migrating to the right iliac fossa. Following further investigation, with routine blood tests, plain radiographs, ultrasound examination of the abdomen and pelvis, and CT scanning not pointing towards a definitive diagnosis, she eventually underwent a diagnostic laparoscopy which revealed primary omental torsion. An open omentectomy was performed and 2 months on she remains well.
Omental torsion; Appendicitis; Omentectomy
We describe the case of a 68-year-old otherwise healthy male who presented to our emergency room with signs and symptoms of acute appendicitis. Exploratory surgery revealed a normal appendix. Further examination revealed an enlarged lymph node-like mass of tissue near the appendix, in the ileocecal mesentery. This mass was removed and was found to be inflamed heterotopic gastric tissue. Although reports of heterotopic gastric tissue in the literature are common, we believe that this case represents the first report of inflamed heterotopic gastric tissue simulating appendicitis.
Heterotopic gastric mucosa; Acute appendicitis
The differential diagnosis of right lower quadrant abdominal pain includes both ureterolithiasis and acute appendicitis. Surgical treatment can be undergone without confirmatory imaging studies after a clinical diagnosis is made. For this reason, an occult, second abdominal process may be present.
A 47-year-old male presented with a three-day history of acute right lower quadrant abdominal pain. A contrast CT revealed both a 6 mm calculus obstructing the right ureter and acute appendicitis. The patient underwent appendectomy and ureteroscopy with stent placement at the same time.
Simultaneous appendicitis and ureterolithiasis may present with similar clinical findings. Due to the potential risks associated with missing either diagnosis, imaging studies may be an appropriate as a step in the management of the patient with right lower quadrant pain.