Lower Quadrant Pain Research Articles

Conservative treatment of rectus sheath hematoma after diagnostic laparoscopy

This case report aims to present rectus sheath hematoma's diagnosis and conservative treatment process after diagnostic laparoscopy in a patient with right lower quadrant pain. A sixty-seven-year-old lady was admitted with abdominal pain, right inguinal pain, and nausea for about five days. She had coronary artery disease followed by acetylsalicylic acid. On physical examination of the abdomen, there was tenderness and defence on deep palpation. No pathology was seen on laboratory parameters, ultrasonography (USG) and computed tomography (CT). Despite medical treatment, the patient's complaints did not improve, so a laparoscopic appendectomy was performed. A mass was detected in the left lower abdominal wall of the patient at the sixth postoperative hour. The control hemogram level of the patient was 10.8 g/L, a 3.7 g/L haemoglobin decrease compared to the preoperative period. A left rectus sheath hematoma was detected on CT. The hematoma was treated conservatively. On the 12th day of her hospitalisation, the patient with a haemoglobin value of 10.9 g / L was discharged without complications.

Rupture-mediated large uterine defect at 30th gestational week with protruded amniotic sac and fetal head without fetal compromise after laparoscopic electromyolysis: Case report and literature review.

We describe a case of a rupture-mediated large uterine defect, which occurred on the 30th gestation week presenting a protruding amniotic sac sac without fetal compromise after a laparoscopic electromyolysis. A 28-year-old woman in her 30th week of gestation (gravida 2, para 0) presented with whole abdominal and right lower quadrant pain at Sanggye Paik Hospital. Ultrasound examination showed normal amniotic fluid and placentation but with breech presentation. She had undergone laparoscopic right ovarian cystectomy due to endometriosis 5 years earlier. Cardiotocography revealed an intermittent variable deceleration and no uterine contraction. Magnetic resonance imaging ruled out acute appendicitis. Four hours later, we observed a protrusion of the amniotic sac with the fetal head through a large uterine defect on magnetic resonance imaging, and performed emergency cesarean section. A boy was delivered without fetal compromise. During the cesarean section, multiple myometric wall defects and thinning were identified. After reconstruction of the uterine wall, the flaccid uterus bled persistently; thus, a cesarean hysterectomy was performed. Packed red cells and frozen plasma were transfused. The mother and neonate had uneventful puerperal and neonatal courses, respectively. After cesarean hysterectomy, we were informed that the mother had undergone a combined laparoscopic electromyolysis during the laparoscopic right ovarian cystectomy. Three years later, the child showed normal neural development. Before myomectomy or electromyolysis, patients should be informed of the possibility of uterine rupture during subsequent pregnancies. If a pregnant woman has abdominal pain, clinicians should take a detailed history of uterine surgery and consider uterine rupture. Although, fortunately, the outcomes in this case were uneventful, urgent delivery is required when uterine rupture is diagnosed.

Enlightenment for clinicians from the case of digestive tract metastases from primary lung cancer: a case report

Background: About 50% of patients with initially diagnosed lung cancer have developed distant metastasis. The probability of occurrence of digestive tract metastases found by autopsy is rarely. This report presents a rare clinical case of small intestinal metastasis from primary squamous cell carcinoma of the lung. Case presentation: An 82-year-old male with aggravated cough and more acute shortness of breath than usual was diagnosed with primary squamous cell carcinoma of the lung Stage IV,because of the advanced age, underlying diseases, and poor cardiopulmonary function,the family refused the chemoradiotherapy. One month later, the patient gradually developed right lower quadrant pain. An upright abdominal X-ray suggested small intestinal obstruction and partial resection and anastomosis of the small intestine were performed. Postoperative pathology revealed poorly differentiated squamous-cell carcinoma of the small intestine. The patient died of sudden cardio-respiratory arrest one month later. Conclusions:We conclude that the real incidence of digestive tract metastases from lung cancer may be higher than the reported because of the symptoms of those patients are not obvious. Clinicians should select the appropriate examination methods (such as positron emission tomography) and pay attention to the assessment of abdominal hollow organs

S46 Persistent Risks of TNF Inhibitors Despite Benefits: 31 Years Old Pregnant Patient With Crohn’s Disease

Introduction: TNF inhibitors have been used to treat inflammatory bowel diseases for the past 2 decades. These medications act to control acute flares as well as reach and maintain remission. However, side effects remain a large concern. Physicians should maintain a low threshold of suspicion for both opportunistic infection and malignancy, particularly lymphoma and leukemia, in their patients taking TNF inhibitors. Case: A 31-year-old 19 weeks pregnant female (G1P0, GA 19w0d) with Crohn’s disease presented with one month of right lower quadrant pain, fever, chills and fatigue. She had an incision and drainage performed for right thigh folliculitis 6 weeks before, and since then had continued pain in the right inguinal and lower quadrant area. She has been on adalimumab and azathioprine since 2015 with no recent flare ups; her last dose of adalimumab was given just before this admission. On admission, patient was febrile, tachypneic, and tachycardic, with leukocytosis. Given concern for sepsis in the setting of pregnancy, she was admitted to ICU and started on vancomycin and ampicillin-sulbactam for broad coverage. Imaging revealed extensive retroperitoneal lymphadenopathy along the right iliac chain and right inguinal region. She underwent an excisional biopsy from right inguinal lymph nodes. While final pathology results were pending, respiratory symptoms worsened, leading to an increased oxygen requirement. Chest CT showed progressive patchy ground glass opacities. Azithromycin and steroids were started, with pentamidine to cover possible Pneumocystis carinii pneumonia (PCP). On hospital day 15, the patient had a spontaneous vaginal delivery of a nonviable fetus. She experienced multi-system organ failure in following days, requiring vasopressor support, intubation, mechanical ventilation, and continuous renal replacement therapy due to severe metabolic acidosis. Antibiotics were broadened to vancomycin, meropenem, clindamycin, micafungin, azithromycin and pentamidine without meaningful clinical improvement. Multiple cultures, including a bronchoalveolar lavage, showed no pathogen. Final pathology revealed ALK-positive anaplastic large-cell lymphoma, a type of non-Hodgkin lymphoma, and the patient was started on chemotherapy with cyclophosphamide and doxorubicin. She had drastic clinical improvement following the first dose. She was then weaned off vasopressors and extubated. Antibiotics were discontinued, except atovaquone for PCP prophylaxis, and the patient was discharged on hospital day 26. Discussion: It is hypothesized that T cell dysfunction is involved in the pathogenesis of Crohn’s disease and studies have reported that patients with chronic inflammatory disorders might have an increased baseline risk of lymphomas regardless of TNF antagonist treatments. As physicians, we maintain high suspicion for opportunistic infections in IBD patients on TNF inhibitors presenting with signs of a systemic inflammatory response. However, clinical features associated with sepsis– such as fever, tachycardia, tachypnea, and leukocytosis– can indicate malignancy as well. Some lymphomas cause inflammatory responses that respond to chemotherapy. This case emphasizes the importance of avoiding singular focus on opportunistic infection in IBD patients.

Surgical approach for appendicitis in neutropenia: a case report and review of the literature

BackgroundAcute appendicitis is a common abdominal pathology, particularly in younger patients presenting with abdominal pain. The clinical presentation is typically characterized by right lower quadrant pain (with local peritonitis) accompanied by fever and nausea. In neutropenic patients it is challenging to diagnose acute appendicitis. It is much more challenging because the characteristic symptoms are different, and diagnosis may be delayed or missed.Case presentationWe present the case of a 33-year-old Caucasian male patient with fever, abdominal pain, and an absolute granulocyte count of 0 × 109/L. Abdominal CT demonstrated an uncomplicated acute appendicitis. We initiated a conservative in-hospital treatment with intravenous antibiotic therapy and simultaneous bone marrow stimulation, with close monitoring. On day three, there was evidence of monocyte increase, one of the first signs of bone marrow regeneration, and delayed laparoscopic appendectomy was performed. The perioperative and postoperative course was uneventful.ConclusionWe discuss the different treatment strategies in patients with neutropenia presenting with acute appendicitis (i.e., conservative management, delayed appendectomy, and immediate appendectomy) based on our experience and a review of the literature. In summary, delayed laparoscopic appendectomy at the onset of granulocyte regeneration under antibiotic and G-CSF therapy represents a viable surgical option for adults as well as for children and should be discussed compared with conservative therapy.

Review of appendicitis: routine, complicated, and mimics.

Appendicitis is one of the most common sources of abdominal pain in the emergency setting and is generally considered a straightforward diagnosis. However, atypical appearances, non-visualization, and inconclusive features can make these cases more complicated. The objectives of this article are to review the differential diagnoses for right lower quadrant pain, discuss the imaging characteristics of simple appendicitis on computed tomography (CT), and provide guidance for equivocal cases, complicated appendicitis, and appendicitis mimics. This review will also discuss the identification and management of neoplasms of the appendix.

8400 Distal Ureteral Resection with Ureteroneocystotomy; A Case of Robotic Assisted Laparoscopic Management of Ureteral Endometriosis

<h3>Study Objective</h3> Video presentation showing distal ureterectomy and reimplantation. <h3>Design</h3> Case presentation with showing procedural techniques in detail. <h3>Setting</h3> Tertiary academic teaching hospital. <h3>Patients or Participants</h3> 39-y.o. G6P3033 with past medical history of upper extremity deep venous thrombosis and surgical history of tubal ligation as well as endometrial ablation for menorrhagia, presented to the emergency room with right lower quadrant pain and was found to have right hydronephrosis and a 1.6 cm right ureterovesical junction mass on CT scan. She underwent a cystoscopy and right ureteric balloon dilation with stent placement with no evidence of bladder endometriosis. MRI showed a 1.6cm nodule at a low-intensity signal in T2-weighted sequences, suspicious for ureteral endometriosis. <h3>Interventions</h3> She underwent diagnostic laparoscopy with total hysterectomy and bilateral salpingectomy, robotic assisted distal ureterectomy with ureteroneocytotomy and stent placement. Her anticoagulation was held 48h prior to the surgery and re-initiated the day after her surgery. <h3>Measurements and Main Results</h3> The stent was discounted at 8 weeks post-operative. At 12 weeks post-operative she had an ultrasound done with normal fin dings and resolved hydronephrosis. <h3>Conclusion</h3> Preoperative planning and multidisciplinary team approach to management of severe endometriosis affecting the ureter is of paramount importance. While medical management is often the first-line therapy for endometriosis, urinary tract involvement often represents advanced stage of the disease, thereby timely diagnosis and appropriate surgical intervention is required to avoid permanent kidney injury.

Two-dimensional shear wave elastography can improve the diagnostic accuracy of ultrasonography in acute appendicitis.

We aimed to evaluate the effectiveness of combining 2-dimensional shear wave elastography (2D-SWE) with ultrasonography (US) in diagnosing acute appendicitis in patients with suspected acute appendicitis. Clinical and laboratory findings, gray-scale US and 2D-SWE imaging features, operation information, and pathology results of 48 patients diagnosed with acute appendicitis who presented with right lower quadrant pain were prospectively evaluated. We compared the findings to the US and SWE imaging features of 79 asymptomatic patients. Mean Alvarado score and appendix diameter were statistically significantly higher for acute appendicitis (p < 0.001). In patients with acute appendicitis, mesenteric lymphadenopathy and fat stranding were also more frequent (p < 0.001). The mean velocity and kPa values for appendix and mesenteric fat were statistically significantly higher in acute appendicitis (p < 0.001). In the diagnosis of acute appendicitis, 2D-SWE increases the diagnostic performance of gray-scale US in the differentiation of inflamed and normal appendixes.

Woman with Right Lower Quadrant Pain

A healthy, 25-year-old woman presented to the emergency department complaining of abdominal pain and a low-grade fever for 5 days. A physical examination demonstrated a temperature of 37.8 °C and tenderness in the right lower quadrant. Blood test results included a white blood cell count of 13,000 cells/μL and a C-reactive protein level of 5 mg/dL. The emergency physician performed a point-of-care ultrasound examination, which demonstrated the marked thickening (up to 8 mm) of the terminal ileum adjacent to the ileocecal valve.

Stercoral perforation of a cecal diverticulum: A rare presentation

Introduction: Right-sided diverticular disease, including cecal diverticulum, is a relatively uncommon occurrence when compared to left-sided diverticular disease, particularly in Western countries. Even more rare than this is the perforation of these diverticulum due to stercoral colitis. Case Report: We report the case of an 83-year-old man who presented to the Emergency Department with a relatively brief history of periumbilical and right lower quadrant pain, associated with nausea and low-grade fevers, and a computed tomography (CT) scan demonstrating perforation of a large cecal diverticulum requiring acute surgical management. Conclusion: Perforation of a cecal diverticulum is rare, particularly when due to stercoral colitis, and can be often misdiagnosed. It should be considered in the context of the systemically unwell older patient with a history of constipation.

S2715 Clinical Correlation Recommended: Appendiceal Crohn’s Masquerading as Acute Appendicitis on CT

Introduction: Granulomatous appendicitis is uncommon, often caused by Crohn’s disease (CD), infiltrative disease (ie sarcoidosis), or infection (ie Yersinia). We report an unusual presentation of CD limited to the appendix. Case Description/Methods: A 46-year-old male with celiac disease presented to clinic for evaluation of intermittent epigastric and right upper quadrant (RUQ) abdominal pain occurring four times per year. When present, the pain was constant, pressure-like and gradually worsened over a three-day period. He denied nausea or vomiting, but reported non-bloody diarrhea with episodes. His symptoms persisted despite a gluten free diet and normalization of celiac serologies. In the clinic, he was afebrile with normal vital signs. Abdominal exam demonstrated mild tenderness to deep palpation of the RUQ. CT enterography demonstrated inflammation around his appendix, terminal ileum, and right ureter concerning for acute appendicitis (Figure). Given incongruity of his mild clinical presentation and chronicity of his symptoms, he underwent colonoscopy which showed inflammation of the appendiceal orifice, surrounding cecum, and distal rectum. Biopsies of the rectum and cecum demonstrated active inflammation without chronicity, with a normal terminal ileum. Due to evidence of active inflammation of unknown etiology, he underwent laparoscopic ileocecectomy with anastomosis. Pathology findings were consistent with moderately active Crohn’s colitis isolated to the appendix. He had no signs or symptoms of extra-intestinal manifestations of inflammatory bowel disease. Following surgery, his symptoms resolved and repeat CT six months later demonstrated resolution of inflammation. The patient remains asymptomatic without CD treatment. Discussion: Isolated appendiceal CD is a rare entity that is most often seen in men in their 20-30s. It typically presents with acute right lower quadrant pain, occasionally with diarrhea, lasting 0-14 days, but can become protracted. Our patient’s history and nontoxic exam did not fit acute appendicitis as initially suspected on CT scan, instead suggesting a chronic process such as CD. There is no consensus regarding surveillance and treatment of isolated appendiceal CD. Recurrence rates after appendectomy are low, suggesting that appendectomy alone is a sufficient treatment for isolated disease. It was therefore recommended that this patient return for further evaluation based on symptoms alone, rather than undergo surveillance.Figure 1.: CT Abdomen Pelvis Enterography with IV Contrast demonstrating appendiceal inflammation.

S2710 Atypical Cutaneous Eruption to Mesalamine

Introduction: Mesalamine, 5-aminosalicylic acid (5-ASA), is an anti-inflammatory drug that is used in the treatment of ulcerative colitis (UC). Mesalamine use is associated with rare, but well-described hypersensitivity reactions with renal, cardiac, and pulmonary involvement. We present a case of an atypical cutaneous reaction in a patient with UC associated with mesalamine therapy. Case Description/Methods: An 85 year old male with hypertension, diabetes, and mucinous adenocarcinoma of the lung presented to inflammatory bowel disease (IBD) clinic to establish care. He was diagnosed with UC in the 1970s and had previously been treated with sulfasalazine. For lung cancer, patient was treated with pembrolizumab, which was discontinued 18 months prior. Upon presentation, he reported 1-2 bowel movements daily with intermittent blood per rectum and right lower quadrant pain. Colonoscopy done 2 years prior to presentation had demonstrated quiescent disease. The patient was started on mesalamine 4800mg daily. Two weeks after starting mesalamine, patient endorsed hypopigmented spots on scalp and torso, generalized pruritis, and bilateral foot pain. Mesalamine was stopped. Within 2 weeks, patient developed a new rash (Figure). He was urgently referred to Dermatology clinic and noted to have tense bullae and pruritic pink plaques on his torso. Punch biopsy was performed, and labs were sent including pemphigoid Ab panel that confirmed diagnosis of bullous pemphigoid (BP). Patient was started on prednisone 40mg daily for 2 weeks. At return visit in two weeks, skin lesions had resolved, and the patient was weaned from prednisone. Discussion: We presented a case of drug-associated bullous pemphigoid (DABP) associated with mesalamine therapy. There are multiple reports of mesalamine-induced Steven Johnson Syndrome, but BP has been rarely described. Although our patient was on a PD-1 inhibitor, his discontinuation 18 months prior makes the likelihood of it causing his cutaneous symptoms exceedingly unlikely. Mesalamine-DABP is a cutaneous manifestation of mesalamine hypersensitivity and can be recurrent upon re-introduction of mesalamine. Although a rare complication, mesalamine-DABP is an adverse event that gastroenterology providers should be aware of when starting patients on mesalamine.Figure 1.: Drug-associated bullous pemphigoid after mesalamine treatment.

S3111 An Unusual Case of Acute Liver Failure Secondary to Autoimmune Hepatitis (AIH) From Drug-Induced Liver Injury (DILI)

Introduction: A broad differential diagnosis and detailed workup is necessary in the evaluation of acute liver failure, as the below case demonstrates. Case Description/Methods: A 68-year-old Caucasian man presented to the ED complaining of chronic right lower quadrant pain, worsening over the last few weeks. He reported taking up to 20 tablets of naproxen a day. Review of systems was positive for diffuse pruritis of recent onset. Past medical history consisted of COPD, inguinal hernia status post mesh repair, knee osteoarthritis and a cholecystectomy. He endorsed daily tobacco use and minimal alcohol intake. Medications consisted of Albuterol inhaler and Naproxen. He had been diagnosed with a urinary tract infection one month prior that was treated with a ten-day course of Cephalexin. Exam was notable for diffuse excoriation and right upper/lower quadrant tenderness. Initial labs demonstrated creatinine 0.87, AST 2635, and ALT 887, with the remainder of his comprehensive metabolic panel being normal. Contrasted CT scan of the abdomen and pelvis revealed no abnormalities. A right upper quadrant ultrasound was notable for left sided intrahepatic biliary dilatation. Over the next day, his mentation worsened, with repeat labs notable for bicarbonate 13, creatinine 3.08, AST 12050, ALT 3950, total bilirubin 2.4 with direct bilirubin 1.5, INR 3.11 and ammonia 164. A broad infectious workup was unremarkable including negative viral hepatitis serologies. Smooth muscle antibody was weakly positive at a low titer of 1:20. Anti-nuclear and anti-mitochondrial antibodies were negative. Serum IgG level was normal. Endoscopic retrograde cholangiopancreatography revealed a severe left intrahepatic biliary stricture with resulting stent placement into the left hepatic duct. Bile duct brushing was negative for atypical cells. Liver biopsy demonstrated centrilobular necrosis and parenchymal collapse with focal bridging necrosis and mixed inflammatory infiltrate. A diagnosis of AIH secondary to DILI leading to acute liver failure was made, with either Naproxen or Cephalexin being the inciting drugs. Discussion: He was started on a prednisone taper and showed improvements in mental status and kidney and liver function on lab-work prior to discharge. Labs obtained on clinic follow-up one month after discharge revealed complete resolution of his kidney and liver injury. This case illustrates a rare clinical entity as neither Naproxen nor Cephalexin are classically associated with causing AIH or acute liver failure.

Impacted golf tee shaped appendiceal fecalith causing appendiceal non-visualization and mimicking cecal mass: A case report

Introduction: When fecaliths occur in the appendix, they commonly cause obstruction and bacterial overgrowth leading to appendicitis presenting as right lower quadrant pain. Fecaliths can be identified radiographically, and their presence raises high suspicion of appendicitis in the right clinical setting. Case Report: A 25-year-old Caucasian male presented with persistent lower abdominal pain, which was suspected to be a cecal mass on colonoscopy. Radiography by X-ray and computed tomography (CT) scan described a non-visualized appendix and no evidence of a fecalith. Colonoscopy was performed, and biopsies revealed an inflamed colonic mucosa with fecalith-like material. Subsequent right hemicolectomy revealed no cecal mass but an impacted golf tee shaped appendiceal fecalith which caused neither obstruction nor appendicitis due to its unique structure. Conclusion: This case report describes an appendiceal fecalith that grew in the form of a golf-tee starting at the tip, growing to the appendiceal orifice, and deviating from every known clinical and radiographic presentation of appendiceal fecalith with unusual pathogenesis. Specifically, this uncommonly shaped fecalith rendered the appendix difficult to visualize radiographically, mimicked a cecal mass on coloscopy, and caused persistent lower abdominal pain, in the absence of obstruction and without leading to appendicitis. This novel presentation widens the spectrum of appendiceal pathologies and clinical signs and symptoms that may be caused by a fecalith.

Impact of the coronavirus disease 2019 (COVID-19) pandemic on the presentation of paediatric acute appendicitis: an observational study

AimTo determine whether there were differences in the clinical presentation of patients imaged to evaluate for acute appendicitis in 2020 compared to 2019 with the hope that this information might better identify patients who should undergo imaging work-up and those who should not.Materials and methodsThis retrospective observational study included patients <18 years who were evaluated for appendicitis between 1 March and 31 May 2019 and 2020. A total of 465 patients were stratified by final diagnosis (appendicitis versus not appendicitis) and compared based on presenting symptoms, physical examination findings, vital signs, and laboratory test results.ResultsSymptoms and physical examination findings that were significant in the positive cohort in both years included right lower quadrant pain, pain with movement, migration of pain, right lower quadrant tenderness, and peritoneal findings. Reporting upper respiratory symptoms was an independent predictor of negative results among all patients and in 2019. Both negative cohorts were more likely to have negative physical examinations. Anorexia and nausea/vomiting were more likely among positive cases in 2019 whereas diarrhoea was more likely among positive cases in 2020.ConclusionsThe COVID-19 pandemic did not significantly change the presenting features of acute appendicitis. The results of the present study emphasise the importance of the physical examination. The ambiguity of symptoms that mimic gastroenteritis justifies imaging in these patients.

Acute appendicitis in pregnancy; A single center experience

Objective&#x0D; Appendicitis is the most common cause of extrauterine acute abdomen during pregnancy. There are scoring systems, such as Alvarado, based on physical examination and laboratory values developed for the diagnosis of appendicitis in the general population. However, when it comes to pregnant women, the effectiveness of the methods used in daily practice decreases considerably. In our study, we aimed to share the data of our patients who were diagnosed with acute appendicitis during pregnancy in our clinic.&#x0D; Material methods&#x0D; Pregnant women who were operated for acute appendicitis between April 2008 and May 2021 were included in the study. Demographic data of the patients, gestational week, physical examination and laboratory values at the time of admission, USG findings, type of surgery performed, surgical findings, pathology results and fetal-maternal complications that developed during postoperative follow -up were reviewed retrospectively through the hospital system.&#x0D; Results &#x0D; From the clinicopathological features of the patients, only re-operation due to appendiceal stump leakage (p:0.04) and drain placement during operation (p:0.046) were significantly associated with miscarriage. Although complications and abortion rates were higher in patients with perforation and periappendicular abscess, the difference was not statistically significant.&#x0D; Conclusion&#x0D; Detailed history and physical examination are key for the diagnosis of acute appendicitis in pregnant women. Any patient with right lower quadrant pain, nausea, vomiting and fever, who has tenderness and defensive rebound in the right lower quadrant on physical examination should be considered as appendicitis after obstetric causes are excluded, until proven otherwise.

Excreted 99m Tc-Pertechnetate in a Renal Pelvis as a Potential False Positive in a Meckel's Scan.

A 14-year-old girl presented with right lower quadrant pain. A 99m Tc-pertechnetate scan with SPECT/CT was performed to exclude a Meckel's diverticulum. The images demonstrated focal tracer uptake in the right midabdomen, which appeared early and decreased over time. However, SPECT/CT revealed that this uptake corresponded to the right renal pelvis, which was located more inferior than expected. This case emphasizes the importance of recognizing anatomic variants that may cause focal tracer uptake, as well as leveraging an understanding of tracer kinetics to inform a diagnosis.

Rare Case of Appendiceal Signet-ring Cell Carcinoma Mimicking Advanced Ovarian Cancer

Primary signet-ring cell carcinoma of the appendix is extremely rare, and because the symptoms are vague and nonspecific, obtaining a preoperative diagnosis is difficult. It cannot be detected using imaging modalities because its radiologic features are undefined, and its appearance on both computed tomography and ultrasound images is similar to that of nontumorous appendicitis. Usually, a diagnosis is made after surgery for other diseases involving the removal of the appendix. The right hemicolectomy is suggested for invasive adenocarcinoma; however, diagnosing primary signet-ring cell carcinoma before surgery and managing tumors with adequate surgical resection remain challenging. We present a case of a large ovarian tumor with peritoneal carcinomatosis diagnosed with advanced ovarian cancer but subsequently revealed through pathology to be primary appendiceal signet-ring carcinoma. Detecting appendiceal signet-ring carcinoma warrants additional surgical management, and treating it involves chemotherapy. This rare disease should be kept in mind when encountering abdominal right lower quadrant pain and tumors to allow for a full treatment plan.

P-269 Malignant tumors of the appendix: A retrospective study

Malignant tumors of the appendix are a rare group of tumors often found fortuitously during surgical removal of the appendix, representing approximately 2% of appendectomy specimens. Our objective was to describe the clinico-pathological characteristics of appendicular tumors, the therapeutic modalities proposed and patient’s evolution after treatment. We conducted a retrospective review of 52 patients diagnosed with malignant tumors in the Medical Oncology department at Mohamed VI University Hospital, Marrakech, Morocco between 2012 and 2021. The clinical, biological, radiological, therapeutic and evolution data were collected. The median age was 50 years. The sex ratio was 0.7. Right lower quadrant pain was a constant complaint, followed by constipation, abdominal bloating and/or distension and vomiting. The diagnostic was based on ultrasound and/or abdominal scan. A complementary colonoscopy was proposed for 4 patients. An appendicectomy for performed on all patients after suspecting an acute appendicitis, an appendicular mucocele or for a diagnostic exploration. 42% (22 cases) were found to have a low-grade appendicular mucinous tumor, 34% a mucinous adenocarcinoma (including 5 patients with pseudomyxoma peritonei) and 24% (12 cases) an neuroendocrine tumor. 36% had localized only in the appendix while 64% were already metastatic. The therapeutic management was based on an additional surgical revision by right hemi-colectomy with ileocecal resection and lymph node dissection in 32% (17 cases), while 3% (2 cases) had undergone cytoreductive surgery with intravenous chemotherapy-peritoneal. Adjuvant chemotherapy was indicated to patients with a localized tumor with R0 and positive lymph node dissection which is the case in 7 patients. Palliative chemotherapy was proposed for metastatic patients with an unresectable tumor 26% (14 cases). 55% were under medical surveillance and screening, and 24% of patients relapsed. 21% (11 cases) were lost to follow-up. Appendicular malignant tumors represent a wide histological spectrum with various clinical subtypes, early diagnosis conditioning its management. Multidisciplinary molecular tumor boards are recommended.

Asymptomatic Appendiceal Mucocele with Typical Onion Skin Sign on Ultrasound

Appendiceal mucocele is an obstructive dilatation of the appendix caused by abnormal accumulation of mucoid material. Its incidence is 0.2-0.3% of all appendectomy specimens and it does not have typical clinical features. It can mimic acute appendicitis in patients with right lower quadrant pain. Some patients have appendiceal mucocele with acute appendicitis. For this condition, 25% of cases were asymptomatic and were discovered incidentally on ultrasound examination, computed tomography, or colonoscopy due to nonspecific abdominal symptoms. Ultrasound examination or computed tomography is an important diagnostic tool for accurate preoperative diagnosis. If mucocele is treated incorrectly, pseudomyxoma peritonei may develop. The present study reports a case of a 79-year-old male with constipation. Ultrasonography showed a typical layered echogenic pattern of the appendiceal wall (onion sign or onion skin sign), which suggested appendiceal mucocele. Computed tomography showed a dilated appendix filled with low-attenuated material, indicating a pathologic diagnosis of low-grade appendiceal mucinous neoplasm.