Huge cystic communicating duplication of the right colon with perforated appendicitis

Abstract

A 15-year-old girl, a high school student and volleyball player, was referred to our hospital with severe acute abdominal pain and a high fever (up to 38.5° C). We found generalized abdominal tenderness with rebound tenderness and guarding, with the point of maximum tenderness in the upper abdomen above the navel. Computed tomography (CT) depicted a huge distended right colon occupying the abdomen from the upper right quadrant to the entire pelvic region and containing massive solid feces. Because of the distension of the right colon, the appendix was shifted toward the left to the upper abdominal midline above the navel. The swollen appendix contained multiple fecaliths with localized ascites on the appendix (Fig 1). Laboratory values were almost all within normal range, except leukocytosis (16,000/mm3) and C-reactive protein elevation (12.0 mg/dl) were found. Panperitonitis was diagnosed owing to the perforated appendix and severely distended right colon, and we planned an emergency laparotomy under general anesthesia, even though we could not fully determine the reason for solid feces within the dilated right colon. Upon entrance into the abdomen, the perforated appendix, as diagnosed preoperatively, and the apparently normal cecum were identified just under the midline incision. After routine appendectomy, we realized that the lower abdomen was wholly occupied by a cystic mass that communicated with the cecum, and that this mass was a huge cystic communicating duplication of the right colon (35 × 15 × 6 cm, 2,000 g, Fig 2). Resection of the abnormal colon was performed; no other abnormalities, including malrotation, Meckel's diverticulum, or genitourinary system or vertebral abnormalities were found. The resected specimen contained massive solid paste-like feces; no malignant lesion or ectopic gastric mucosa was identified. The myenteric neural plexus was less apparent on the cystic formation than on the tubular part of the duplication. Fig 2Intraoperative photograph. The duplication contained both tubular and cystic parts. Arrow, Stump of the appendix. TE, Terminal ileum; Ce, cecum; DT, tubular part of duplication; DC, duplicated colon (cystic part of duplication). Size, 35 × 15 × 6 cm; weight, 2,000 g. View Large Image Figure Viewer