An unsuspected clinical condition: Appendicitis of appendicular residual, three cases report

Abstract

INTRODUCTION

Stump appendicitis is a rare complication of appendectomy unusually included in the differential diagnosis. This is found in appendectomized patients with similar symptoms to those of a previous appendicitis.

PRESENTATION OF CASE

We present three cases, two women and a man of 67, 30 and 24 years old, respectively. They underwent surgery at our centre and their appendectomies presented technical difficulties: problems when identifying the appendicular base or the complete appendicular structure. In the first case, diagnosis and therapy were performed with laparoscopy. The second case was diagnosed by an abdominal ultrasound (US) which revealed a tubular structure with thickened walls. An abscess was observed in the computed tomography (CT) scan for the third case and a laparotomy revealed the retained appendix.

DISCUSSION

Although there are several factors that can contribute to this rare pathology, the main cause of stump appendicitis is the persistence of a large appendicular remnant. CT and US are very useful diagnosis tools. Treatment consists to a completion appendectomy of the stump which can be carried out by an open or a laparoscopic approach.

CONCLUSION

In this rare pathology a prior history of appendicectomy can delay the diagnosis and increase its associated morbidity and even mortality. In patients with abdominal pain in the right lower quadrant and previous appendectomy, it is important to include this pathology in the differential diagnosis, in order to not delay the treatment and thus avoid complications.

1. Introduction

Although appendectomy is initially a simple technique it is not free of complications, one of them is appendicitis of appendicular remnant.

Inflammation of the appendicular stump is quite rare, throughout the English medical literature there are only 63 cases described. A delayed identification of this condition implies an increase in the number of complications that arise.

We describe three new cases of residual appendix appendicitis.

2. Cases

2.1. Case 1

A 67-year-old woman was admitted into emergency department with a 12-h history of diffuse abdominal pain. Her most outstanding medical history was a stable ischaemic cardiopathy and open appendectomy for gangrenous appendix 7 months ago. At that time the patient had presented with an abscess adjacent to appendix, making difficult to identify the appendicular base.

Abdominal examination revealed diffuse tenderness, McBurney's incision scar and increased peristalsis. Due to uncontrolled pain, it was decided to observe the patient for further assessment 12 h later. Diffuse tenderness persisted at re-examination after 12 h in both iliac fosses, with tenderness and rebound in the right lower quadrant (RLQ). Patient's blood test showed 6900/μL leucocytes with neutrophil (79%).

An abdominal CT was requested (Fig. 1A and B); it reported a thickening of the caecum, inflammatory changes of the pericecal fat and a tubular structure. A small appendicular stump was suspected although terminal ileitis was not rejected.

Fig. 1.

(A and B) Case 1, abdominal CAT diagnosis: tubular structure, apparently appendicular stump 1, thickening of the caecum 2, pericecal fat thickening 3.

A laparoscopic exploration was performed and, having divided adhesions around the pericecal area, a hard and inflamed 2 cm appendicular stump was excised and extracted (Fig. 2).

Fig. 2.

Appendicular stump, Case 1, after removal.

During postoperative recovery she presented with precordial pain treated with nitrates. An ECG did not reveal enzymatic alterations until the 5th day and she was transferred to the cardiac department. She had no abnormality at abdomen site and was discharged with the diagnosis of stump appendicitis and unstable angina on postoperative day 12.

2.2. Case 2

A woman 30-year-old with a 12-h history of abdominal pain in RLQ was admitted. She had undergone an open appendectomy 6 months before due to retrocecal appendicitis with multiple adhesions to the cecum. The appendicular stump has not been inverted in prior surgery.

Abdominal examination showed a former McBurney's scar, both tenderness and rebound in RLQ, 18,500 leucocytes/μL with neutrophil (89%). An abdominal US revealed a tubular structure arising on the caecum of retrocecal origin, with thickened walls and hyperechogenity of local fat compatible with stump appendicitis (Fig. 3).

Fig. 3.

Abdominal ecography, Case 2: with tubular structure depending on caecum 1. Hyperechogenicity of local fat, 2.

The patient underwent an urgent laparotomy. A retrocecal abscess was found close to a 3-cm appendicular stump. An appendectomy of the stump and abscess drainage was performed. Postoperative course was uneventful and she was discharged 6 days after admission.

2.3. Case 3

A 24-year-old man was admitted to our centre with a complicated appendicitis with abscess. A laparoscopic appendectomy and abscess drainage were performed and a retro-ileal appendix was determined.

Twenty-four hours after surgery, despite antibiotic treatment, the patient had 38 °C temperature, pain in the inferior hemiabdomen with rebound, tenderness, leucocytosis (leucocytes 12,000 μL; neutrophils 87%) and increasing C reactive protein (CRP): 26.28 mg/L. An abdominal US revealed an enlarged small bowel with liquid inside and decreasing peristalsis; thickened iliac fossa with hyperechogenity, neither free liquid nor collections.

A conservative approach was adopted with antibiotic treatment. Due to a lack of response, an abdominal CT was performed two days later: a 9 cm × 3.5 cm × 5 cm collection was identified, located in the mesentery, between aorta, mesentery vessels and under the duodenum, associated with inflammatory changes in the local fat and a small amount of free liquid in the right parietocolic area and pelvis.

A median infraumbilical laparotomy was carried out: it was identified an abscess at the root of the mesentery that required drainage as well as an appendicular remnant that was removed.

After the second surgery, the patient recovered well and left the hospital on the 10th day.

Pathology reports confirmed severe stump appendicitis in all the three cases.

3. Discussion

Appendectomy is one of the most frequent abdominal emergency surgeries.¹ Complications in the procedure can be classified into two groups: the early ones: post-operative haemorrhage, wound infection, intraabdominal abscesses and the later ones: adhesions, nerve entrapment signs, eventrations and stump appendicitis.^1,2 This last seems to be a rare event: around 70 cases have been described since the first published by Rose in 1945.³ This low frequency together to the fact that it is probably an under diagnosed entity make clear the lack of series to measure its real incidence. The described interval between the first surgery and the development of the symptoms is between 4 days and 50 years.⁴ In our third case, symptoms started 24 h after the first surgery.

The main cause for stump appendicitis is the persistence of a large appendicular remnant, this should be <3 mm⁵ because an appendiceal stump larger than 5 mm is a possible reservoir for appendicolith and may get blocked, inflamed or damaged causing pathology; other causes of stump appendicitis are an incomplete removal of the appendix and the incomplete inversion of the stump.^1,6 The presence of local inflammatory changes with severe oedema, pericecal abscesses (first and third case), local peritonitis, adhesions, retrocecal or subserosal appendix localization (second case) are related factors leading to a wrong identification of the appendiceal base which, at the same time, can lead to the incomplete resection of the appendix.^2,7

No an agreement on whether the stump inversion makes us think that the ligation is the result of technical difficulties, but we can’t consider it the reason for an appendicitis of the remnat [5].

Although there has been an increasing incidence of this pathology during the last years which can be linked to the increasing use of laparoscopic approach, nothing can be proved. In that sense, most of the referred cases presented an open approach (58.3% laparotomy vs. 31.6% laparoscopy).^2,4 This relationship is likely to be due to its own limitations: limited field of vision and a lack of sense of touch and depth. In our opinion the main factor could be a wrong identification of the appendicular base; it would be improved following the colic tenias until getting to the appendicular base and then ligating and resecting at this level.⁸ The fact of not having identified the appendicular base indicates the conversion to laparotomy.⁴

Stump appendicitis clinical presentation is similar to that of a severe appendicitis: all cases present abdominal pain (81% located in the RLQ with tenderness and rebound); nausea and vomiting are present in 90%; anorexia and temperature are also related factors^9,10; leucocytosis appears in 85% of the patients. The surgeon usually does not include this pathology in the differential diagnosis, this issue cause a delayed identification and increased rate of complications, so stump perforation is found in 36% of cases and gangrenous appendicitis in 6.6%, being associated or not to an abscess.⁴

Diagnosis by US is quite complicated. Our second case was diagnosed by this and a thickened appendicular stump which revealed inflammatory changes in the pericecal fat was observed. Otherwise a thickening of the caecum or free liquid can be seen.⁶ Abdominal CT provides the greatest amount of information, indirect signs of stump appendicitis are generally depicted: thickening of caecum walls, inflammatory changes in the pericecal fat, presence of appendicolith, pericecal abscess and liquid in the parietocolic area, etc. In some cases, the appendicular stump is directly visualized.¹¹

Despite all the diagnostic techniques, sometimes it is not possible to reach a definite diagnosis; in those cases a laparoscopy gives an improved chance of examination while being also therapeutic. In the first case we confirmed the diagnosis with laparoscopy, and resection of the stump after a proper identification of the appendicular base, plus drainage of the abscess, were performed. This is the initial treatment: appendectomy of the stump after a proper identification of the appendicular base. It can be performed in an open or laparoscopic intervention (there are as many as 8 cases described using this option).⁸ More aggressive treatments are applied such as ileocecal resection when diagnosis is delayed and the pathology has more time to progress.

4. Conclusion

Appendicitis of the appendicular stump is a rare event that takes place after inflammation of the large residual appendicular stump. This can be avoided by proper identification of the appendicular base in the first surgery. Clinical findings are similar to that of the previous appendicitis. A delayed diagnosis must be avoided and, in order to achieve this, imaging techniques such as US, CT and laparoscopic examination should be used. This last one may also be therapeutic. When a patient present with symptoms of acute appendicitis and had a prior history of difficult appendectomy, one should incorporate this diagnosis into the list of possible entities to rule out.

Conflicts of interest

Authors state not to have any conflicts of interests.

Funding

None.

Ethical approval

Written informed consent was obtained from patients for publication of this report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Author contributions

Mínguez G., Gonzalo R. and Tamargo A. were designed and wrote the paper, Mínguez G. reviewed the bibliography, Mesa A. contributed the radiology imaging, Turienzo E. corrected the paper, and Vazquez L. who is the chief surgeon of the service approved the final version of the paper for publication.

All authors read and approved the paper's final version.