3077 Inverted Appendix Caused by Inversion-Ligation Appendectomy: An Unusual Case of Cecal Mass

Abstract

INTRODUCTION: Polypoid lesions involving the cecum and more specifically the appendiceal orifice (AO) can be a diagnostic dilemma. The thin walled cecum poses risk of perforation, therefore resection should be avoided for benign lesions. Invasive adenocarcinoma or adenocarcinoma is situ arising from the appendiceal lumen or AO are rare with less than 250 reports. Other lesions include appendiceal endometriosis, juvenile polyps, adenomatous polyps, and appendiceal inversion. CASE DESCRIPTION/METHODS: A 68-year-old female with a past medical history of fibroids s/p hysterectomy and prophylactic appendectomy over 30 years ago presents for first time screening colonoscopy. She denies history of rectal bleeding, constipation, weight loss or family history of colon cancer. An elongated tubular lesion was identified in the cecum (Figures 1 and 2). During inspection, the lesion appeared to arise from the AO. Due to risk of perforation, the polypoid lesion was not removed and multiple biopsies were obtained. The patient had 4 additional polyps, ranging from 4-10 mm, that were removed during the procedure. Pathology report of the cecal mass showed normal colonic mucosa with mild inflammation. DISCUSSION: Inversion of appendiceal base is an expected occurrence after inversion-ligation appendectomy. This surgical procedure has been performed historically as an incidental appendectomy, which avoids the transection of the appendiceal lumen and decreasing risk of bacterial peritonitis. The majority of these cases result in atrophy of the appendiceal stump causing scar tissue formation in the AO. However, few autopsy reports show a retained polypoid appendiceal stump that occasionally increases in size. A few reports have described appendiceal inversion resembling a neoplastic polyp during routine colonoscopy. Many of these patients have undergone inversion-ligation appendectomy. The risk of perforation and major bleeding is dramatically increased if endoscopic resection is attempted. We recommend a conservative approach with biopsy to assess for dysplasia or malignancy. If endoscopic resection is attempted, complications can be minimized with the utilization of endoloop or endoscopic clips.