Lower Quadrant Mass Research Articles

Meckel’s Diverticulitis: Diagnosis With Computed Tomography and Tc-99m Pertechnetate Scintigraphy

A diagnosis of Meckel's diverticulitis was reached preoperatively in a 7-year-old boy with severe left-sided abdominal pain and fever after technetium-99m pertechnetate scintigraphy indicated the presence of heterotopic gastric mucosa in a left lower quadrant mass that had been shown by computed tomography. The case illustrates the use of scintigraphy in confirming a suspected diagnosis of Meckel's diverticulitis and is an example of a Meckel's diverticulum in the lower left abdomen rather than the more common locations of the lower right and midabdomen.

Myxoglobulosis of the Appendix in a Postpartum Patient

A 23-year-old female underwent a cesarean section for breech presentation at term. Her postpartum course was complicated by multiple admissions for pelvic pain presumed to be endometritis. Her symptoms were temporarily alleviated with intravenous antibiotics during each hospitalization. Imaging to evaluate persistent abdominal pain revealed a large cystic right lower quadrant mass adjacent to the ovary. Findings at diagnostic laparoscopy included a 15-cm × 4-cm appendix with pathology confirming myxoglobulosis. This case describes the only reported case of myxoglobulosis of the appendix presenting as a rare cause of pelvic pain in a postpartum patient. (J GYNECOL SURG 20:127)

Abdominal wall adenocarcinoma

An 81-year-old man presented with a right lower quadrant mass in the area overlying an appendectomy scar. He first noticed the mass, a few months before presentation, as a papule, which then had gradually enlarged. The mass became tender to palpation and was associated with a brown discharge. On examination, there was a 3-cm exophytic lesion in the right lower quadrant, with an associated sinus tract, draining brown liquid, that was surrounded by erythema to a diameter of 10 cm (A, B). An incisional biopsy specimen was positive for mucinous adenocarcinoma. CT revealed a mass in the ascending colon and cecum, extending through the anterolateral abdominal wall in the right lower quadrant. At colonoscopy, there was a large mass obstructing the ascending colon (C). The patient underwent abdominal surgical exploration and right hemicolectomy, with removal of the tumor and involved abdominal wall and lymph nodes (D). No metastasis to surrounding organs was identified. The histopathologic stage of the mucinous adenocarcinoma was T4M1N0. The patient declined adjuvant chemotherapy and is alive and doing well at 4 months' follow-up.

Gastrointestinal Kaposi Sarcoma Presenting In A Nigeria African With HIV / AIDS

Adult intussusception is a rare condition that is seen once in a while in surgical practice, 1. In this report we the case of a thirty –five year old Nigeria male on medical treatment of earlier diagnosed AIDS who had no evidence of cutaneous Kaposi sarcoma. He later presented with a palpable right lower quadrant mass and classic symptoms of intestinal obstruction for which he was referred to surgery. The findings at laparotomy were right ileo – colonic intussusception with polypoid lead point. There were also multiple intra – luminal growths involving the entire right colon, the caecum the appendix and the terminal ileum. A right hemi – colectomy with ileo – colonic anastamosis was performed, and the resulting specimen sent for histological examination confirmed Kaposi sarcoma. Assessment of the patient's clinical condition five months post – operatively revealed a significant improvement; patient regained weight from 43 kg on admission to 58.3 kg .We conclude that Kaposi sarcoma be included in the aetipathogenesis of adult intussusception KEY WORDS: Kaposi Sarcoma, Adult Intussusception, Surgical Outcome Nigerian Journal of Clinical Practice Vol.6(2) 2003: 117-119

Ventral Bladder Hernia Following Tubal Ligation

While involvement of the bladder in inguinal hernias is relatively common (1% to 10% incidence), reports of midline bladder hernias are rare.1–3 Such hernias are classified according to the relationship of the hernia to the peritoneum. The more common paraperitoneal bladder hernia involves the extraperitoneal part of the bladder that lies along the medial aspect of the hernial sac. In the intraperitoneal form the bladder is completely covered by peritoneum. The least common extraperitoneal form has no peritoneal covering.3 To our knowledge we report the first case of ventral bladder hernia following tubal ligation. CASE REPORT A 64-year-old female presented with a right lower quadrant mass 2 years in duration, and recent onset of dysuria and chills. Pressure on the mass caused suprapubic discomfort and an urge to urinate. History was significant for breast cancer, recurrent urinary tract infection and a tubal ligation 10 years previously. On physical examination the patient was obese and a 10 cm. mass was palpated in the right lower quadrant 2 cm. from the midline. The mass was believed to be protruding through the fascia of the abdominal wall and was nonreducible and tender on palpation. There was a well healed 2 cm. infraumbilical midline incision consistent with tubal ligation. There were no peritoneal signs, no inguinal or femoral hernias, and bowel sounds were present. Urinalysis revealed pyuria, bacteriuria and positive nitrites. Urine cultures yielded Escherichia coli. The patient was treated with ciprofloxacin for 5 days, which relieved the irritative voiding symptoms. Computerized tomography (CT) of the abdomen and pelvis showed a ventral abdominal wall hernia in the right lower quadrant that contained bladder (fig. 1). Cystography confirmed these findings (fig. 2). Ventral bladder hernia repair was performed through a Pfannenstiel incision. The abdominal wall fascial defect was identified and the bladder hernia was dissected off of the surrounding tissue. Attempts were made to reduce the bladder hernia without success and, thus, it was necessary to excise the segment of herniated bladder at the level of the fascial defect. The bladder was then mobilized from the abdominal wall fascial defect and closed, and the abdominal wall fascial defect was repaired. A layer of perivesical fat was left over the bladder suture line. A suprapubic tube was left indwelling for 10 days to drain the bladder. DISCUSSION

Ileocecectomy is Definitive Treatment for Advanced Appendicitis

Although appendectomy is the most commonly performed emergency operation septic complications of appendectomy remain a major source of morbidity. Historically, advanced appendicitis has been treated by appendectomy with cecostomy and/or drainage tubes. Our objective was to evaluate the use of ileocecal resection for the immediate treatment of advanced appendicitis. We examined the cases of all patients undergoing ileocecal resection for appendicitis from August 1989 through April 2000. There were 92 patients (60 male and 32 female) with a median age of 34 (range 6-71). Abdominal pain was present in 98 per cent of patients with duration of 5.1+/-0.6 days. Right lower quadrant tenderness was present in 91 per cent with accompanying right lower quadrant mass in 30 per cent. Temperature on admission was 38.0+/-0.1 degrees C with a white blood cell count of 15,300+/-500. Preoperative radiological studies included abdominal X-rays (33), contrast enemas (two), CT scans (41), and abdominal ultrasound (17); these studies yielded a correct preoperative diagnosis in 89 per cent. Previous appendectomy had been performed in six patients with failed percutaneous drainage of intra-abdominal abscesses in five. There were 94 cecal resections performed in 92 patients. The extent of surgical resection varied between patients and ranged from partial cecectomy (34) to ileocecectomy (55) to ileocecectomy with diverting ileostomy (five). Intra-abdominal abscesses were present at operation in 46 cases (50%), and drains were placed in 38 (41%). Skin incisions were packed open in most cases (65); there was skin closure in 27. There was no mortality encountered in this period. There were 25 complications in 23 patients (25%). Complications included postoperative abscess (10; 11%), wound infection (10; 11%), partial small bowel obstruction (two) and pulmonary embolus (one). Reoperation was required in seven patients and CT-guided percutaneous drainage in five patients. Anastomic leaks occurred in two cases of partial cecectomy and required conversion to ileocecectomy. Mean hospital stay was 10.5+/-1.0 days with adjusted hospital costs of $31,689+/-3018. We conclude that definitive treatment of advanced appendicitis can be performed by resection of the involved areas of the ileocecum. This can be accomplished with a primary anastomosis obviating the need for ileostomy and secondary operation. This aggressive surgical approach may reduce infectious complications and reduce hospital costs.

Appendicitis in patients with previous spinal cord injury

Background: Acute abdominal emergencies are particularly dangerous in patients with impaired sensation. Methods: Thirty patients with spinal cord injury who later developed appendicitis were identified in Department of Veterans Affairs computer files over a 5-year period; 26 were evaluable. Results: The mean age was 55 years (range 27 to 79); all were males. Abdominal distention or discomfort was present in 16 of 26 (62%), while 2 of 26 (8%) presented in shock. A palpable right lower quadrant mass was present in 6 of 26 (23%). The mean initial white blood cell count was 18,000/mm 3. Only 9 of 26 (35%) had the diagnosis of appendicitis made on admission. In 12 of 26, computed tomography was done; all correctly diagnosed appendicitis. The mean delay in diagnosis after hospitalization was 2 days (range 0 to 5). Perforated appendicitis was found at surgery in 24 of 26 (92%). Twenty-three of 26 (88%) underwent appendectomy; 3 of 26 (12%) underwent right colectomy. The 30-day mortality rate was 4%. Six of 26 (23%) developed a postoperative complication. The mean length of stay was 16 days. Conclusions: Acute appendicitis in spinal-cord-injured patients frequently presents late and complications are common. Computed tomography appears to be an excellent diagnostic modality. Some of the adverse outcomes which are related to preexisting spinal cord injury may be preventable with early intervention.

A CASE REPORT OF INCARCERATED SPIGELIAN HERNIA

Spigelian hernia is considered an uncommon spontaneous hernia of the abdominal wall. We report a case of Spigelian hernia with incarcerated small bowel and greater omentum. A 63-year-old woman was admitted to the hospital because of a right lower quadrant mass and pain. The abdominal findings showed a 15×10cm sized tender mass. CT scan of the abdomen showed the mass lateral to the linea semilunaris and contained loops of small bowel. The palient was diagnosed as having a Spigelian hernia with incarcerated small bowel and underwent an emergency surgical repair. We found herniated small bowel and greater omentum under the linea semilunaris. The hernia orifice was 2×2cm in size and was closed with interrupted suture. The patient was discharged foon the hospital 10 days later. There has been no recurrence as of 13 months after the operation. Spigelian hernia presents difficulty in presperative diagnosis because of its rarity, nonspecific symptoms and only a limited knowledge of this disease. We should consider this disease as a probable differential diagnosis for patients with an abdominal mass and pain. Liberal the most use of abdominal sonography and CT scan may allow to make the preoperative diagnosis.

Mesenteric adenitis-acute ileitis: A constellation of findings definable with ultrasound

We present the ultrasonographic findings in 45 pediatric patients referred to us for acute abdominal pain mimicking appendicitis. All of the patients demonstrated right lower quadrant or para-aortic tender adenopathy consistent with the diagnosis of mesenteric adenitis, but in addition, many of the patients demonstrated other findings, including intestinal hyperperistalsis, small bowel (jejunal and ileal) mucosal thickening (both circumferential and nodular), mesenteric thickening around the nodes, fluid-filled loops of intestine, a visible appendix which was often fluid filled, free fluid, a right lower quadrant mass, and cecal involvement. These diverse findings suggest that mesenteric adenitis need not be limited to adenopathy and ileocolitis in the right lower quadrant. These additional findings are helpful in differentiating mesenteric adenitis from appendicitis, even in those patients in whom a fluid-filled appendix is visualized.

Castleman's disease presenting as a pediatric surgical problem

A 9-year-old girl presented with anemia, fever, and poor growth over a 2 1 2 - year period. On physical examination, a right lower quadrant mass was palpated. Her signs and symptoms were consistent with Castleman's disease of the plasma cell type. The mass, a giant hyperplastic lymph node, was excised, and the patient's symptoms resolved. Castleman's disease is a benign lymph node disorder that occurs very rarely in the pediatric population and is cured by operative excision of the lymphatic mass.

Appendicitis: efficacy of color Doppler sonography.

To determine whether the addition of color Doppler ultrasonography (US) to gray-scale US can help diagnose appendicitis in children. One hundred children with suspected appendicitis were evaluated with gray-scale and color Doppler US scanning. Color Doppler US scans were considered positive for appendicitis if increased vascularity was demonstrated in the appendiceal wall and positive for perforation with abscess if a hyperemic right lower quadrant mass was seen. Gray-scale US was positive for appendicitis if a blind-ending, noncompressible appendix larger than 6 mm in diameter, a loculated periappendiceal mass, or both were identified. Thirty-nine patients had acute appendicitis; 26 had uncomplicated appendicitis, and 13 had perforation. Acute appendicitis was identified in 34 of 39 patients (87%) on color Doppler US scans with a sensitivity of 87%, specificity of 97%, and accuracy of 93%. Gray-scale US sensitivity was 87%; specificity, 92%; and accuracy, 90%. Blood flow in the appendiceal wall or right lower quadrant mass on color Doppler US scans suggests appendicitis, but absence of flow cannot definitively distinguish a normal from an abnormal appendix.

Fine‐needle aspiration of cutaneous malakoplakia

A 99-yr-old Chinese woman with cutaneous malakoplakia and concomitant urinary tract infection was reported. The patient presented with an ulcerated right lower quadrant mass and computerized tomography showed that it was limited to the skin and subcutaneous tissue with no extension to the pelvic or abdominal structures. The patient also suffered from urinary tract infection and was treated with oral norfloxacin. The ulcerated subcutaneous mass disappeared on follow-up visit 6 months after presentation. The cytologic (fine-needle aspiration), histologic (trucut biopsy) and ultrastructural features of cutaneous malakoplakia were described. The possible usefulness of fine-needle aspiration in the diagnosis of this condition was discussed.

Mucocele of the Appendix: With Special Emphasis on Image Studies

In a review of 1,268 appendectomies from January 1984 to April 1989, ten cases were diagnosed as ”mucocele” by pathology. All these cases presented with a right lower quadrant (RLQ) mass or pain of variable duration except one whose mucocele was found incidentally during an operation for gastric cancer. One case revealed curvilinear and mottled calcification outlining a large mucocele on plain film of the abdomen. Abdominal ultrasonography in 7 patients showed negative finding in one case, a hypoechoic or anechoic tubular lesion with good transmission in two, an ovoid cystic lesion with variable internal echoes in dependent portion in two, intussusception in one and a periappendiceal abscess in one. Barium enema of 4 patients showed nonvisualization of the appendix but either filling defects with round smooth shape or external compression to the cecum were found. Fibercolonoscopy was performed in 4 cases, all were disclosed intrusions of mucocele from the appendiceal orifice. In one of them, the mucocele invaginated deeply and caused chronic appendico-cecal intussusception. Computed tomography was performed in one case, the mucocele showed a near-water-density tubular lesion with good enhancement of the wall after contrast injection. Though appendiceal mucocele is a rare clinical entity, it should be in the list of differential diagnosis of RLQ pain. With the disease in mind and advanced imaging modalities available, preoperative diagnosis is probable.

Primary Adenocarcinoma of the Appendix: A Review

A review of cases of primary adenocarcinoma of the appendix seen at the Hines VA Hospital (1950-1987) and Loyola University Medical Center (1977-1987) revealed a total of 14 cases. All patients presented with a clinical picture suggesting acute appendicitis or a right lower quadrant mass. Malignancy was not suspected in any of the patients prior to surgery. The age group ranged from 25 to 66 years (mean, 51.8 years) with 29% of the patients under 45 years old. The presence of carcinoma should be carefully looked for in middle-aged and elderly patients presenting with acute appendicitis.

Sonographic appearance of mucocele of the appendix.

Mucocele of the appendix is an uncommon entity infrequently diagnosed prior to surgery or autopsy. Patients may be asymptomatic or present with a palpable right lower quadrant mass and/or pain. Barium enema findings are nonspecific and include nonfilling of the appendix and occasionally mass impression on the cecum. When visualized, calcification of the rim of a right lower quadrant mass may aid in diagnosis. The sonographic appearance in two cases is presented and compared with that in three other case reports in the literature, illustrating a spectrum of sonographic findings. Differential diagnosis is discussed.

Calcified papillary tumour of the peritoneum

A 65-year-old white female was admitted for evaluation of an abdominal mass associated with recurrent episodes of right lower quadrant pain. The past history included an appendicectomy and a total abdominal hysterectomy with bilateral salpingo-oophorectomy for post-menopausal bleeding three years prior to this admission. Routine gross and microscopic examination of the ovaries revealed no abnormality. There was no known history of exposure to asbestos. Physical examination revealed an irregular, tender right lower quadrant mass which was fixed and adherent to the abdominal wall. A plain film of the abdomen (Fig. 1) showed multiple granular amorphous calcific masses which were persistently related to the antimesenteric border of the colon. The largest of these masses was related to the lateral aspect of the caecum.

Computed tomography and angiography in ileal carcinoid tumor and retractile mesenteritis.

Computed tomography and angiography were performed in two patients with ileal carcinoid tumor and in one with retractile mesenteritis. In each instance, a low density right lower quadrant mass with small bowel displacement and thickened mesenteric neurovascular bundles was identified at CT. Superior mesenteric artery (SMA) angiography revealed contraction, kinking and irregularity of mesenteric branches in all cases, but specific histologic diagnosis was not established by angiography alone. Our preliminary experience suggests that SMA angiography may not always be necessary in the diagnosis of either carcinoid tumor or retractile mesenteritis.

Hematometria and hematosalpinx in a duplicated uterus with congenital absence of one kidney

M.L.. 47-47-68, was born on 1 l/30/62 and passed meconium at birth. No external anal opening or tistula were seen. Examination under anesthesia revealed a rectal fistula entering the postertor wall of the vagina at the level of the cervix. A sigmoid end colostomy was performed. The distal rectum was oversewn and returned to the peritoneal cavity. During the first week of life, an intravenous pyelogram revealed congenital absence of the right kidney uith a normal-appearing left upper urinary tract. A cystourethogram performed at this time revealed a large bladder with low pressure left ureteral reflux: there was mild dilation of the ureter and calices. At 9 mo of age. an abdominoperineal pull-through procedure was carried out. At this operation it was noted that the patient had a complete duplication of the uterus. Each uterus had a single fallopian tube and a single ovary. At I I mo of age, she was readmitted to the hospital for correction of an anal stricture at the mucocutaneous junction by means of bilateral “V plastics.” The patient’s diapers were noted to be constantly wet and she had a chronic lower urinary tract infection that was treated with the approprtate antibiotics, She was watched in a conservative f;lshion for the anticipated appearance of urinary continence. By 5 yr of age, she was noted to be almost completely incontinent of urine. She underwent cystourethrogram and intravenous pyelogram annually and during thtr period of time, there was no change in her upper urinary tract. nor in the degree of retlux. Because of the persistence of the urinary incontinence and because urcthroscopy revealed a short patulous urethra, it was decided to perform a Young-Dees urethroplasty and left ureteroneocystostomy. This procedure was carried out on 3/15/67 without dihiculty. Postoperatively. the patient continued to be incontinent and displayed low pressure left ureteral reflux by cystogram. The patient was followed carefully and one year later. on 3/13/68. while still demonstrating low pressure reflux, she underwent exploration of the left ureter with the hope of performing another Young-Dees urethroplasty and ureteroneocystostomy. After dissecting out the ureter. it was obvious that the distal one-third was too scarred and fibrous to permit a successful uretero neocystostomy. She, therefore, underwent a left ureteral cutaneous anastomosis. Microscopic examination of the distal ureter revealed fibrosis and chronic inflammation, She had an uncventful postoperative recovery and was discharged. She was seen annually through April of 1973. The last intravenous pyelogram on J/26/73, revealed a normal appearing left upper urinary tract with no ureteral obstruction. It was noted at this ttmr that the patient cared for her uretcrostomy apphance herself without any difficulty. She stimulated a daily bo*rl movement by means ol a minienema using an all rubber ear syringe. At age I2 yr, she experienced menarche and each menstrual period was accompanied by such srvcre pain that she had to remain in bed and take large amounts of aspirin and codeine uith only partial relief of pain. After one year. the patient was seen by her pediatrician \nho made the diagnosis of urinary tract infection. Examination revealed a well formed left uretcrostomy that drained without obstruction into a urinary collecting bag. There was a large obvtoua right lower quadrant mass. This was easily palpable. stony-hard and projected above the level of the abdomen when the child lay flat. A No. 12 Coude catheter was passed into the bladder with ease. The bladder was found to be empty and irrigated clear. An intravenous pyelogram revealed a normally-functioning left uppet

Mild Cystic Fibrosis Presenting as an Asymptomatic Distended Appendiceal Mass: A Case Report

A case of cystic fibrosis presenting as a right lower quadrant mass in a five-year-old white female is presented. At laparotomy, a mucoid, impacted appendix was found which microscopically suggested the diagnosis of cystic fibrosis. Cystic fibrosis must be added to conditions presenting with abdominal masses.

Abdominal complaints and appendiceal changes leading to the diagnosis of cystic fibrosis

Twelve patients with abdominal complaints had an operation that included incidental appendectomy. They were later diagnosed as having cystic fibrosis. Four groups of presenting signs and symptoms were right lower quadrant mass, chronic abdominal pain, intestinal obstruction, and hepatomegaly. In all cases the symptoms precipitating operation were due to the underlying unrecognized condition: cystic fibrosis. Review of the histology of the appendix revealed the classic changes of hypersecretion of the mucous glands to be present. The appendix shares in the generalized intestinal mucous gland involvement peculiar to cystic fibrosis. Awareness of this fact has not been widespread, perhaps because of the usual emphasis on the pulmonary and pancreatic aspects of the disease. Greater appreciation of the clinical symptoms of cystic fibrosis and more liberal use of the sweat test could have diminished the number of exploratory celiotomies. Recognition of the histoloc changes in the removed appendices can also suggest the proper diagnosis and lead to earlier institution of treatment with an imporved prognosis. Twelve patients with abdominal complaints had an operation that included incidental appendectomy. They were later diagnosed as having cystic fibrosis. Four groups of presenting signs and symptoms were right lower quadrant mass, chronic abdominal pain, intestinal obstruction, and hepatomegaly. In all cases the symptoms precipitating operation were due to the underlying unrecognized condition: cystic fibrosis. Review of the histology of the appendix revealed the classic changes of hypersecretion of the mucous glands to be present. The appendix shares in the generalized intestinal mucous gland involvement peculiar to cystic fibrosis. Awareness of this fact has not been widespread, perhaps because of the usual emphasis on the pulmonary and pancreatic aspects of the disease. Greater appreciation of the clinical symptoms of cystic fibrosis and more liberal use of the sweat test could have diminished the number of exploratory celiotomies. Recognition of the histoloc changes in the removed appendices can also suggest the proper diagnosis and lead to earlier institution of treatment with an imporved prognosis.