Endoscopic Appendectomy for Inverted Appendix: A Case Report and Review of Literature

Abstract

Inverted appendix is a very rare anomaly and presents a diagnostic challenge. We report a case of inverted appendix in a 10-year-old boy and its management.

INTRODUCTION

Congenitally inverted appendix is a very rare anomaly. We report a case of acute appendicitis in a congenitally inverted appendix which was treated endoscopically. Relevant literature is reviewed.

CASE REPORT

A 10-year-old boy presented with a history of recurrent episodes of severe right lower abdominal pain of 2 months duration. His previous medical history was significant. He had undergone staged repair of a high anorectal malformation in early infancy. At 6 years of age, a Mitrofanoff procedure was performed to facilitate clean intermittent catheterization for neurogenic bladder. Interestingly, at this time, the appendix could not be identified and an ileal Monti tube was used.

On examination, he was hemodynamically stable with tenderness and guarding in the right iliac fossa. In lieu of the previous operative findings, a contrast-enhanced computed tomography of the abdomen was performed, which showed a tubular structure in the cecum (possible ascariasis). On colonoscopy, an inflamed and turgid tubular structure was identified, base of which appeared to arise from the appendicular orifice [Figure 1]. A possibility of inverted appendix was considered and two endoloops (30 mm Olympus loop: MAJ 254) were applied [Figure 2a] which resulted in shrinking of the structure [Figure 2b]. The appendix sloughed out in a few days and the patient's symptoms subsided. He was discharged on the postprocedure day 2 and made an unremarkable recovery.

Figure 1.

Inverted appendix seen on colonoscopy

Figure 2.

(a) Endoloops applied at the base of appendix. (b) Appendix shrinks on application of the endoloops

DISCUSSION

Congenital anomalies of the appendix are rare and include agenesis, duplication, and diverticula formation. Very few cases of appendix inversion into the cecum have been reported. The appendix may be inverted in one of the following situations. First, the appendix could be inverted surgically, typically after malrotation correction. Here, the appendicular mesentery is cauterized, the appendix is inverted into the cecum, and it usually sloughs out in a few days. Second, an appendix may be within the cecum in cases of appendicular intussusception. Appendicular intussusception is more commonly seen in adult females, generally in the fourth decade of life. Most of these patients present with chronic abdominal pain, vomiting and bleeding per rectum.[1]

Rarely, inverted appendix is seen in patients without any history of previous surgical intervention. These are congenitally inverted appendix. Very few such cases have been reported in the literature. All these cases were diagnosed incidentally on colonoscopy. The colonoscopic findings are that of a polypoidal lesion in the cecum at the site of the appendix opening. The specific location and the typical appearance of the appendix allows its recognition.[2,3,4,5]

In general, the inverted appendix can be left alone as overzealous resection may cause cecal perforation. The first recorded endoscopic removal of a symptomatic inverted appendix was reported in 1976.[6] It can be done safely when the base of the appendix is not very inflamed and turgid. Today, there are accessories such as endoloops and clips that allow the procedure to be performed with comparative safety. Although the risk of complications from an inverted appendix remain unclear, there are case reports of intussusception.[7,8,9,10]

CONCLUSION

Inverted appendix is a rare entity. It can be congenitally present and it should be kept in mind when a cecal polypoidal lesion is found on colonoscopy or when appendix is absent at surgery. Colonoscopic endoloop appendectomy may be performed safely. This report is being presented for its unusual nature.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.