A Double Agent in the Cecum

Abstract

Appendicitis is the most common acute abdominal surgical emergency in the world. Despite its pathophysiology not being understood, appendiceal obstruction has been proposed as the primary cause. In older patients, appendicitis warrants further evaluation as it may be the first symptom of malignancy. This is a 70 year-old-male with medical history of chronic liver disease secondary to alcohol, paroxysmal atrial fibrillation on Warfarin, arterial hypertension and diabetes mellitus type II who presented to the Emergency Department after a call back from the laboratory reporting a hemoglobin drop from a baseline of 13.5 gm/dL to 9.3 gm/dL. Patient complained of a sharp stabbing abdominal pain localized to the right lower quadrant (RLQ) associated to dizziness, loss of appetite and general malaise for a week prior to presentation. Denied changes in bowel habits, bloody stools, dark stools, weight changes, nausea, vomits, diarrhea, constipation, fever or chills. Vital signs were stable. Physical examination was pertinent for a distended abdomen, adequate bowel sounds, soft and depressible, RLQ tenderness to palpation, but no rebound or guarding. Anemia work up revealed iron deficiency anemia. Abdominal CT without contrast revealed a dilated appendix with surrounding fat stranding and a small amount of fluid indicative of appendicitis with several enlarged lymph nodes in the right abdomen. Abdominopelvic CT with IV and PO contrast 3 days later due to progressive abdominal distention and pain revealed a distended appendix with a mass involving the cecum causing appendiceal obstruction and surrounding lymphadenopathy. Gastroenterology service recommended surgical intervention. Surgery service performed a colonoscopy and a large mass was identified at the cecum obstructing approximately 70% of the lumen. The procedure was aborted and biopsies were not taken because patient developed respiratory distress requiring endotracheal intubation. Patient had a prolonged and complicated admission leading to his demise. Autopsy report confirmed a poorly differentiated adenocarcinoma with metastasis. Cecum-Appendix adenocarcinoma is rare and it may mimic symptoms of an acute appendicitis. Therefore, it should raise concern when evaluating patients with physical and radiological findings suggestive of appendicitis in this age group. Management should be surgical due to increased risk of perforation and complications during colonoscopy.