McBurneyʼs Point Meets Occamʼs Razor: A Not So Simple Case of Appendicitis

Abstract

Purpose: An 81 y.o. female with no pertinent gastrointestinal history and no prior colorectal cancer screening presented with one day of progressively worsening periumbilical and right lower quadrant abdominal pain. She reported anorexia and nausea without vomiting, but no fevers, chills or changes in her stool. She was mildly tachycardic and had direct tenderness to palpation in the right lower quadrant. Her initial laboratory evaluation demonstrated a leukocytosis of 11.9 and CT imaging revealed a dilated, fluid-filled appendix with periappendiceal stranding. She underwent an uncomplicated appendectomy and was discharged soon thereafter. Five months prior to her episode of appendicitis, she was diagnosed with iron deficiency anemia. An EGD was unremarkable, but she refused colonoscopy. Iron supplementation led to normalization of her H/H, but this medication was stopped perioperatively and was not restarted. Eight months later, she presented with a three week history of rectal bleeding consisting of bright red blood on the toilet paper and streaking her formed brown stools. Examination revealed large, non-thrombosed external hemorrhoids which were thought to be the etiology of her rectal bleeding. Laboratory evaluation showed a return of her iron deficiency anemia. She agreed to undergo a colonoscopy which was unremarkable until the cecum was reached. There, a 1.6 cm smooth-appearing mass was seen protruding from the appendiceal orifice. Biopsies revealed a moderately-differentiated adenocarcinoma arising from a tubular adenoma. CT imaging showed only a tubular soft tissue density in the cecum. The patient was taken to the operating room for a right hemicolectomy during which it was discovered that her cecal tumor adhered to the peritoneum and retroperitoneum and had directly extended into the muscularis propria of two adjacent small bowel segments. Appendicitis is the most common acute abdominal emergency. Its incidence peaks from ages 15-19 and then decreases with age. Classically, the pathogenesis is thought to involve an obstruction of the appendiceal lumen by a fecalith or lymphoid hyperplasia while other causes of luminal obstruction, such as tumors, are uncommon. Some experts suggest, however, that the incidence of appendiceal or cecal cancer in patients over 60 years of age who present with acute appendicitis may exceed 20%. Our case illustrates that follow up colonoscopic evaluation for older patients who present with acute appendicitis may be warranted to rule out polyps or malignancies obstructing the appendiceal orifice. This is particularly true for those whose colon cancer screening is not current.