What Could be Behind Acute Appendicitis?

Abstract

Introduction: Among more than 500,000 appendectomies done yearly in the USA, primary appendiceal cancer is diagnosed in about 1% only. Diagnosis is rarely suspected before surgery and histopathology for symptoms of acute appendicitis. Case Presentation: A 75-year old male patient, presented to the internal medicine clinic with sharp abdominal pain that started suddenly three days prior to his visit. Initially, it was located in the right lower quadrant (RLQ) then moved to the epigastric area and relocated again to the RLQ; he also had nausea and anorexia but reports no vomiting, weight loss, fever or any change in bowel habits. His medical history is significant for coronary artery disease, atrial fibrillation & hypertension. His home medications include: Aspirin, Lisinopril and Amiodarone. He quit smoking many years ago. On initial evaluation, vital signs were stable; Physical examination was unremarkable except for RLQ moderate tenderness; Bowel sounds were active in all four quadrants. Initial laboratory work-up showed mild anemia with a hemoglobin level of 12.5 gm/dl. Serum urea and creatinine levels were 20 & 1.4, respectively. Patient was admitted to hospital. Abdominal/pelvic CT indicated marked inflammatory changes of the terminal ileum and adjacent appendix. General surgery team decided on conservative management since there was no fever or leukocytosis. Patient was followed by serial abdominal exams and diet was advanced as tolerated. He clinically improved over two days. Outpatient colonoscopy showed sigmoid diverticulosis and normal cecum and appendiceal orifice. Multiple random biopsies showed normal mucosa. Three months later, patient returned to the emergency department with similar presentation. Repeat Abdominal CT showed cecal inflammation (typhilitis) without any masses or lymphadenopathy. He was started empirically on Ciprofloxacin and Flagyl. Symptoms partially improved; however, a follow-up abdominal CT two weeks later showed persistent inflammatory changes in the cecum. After re-evaluation by surgery team, laparoscopic appendectomy was done for possible chronic appendicitis. Unfortunately, histopathology showed moderately differentiated adenocarcinoma of the appendix infiltrating into muscularis propria. Discussion: Appendiceal cancer is extremely rare, it is estimated that 1% of diagnosed colon cancer is primarily appendicular in origin. Different histologic types include: carcinoid, mucinous cyst adenocarcinoma, adenocarcinoma and lymphosarcoma. The extension of the tumor is more important in the prognosis rather than the histologic type per se. Treatment for mucinous adenocarcinoma is right hemicolectomy. The patient had right hemicolectomy done and has been doing well for two year now.