Appendicular Lumen Research Articles

FP7.3 - Acute Appendicitis and Lung Metastasis – A rare combination

Abstract Background Lung cancer is the third most common cancer in the UK. Although widespread metastasis is common, metastasis to the appendix is rare. Here we present a case of acute appendicitis secondary to lung metastasis. Case Presentation An 84-year-old man was admitted with a two-day history of right iliac fossa and suprapubic pain. He was known to have previous lung cancer treated with radical radiotherapy. Bloods on admission revealed elevated inflammatory markers with WCC 14.73 x 109/L and CRP 71.1mg/L. A Computed tomography was performed which showed acute appendicitis with perforation. An emergency laparoscopic appendicectomy was performed which showed a mid-appendiceal perforation with a localized abscess cavity. His recovery was uneventful, and the patient was discharged on postoperative day 2. Histological analysis revealed an adenocarcinoma in the appendicular lumen and within the muscle wall extending to the serosal surface. Immunochemistry profile was positive for CK, CK-19, TTF1 and Napsin A favoring a diagnosis of lung adenocarcinoma which was rationalized in the lung MDT. The patient remains under the respiratory physicians for close follow up. Discussion Lung metastasis to the appendix causing acute appendicitis is uncommon, with only twelve cases of appendiceal metastasis reported in the literature, ten of which presented with a perforated appendix. It may be considered as a differential for the cause of perforated acute appendicitis especially in patients with background of lung cancer.

Compilation of Evidence Supporting the Role of a T Helper 2 Reaction in the Pathogenesis of Acute Appendicitis.

Despite being the most common abdominal surgical emergency, the cause of acute appendicitis (AA) remains unclear, since in recent decades little progress has been made regarding its etiology. Obstruction of the appendicular lumen has been traditionally presented as the initial event of AA; however, this is often the exception rather than the rule, as experimental data suggest that obstruction is not an important causal factor in AA, despite possibly occurring as a consequence of the inflammatory process. Type I hypersensitivity reaction has been extensively studied, involving Th2 lymphocytes, and cytokines such as IL-4, IL-5, IL-9 and IL-13, which have well-defined functions, such as a positive-feedback effect on Th0 for differentiating into Th2 cells, recruitment of eosinophils and the release of eosinophilic proteins and the production of IgE with the activation of mast cells, with the release of proteins from their granules. Cytotoxic activity and tissue damage will be responsible for the clinical manifestation of the allergy. AA histological features are similar to those found in allergic reactions like asthma. The intestine has all the components for an allergic immune response. It has contact with hundreds of antigens daily, most of them harmless, but some can potentially induce an allergic response. In recent years, researchers have been trying to assess if allergy is a component of AA, with their latest advances in the understanding of AA as a Th2 reaction shown by the authors of this article.

WITHDRAWN: Appendiceal bleeding caused by vascular malformation: A case report and literature review

Introduction and importanceAcute lower gastrointestinal bleeding (LGIB) is common in clinical practice, however, appendiceal bleeding is extremely rare, which easy to be missed and misdiagnosed. Case presentationWe presented a case of a 33-year-old female who complained of hematochezia that had lasted for 1 day, colonoscopy showed continuous bleeding in the appendiceal orifice. A laparoscopic appendectomy was performed immediately, a pulsating blood vessel can be seen in the mesangium of the appendix, accordingly, active bleeding into the appendicular lumen was considered. Appendiceal pathology showed a large number of hyperplastic vessels were seen in the appendix mucosa and capillary vessels were dilated. Clinical conclusionAppendiceal bleeding is rare, lack of related guidelines and consensus, the preoperative detection of appendiceal bleeding is often challenging. Colonoscopy is extremely important, bowel preparation is not recommended for patients with acute LGIB routinely or only low-dose bowel preparation is recommended. Laparoscopic appendectomy is the most appropriate treatment for appendiceal bleeding. DiscussionIn our case, we provided the relevant data of computed tomography (CT), colonoscopy, pathology and laparoscopic surgery, and analysed the appendiceal bleeding caused by vascular malformation, to provide clinical experience.

Cistadenoma mucinoso del apéndice cecal en paciente con cuadro clínico de apendicitis aguda operado de apendicetomía por laparoscopia

Mucoceles of the appendix are rare, predominate in women and usually present as a palpable mass in the right lower quadrant. Most patients are asymptomatic. The mucocele is defined as a cystic dilatation of the appendicular lumen caused by mucin accumulation. We present the case of a male patient in his seventh decade with clinical symptoms of acute abdomen with suspicion of acute appendicitis, laparoscopic hemicolectomy surgery was performed after finding findings of tumor dependent on ascending colon (blind region), indurated 80 × 100 mm approximately, performing right hemicolectomy plus ileocolonic lateroterminal anastomosis with adequate postoperative evolution. Keywords: Mucocele; appendix; appendicitis.

IMPACT OF ENDEMICITY OF ASCARIASIS ON DIAGNOSIS OF ACUTE APPENDICITIS

Objective: To determine the impact of endemicity of ascariasis in the manifestation of acute appendicitis.
 Study Design: Prospective observational study.
 Place and Duration of Study: General Surgery Department, Combined Military Hospital Skardu, from May 2012 to Apr 2015.
 Methodology: Patients presenting with symptoms of acute appendicitis were included in the study. Patients were diagnosed after taking detailed history, clinical examination and blood chemistry. All the patients underwent open appendectomy under general anesthesia. Per-operatively presence of worms was assessed in terminal ileum and after that in the lumen of the appendix initially by palpation and then by opening its lumen after it was removed. Histopathologic diagnosis could not be confirmed due to its non-availability as the surgeries were performed in a remote and resource constraint area of the country.
 Results: A total of 224 patients were included in the study. Out of these, 143 (63.8%) were male and 81 (36.1%) female patients. The mean age of patients was 22 ± 6 years. Per-operatively, 21 (9.3%) patients had worms in both ileum and appendicular lumen while 22 (9.8%) patients had worms only in the terminal ileum and there were no worms seen in either ileum or appendix in 181 (80.8%) patients.
 Conclusion: There is a relation of parasitic infestation especially Ascaris lumbricoides in the manifestation of acute appendicitis in endemic areas.

Appendiceal Mucocele in Sikasso Hospital: Report of A Case

Appendicular mucocele is a rare appendicular tumor characterized by dilation of the appendicular lumen with linear changes in the mucosa and hypersecretion of mucus. We report a case of appendicular mucocele in a 73-year-old patient. Clinically, there was pain in the right iliac fossa, nausea, sometimes vomiting, and a poorly defined mass palpated in the right iliac fossa. The abdominal ultrasound found an appendicular plastron and the complete blood count showed leukocytosis. The patient underwent an appendectomy and the operative consequences were simple, the pathological examination of the operative specimen concluded that there was a mucinous cystadenoma of the appendix.

Giant mucocele of the appendix – laparoscopic management: A case report and review of the literature

A mucocele is an uncommon lesion of the appendix characterized by cystic distension of the appendicular lumen due to the accumulation of a mucoid substance known as mucin. It is often asymptomatic and surgical treatment depends on the histology and the dimension of the mucocele. We, herein, report a laparoscopically managed case of a 55-year-old male who presented with a large mobile mass in the lower abdomen. Abdominal contrast-enhanced computed tomography revealed a large mucocele of the appendix.

1561 Appendiceal Colic Intussusception Due to Mucocele of Appendix: Is Appendectomy Alone Sufficient?

INTRODUCTION: Mucocele of appendix is a rare clinical entity (0.2-0.3% of appendectomy specimens) with obstruction to drainage of mucus from the appendicular lumen. Rarely, does it manifest as bowel obstruction owing to intussusception of mucocele of appendix (0.01%). Diagnosis of mucocele or its intussusception is radiological, can't differentiate if the cause of obstruction is a benign or a malignant process. CASE DESCRIPTION/METHODS: A 40 year female presented with complaints of right lower quadrant pain since a few days, was dull, aching, intermittent, associated with nausea without any obvious aggravating or relieving factors and history of trauma to the abdomen or previous surgery. Abdominal examination revealed tenderness in right lower quadrant without any guarding or rigidity and lump could be felt in the same quadrant. On auscultation sluggish bowel movement. An abdominal CT: intussusception of mucocele of appendix of 4.5 × 3.1 × 2.5 cm. Open appendectomy was planned to avoid accidental spillage of contents and resected margins and regional nodes were negative for malignancy as per histopathology. The postoperative period was uneventful. DISCUSSION: A Mucocele of appendix (MOA) is an abnormal accumulation of mucus in appendix. A cystadenoma, mucosal hyperplasia, retention cyst or mucinous cystadenocarcinoma may be the cause of this obstruction. Multi-detector CT is imaging of choice, classic appearance of a well circumscribed, fluid-filled, distended appendix. Presence of mural calcification differentiate from appendicular abscess. Further, an intussusception of MOA has been likened to a cup & ball pattern. However, features like enhancing mural nodules within the mucocele/size >2 cm point towards a malignant cause. Definitive management is surgery, a mucocele with compromised base, >2 cm require a primary typhlectomy, otherwise a primary appendectomy suffices. Hence, open surgery is preferred over laparoscopic to prevent spillage. Positive margins and/or lymph node involvement translates into right hemicolectomy. A cystadenoma is followed up like an adenomatous polyp while follow up similar to colonic carcinoma is employed in cases of cystadenocarcinoma of appendix.

Acute appendicitis in children under 4 years:a diagnostic dilemma.

Acute appendicitis is a pathology caused by inflammation of the cecal appendix , due tocthe obstruction of the appendicular lumen,witch leads to a venous congestion and then eventually to an arterial compromise of the appendicular wall with the consequent perforation of it.The main problem of this pathology in children under 4 years is the high index of appendicecal preforations presented by patients at the time of diagnosis,mainly driven by an unspecific clinical presentation,which leads to a low index of suspicion and a high percentage of complications in that age group. perform a literature review on the subject and investigate what is known of appendicitis in children under four years old to date. The data were obtained through a systematic bibliographic search in the pubmed data base from 1980 to 2017 Conclussion the increase in morbidity of acute apendicitis in children under 4 years has a mixed origin since organic factors are mixed age,together with a temporary diagnostic delay and with it the appearance of complicated forms of the disease, there is no sign,symptom or group of them that allows early detection of appendicitis in children under 4 years of age.

Faecolith leading to acute exacerbation of chronic appendicitis: case report and review of literature

Acute appendicitis remains the most common acute condition often requiring surgical intervention. Obstruction of appendicular lumen by faecalith or lymphoid hyperplasia is the main cause of acute appendicitis. There is no possible way to prevent the development of acute appendicitis. The only way to reduce morbidity and mortality is by timely intervention and doing appendicectomy before perforation and gangrene of appendix occurs. We report a case of chronic appendicitis by a giant faecolith leading to chronic pain. This case is being reported is an example of how large an appendiceal faecalith can be.

Rol del enteroparásito enterobius vermicularis en la apendicitis cecal

Sixty-five cases of enterobiasis of the cecal appendix are reported by Enterobius vermicularis or Oxiurus vermicularis. Enterobiasis is a cosmopolitan parasite5,8,13 and frequent. It is useful to establish whether it can cause appendicitis and the mechanisms involved. According to the classical literature, E. vermicularis is not a causative agent of appendicitis per se, but allows the reproduction of the germs that infiltrate the wall and produce appendicitis5,9,10. The purpose of the study is to report the prevalence of E. Vermicularis in surgical appendicitis and the anatomopathology to deduce a causal relationship. We report a sample of 2000 surgical pieces of extracted appendages (1992-2003) at the Emergency Hospital of the city of Córdoba, Argentina. On a total of 2000 pieces, we observed 65 cases of appendicular enterobiasis; in 60 cases (3.25%) there was no histopathology of acute inflammation (anodyne cecal appendix). In the remaining 5 cases (0.25%) we observed coexistence of parasites in the appendicular lumen, acute transmural inflammatory infiltrates (acute appendicitis) and fecalitos, which would support the obstructive type etiopathogenesis that leads to the surgical picture. The appendicular location of Enterobius vermicularis would favor the formation of fecalitos in light and the proliferation of germs in the wall that would lead to appendicitis. Reports indicate that the parasitic infection constitutes a percentage of the etiologies in appendicitis and fecalitos are the most common trigger, some parasites (Enterobius vermicularis) may be involved in its formation, although this percentage is minimal9,10,15,16,17 .

Appendicular Mucocele—A Diagnostic Dilemma: Managed Laparoscopically

ABSTRACT Appendicular mucocele is obstructive dilatation of the appendicular lumen by mucinous secretions. In most of the cases, it is caused by Mucinous cystadenoma and rarely by Mucinous cystadenocarcinoma. This rare disorder has a varied clinical presentation, with more than half of the patients being asymptomatic. We report the case of a 65-year-old man who presented with intermittent abdominal colicky pain and altered bowel habits. In spite of extensive preoperative investigations, no definitive diagnosis was made. On diagnostic laparoscopy it was found to be appendicular mucocele. We electively performed a laparoscopic appendectomy. As there is a risk of malignancy in the mucocele, we used an endobag to retrieve the specimen. Histological examination confirmed it as a Mucinous cystadenoma. How to cite this article Darpan B, Gurpreet B, Kamal S. Appendicular Mucocele—A Diagnostic Dilemma: Managed Laparoscopically. Curr Trends Diagn Treat 2017;1(1):38-39.

Synchronous mucinous cystadenoma of the appendix in a patient with colon cancer

Mucinous cystadenoma of the appendix is a rare condition. It is characterized by a cystic dilatation of the appendicular lumen with stasis of mucus inside it. There have also been reports of association with gastrointestinal tract, ovarian, and kidney tumors. In this report, an 82-year-old man was admitted to our hospital with several weeks’ history of low abdominal pain associated with anemia. Colonoscopy showed one tumor at 20 cm from the anal verge, and the entire colon was unobtainable due to bowel obstruction by the sigmoid colon tumor. Computed tomography indicated another cystic mass at the cecum. Following a sigmoid colon resection and appendectomy, the specimen was examined with histopathology, and a diagnosis of synchronous mucinous cystadenoma of the appendix and adenocarcinoma of the sigmoid colon was made. The patient recovered after surgery and was discharged from the hospital 12 days after the operation. We conclude that the incidence of synchronous mucinous cystadenoma of the appendix in colorectal cancer patients is low. Accurate preoperative diagnosis and careful surgical intervention can improve the prognosis of these patients.

Synchronous mucinous cystadenoma of the appendix in a patient with colon cancer

Mucinous cystadenoma of the appendix is a rare condition. It is characterized by a cystic dilatation of the appendicular lumen with stasis of mucus inside it. There have also been reports of association with gastrointestinal tract, ovarian, and kidney tumors. In this report, an 82-year-old man was admitted to our hospital with several weeks’ history of low abdominal pain associated with anemia. Colonoscopy showed one tumor at 20 cm from the anal verge, and the entire colon was unobtainable due to bowel obstruction by the sigmoid colon tumor. Computed tomography indicated another cystic mass at the cecum. Following a sigmoid colon resection and appendectomy, the specimen was examined with histopathology, and a diagnosis of synchronous mucinous cystadenoma of the appendix and adenocarcinoma of the sigmoid colon was made. The patient recovered after surgery and was discharged from the hospital 12 days after the operation. We conclude that the incidence of synchronous mucinous cystadenoma of the appendix in colorectal cancer patients is low. Accurate preoperative diagnosis and careful surgical intervention can improve the prognosis of these patients.

Evaluation of Stump Pressure in Three Types of Appendectomy: Harmonic Scalpel, LigaSure, and Conventional Technique.

Appendectomy is one of the most common operations carried out by general surgeons. The recent introduction of the alternative energy-based devices in surgery and their use in the laparoscopic appendectomy shortened the duration of operations, but these devices are used generally for meso dissection. These devices did not receive wide acceptance among surgeons as there is not enough evidence confirming their use in appendicular lumen operations. Our objective in this study was to test the safety of three types of appendectomy. Twenty-four cases with right hemicolectomy or subtotal colectomy were enrolled into this study. The patients were distributed in three groups. After the colectomy specimen was removed, in Group 1 conventional appendectomy (it was dissected with mesoappendiceal fixation and with electro cauterization) was performed in the operating room, the appendicular stump was ligated with a silk suture; in Group 2 appendectomy was performed with LigaSure™ and the stump was closed also with LigaSure; in Group 3 appendectomy was performed with Harmonic Scalpel™ and the stump was closed also with Harmonic Scalpel. Stump opening pressures were measured in all patients in the groups. Three groups were compared in terms of age, gender, concomitant diseases, clinical diagnosis, previous operations, pathological findings, and applied maximum pressure levels. No statistical difference was detected among the groups. Appendectomies carried out with LigaSure and Harmonic Scalpel are as safe as appendectomies carried out with the conventional methods.

Intestinal helminths in some cases of acute appendicitis operated in Bamenda, Cameroon

Background: Acute appendicitis is the most frequent infectious surgical abdominal emergency and previous studies have noted the presence of parasites in the appendicular lumen.Objective: This study was done to determine the involvement of intestinal worms in the etiology of acute appendicitis.Materials and Methods: This was a prospective and descriptive study concerning cases of confirmed and operated acute appendicitis between 15th April, 2013 and 14th April, 2015 at the People’s Clinic, Ngomgham, Bamenda, Cameroon. The appendicular content was macroscopically examined for parasites and formol-ether concentration technique was carried out for ova detection.Results: A total of 112 patients were operated for acute abdominal pain within the study period. There were 74 (60.8%) cases confirmed with acute appendicitis of which 45 (60.1%) were males and 29 (39.2%) were. The most affected age group was the 21 to 40 years (50%). The removed appendices appeared congestive in 30 (40.5%) cases, suppurated in 27 (40.5%) cases and gangrenous in 17 (23.0%) cases.There was no relationship between the appearance of the removed appendix and the gender of participants (P>0.05).Three different helminth ova were identified in the 74 samples. In decreasing prevalence, the parasite trend was 8 (10.8%) Ascaris lumbricoides, 5 (6.8%) Enterobius vermicularis, 3 (6.0%), Ankylostoma duodenale, Adult Ascaris lumbricoides and Enterobius vermicularis were seen in 1 and 3 cases respectively.Conclusion: A small percentage of parasitic worm eggs were found in the appendicular content, though a good portion of patients took medications against parasites before surgery. Intestinal worms could not be incriminated in the causation of the appendicitis; nevertheless, one adult ascaris was found as an evident cause of appendicular lumen obstruction.Keywords: Intestinal Helminthes, Acute appendicitis, Bamenda

English

Mucocele of appendix (MA) is a rare entity and is defined as mucin filled dilated appendicular lumen which may be due to distal obstruction. It is usually asymptomatic and may present as appendicitis. We present a rare case of an elderly female who presented with features of acute intestinal obstruction secondary to mucinous cystadenoma of appendix for which she had to INTRODUCTION: MA refers to dilated mucin filled appendicular lumen which may be secondary to distal obstruction. It is a rare condition with estimated incidence of only 0.2-0.3% in appendicectomy specimens.(1) It can be asymptomatic, but acute or chronic pain in the right iliac fossa is the most frequent symptom.(2) Intestinal obstruction complicating an appendiceal mucocele has rarely been reported.(3) We describe the case of an old woman who came to emergency with signs and symptoms of intestinal obstruction due to appendiceal mucocele. CASE REPORT: We report the case of a 60years old, previously healthy woman, who presented to our emergency room with a 3day history of acute and diffusely abdominal pain, nausea, vomiting and disruption of bowel movements. Her abdomen was distended and tympanic with diffuse tenderness, especially in the periumbilical areas with exaggerated bowel sounds. She had a history of ant tubercular treatment for pulmonary koch's 5years back. She also had a history of an episode of subacute intestinal obstruction 6months back which was managed conservatively outside. The leukocyte count was 22,000 with 95% neutrophils. An erect film of the abdomen revealed multiple air fluid levels suggestive of small bowel obstruction. CECT abdomen was done which showed small bowel dilatation with abrupt tapering near IC junction with mesentric lymphadenopathy. So, a diagnosis of acute intestinal obstruction secondary to ileocaecal koch's was made. After resuscitation, patient was undertaken for exploratory laporotomy. On inspection, dilated small bowel loops with collapsed large bowel mesentry were found and a 4*3cm in size firm mass was found at the anatomical site of appendix. The mass was preileal in position and was compressing over terminal ileum. About 10ml mucinous collection was found in right iliac fossa and pelvis. So, right sided hemicolectomy was performed. The postop period was uneventful and patient was discharged on day 11 in satisfactory condition. The final histopathology showed mucinous cystadenoma of appendix collection and reactive lymphoid hyperplasia with no epithelial cells in mucin.

An Unusual Cause of Abdominal Pain: Three Lead Pellets within the Appendix Vermiformis.

Most ingested foreign bodies usually pass out in the feces uneventfully. Complications such as intestinal perforation and bleeding usually occur with sharp, thin, stiff, long, and pointed objects. This case describes the management of three lead pellets within the appendix vermiformis. A 45-year-old male visited our clinic complaining of a 4-month history of abdominal pain. The patient inquiry revealed that he had eaten hunted rabbit meat on numerous occasions and had unintentionally ingested three lead pellets. Plain abdominal films and a barium enema showed foreign bodies in the right lower abdominal quadrant. Since the lead pellets were thought to have migrated extraluminally, they were removed through laparotomy under fluoroscopic guidance. An appendectomy was performed. Pathologically, three lead pellets were embedded in the appendix, which showed signs of intramucosal inflammation. Foreign bodies causing appendicitis are rare. However, if stiff or pointed objects enter the appendicular lumen, there is a high risk of appendicitis, perforation, or abdominal pain. An appendectomy was required to remove the ingested lead pellets in the appendix.

CASE REPORT: Cadaveric finding of mucocele appendix

INTRODUCTIONThis case report describes an abnormally enlarged cadaveric appendix subsequently identified as a mucocele. An appendicular mucocele is defined as a general macroscopic dilation of the appendicular lumen caused by abnormal accumulation of mucous (Persaud, 2007). There has been no previous published report of an appendicular mucocele in the cadaver. Of the 608 cadavers dissected in the last 8 years at the University of Alberta this was our first observation.CASE REPORTThe recorded cause of death for this 86 year old female patient was congestive heart failure. Routine dissection of the gastrointestinal system revealed an extremely large vermiform appendix. It was untethered and presented in the pelvic position i.e., directed toward the pelvic brim. Apart from of the usually large size, there were no overt signs of inflammation of the appendix or its surrounding tissue. The mesoappendix did not display any pathology and as expected, it contained the appendicular vessels.CONCLUSIONThis is the first reported case of an aberrantly enlarged mucocele appendix in the cadaver.Grant Funding Source: Professional Expense Allowance

Laparoscopic Management of Gallstone Presenting as Obstructive Gangrenous Appendicitis

We present an unusual case of a 55-year-old man with symptoms of recurrent appendicitis. Laparoscopy revealed a 1.5 cm gallstone impacted at the base of the appendix, leading to gangrenous appendicitis. This patient did not have any features of gallstone ileus. On imaging he had an inflammatory mass in the region of the right iliac fossa with a hyperintense shadow in the cecal area which was reported as an appendicolith. There was no demonstrable cholelithiasis or biliary-enteric fistula. There were dense omental adhesions in the pericholecystic area on laparoscopy. The case was successfully managed by laparoscopic appendectomy with retrieval of the gallstone. No surgery was undertaken for the gallbladder. Diagnosis was confirmed by biochemical analysis of the stone, which contained calcium bilirubinate and cholesterol. A gallstone obstructing the appendicular lumen is a very rare etiology of gangrenous perforation of the appendix peritonitis. This case was successfully managed laparoscopically.