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Stump appendicitis diagnosed preoperatively by computed tomography
StumpAppendicitisDiagnosedPreoperatively by ComputedTomography PATRICK M. RAO, MD,* MARK d. SAGARIN, MD,I CHARLES J. McCABE, MD1Recurrent appendiceal pathology after appendectomy is a rare occurrence that is not often considered even when patients present with findings that suggest appendicitis. Computed tomography (CT) is accurate for imaging clinically suspected appendicitis and can be useful in postappendectomy patients with acute right lower quadrant symptomsJ We describe the case of a recently postpartum woman, 34 years after an appendectomy, who presented with acute right lower abdominal complaints and was preoperatively diagnosed by CT with stump appendicitis.
CASE REPORT A 39-year-old woman (gravida 3, para 2, therapeutic abortion l) who was l 1 days postpartum from a normal, spontaneous vaginal delivery, presented to our emergency department (ED) with the chief complaint of bilateral (right greater than left) lower abdominal pain. She also complained of mild nausea, emesis, and low-grade fever. She denied urinary tract symptoms, excessive vaginal bleeding or discharge, or change in bowel habits. Her medical and surgical histories included an appendectomy at 5 years of age, a partial small bowel and colonic resection for focal ischemia, peptic ulcer disease, and polysubstance abuse. Upon presentation to our ED the patient appeared to be in moderate distress. Vital signs included a temperature of up to 100.4°F, blood pressure of 130/80 mm Hg, pulse rate of 96 beats/min, and respiratory rate of 20 breaths/min. Physical examination of the abdomen revealed well-healed midline and right lower abdominal surgical scars. There was mild to moderate right-greater-than-left lower abdominal quadrant tenderness to palpation, with mild guarding, rebound, and shake tenderness. Psoas and Rovsing signs were both present. Pelvic examination was remarkable only for mild right adnexal tenderness without uterine abnormality detected. The uterus was 12-week size with a mildly tender, firm fundus. Rectal examination found no tenderness and hemoccult negative stools. Pertinent laboratory values included normal electrolyte and blood cell panels except for a white blood cell count of 19,400/pL; urinalysis was unremarkable. The initial clinical impression was postpartum endometritis for which the patient was placed on clindamycin and gentamicin. The atypical presentation and worsening symptoms over the next 2 days prompted a pelvic ultrasound examination, which showed an enlarged but normal postpartum uterus and a small amount of endometrial cavity fluid. Both ovaries were uuremarkable. At this point, because of the possibility of ovarian vein thrombosis, an abdominopelvic CT examination was performed with oral and
From the *Department of Radiology and 1-Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA. Manuscript received March 18, 1997; accepted April 2, 1997. Address repdnt requests to Dr Rao, Department of Radiology, Massachusetts General Hospital, 32 Fruit St, Boston, MA 02114. Key Words:Appendicitis, appendix, computed tomography (CT). Copyright © 1998 by W.B. Saunders Company 0735-6757/98/1603-002558.00/0
intravenous contrast media. The scans showed fight paracolic gutter fluid and a pericecal phlegmon and abscess (Figures 1A,B,C). Two and one half centimeters below the ileocecal valve, along the posteromedial cecal wall, at the expected location of the appendiceal orifice, an 8-rnm by 16-mm oval calcification was noted, as was the CT arrowhead sign of appendicitis (Fig 1D).2 The CT scan was interpreted as diagnostic of appendicitis, in this case, stump appendicitis. At surgery, a periappendiceal stump abscess with cecal perforation was found, and distal ileal and fight colonic resection was performed with primary anastamosis of ileum to mid-transverse colon. Findings were confirmed at pathology. The patient did well postoperatively on a 6-day course of antibiotics, and was discharged on postoperative day 7.
DISCUSSION Appendectomy is a common and safe surgical procedure, whether by laparotomy or by laparoscopic means) In the perioperative period, complications are uncommon but include superficial wound infection, abscess formation, antt bowel obstruction. Remote complications are also uncommon and include infection, hemorrhage, malignancy, intussusception, fistula formation, and recurrent (stump) appendicitis. 4 We are aware of 14 cases of stump appendicitis reported in the medical literature to date, although other unreported cases have likely occurred. Time intervals from initial appendectomy to stump appendicitis have ranged from 3 months to 21 years. 4 All cases have occurred in patients who underwent simple ligation of the appendix without invagination of the stump. Four recently reported cases involved initial laparoscopic appendectomy. 5-7 It is possible that simple ligation with failure to amputate the appendix close to its origin from the cecum is a prerequisite for developing stump appendicitis. It has also been postulated that during laparoscopic appendectomy, difficulty retracting a long appendix can leave a long appendiceal stump. 8 Before the advent of CT, definitive preoperative diagnosis of stump appendicitis was not possible. CT was used in four documented cases of stump appendicitis, and findings have included an irregular ileocecal mass (2 cases), a large pelvic abscess (1 case), and pericecal fat infiltration around a retrocecal tubular structure (1 case). 4,6,7,9 Only in the latter case, in which the appendiceal stump actually resembled a short but distended appendix, were the CT findings diagnostic of stump appendicitis. 4 In the case reported here, the clinical presentation, although typical for appendicitis, was clouded by the patient's postpartum state, prior bowel surgery, and prior appendectomy 34 years earlier. The longest previously reported time lag between appendectomy and stump appendicitis was 21 years. 4 Although the appendiceal stump was 309
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AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 16, Number 3 • May 1998
FIGURE 1. Stump appendicitis at CT. (A) Free fluid (F) along the fight paracolic gutter, posterior to the ascending colon (AC) and lateral to the right kidney (K). (B) The fatty ileocecal valve (arrow) at the junction of the terminal ileum (I) and cecum (C) is an important landmark for identifying the appendiceal origin. (C) Large phlegmordabscess (P) between the cecum (C), fight psoas muscle (PS), and right iliac crest (I). (D) The arrowhead sign (curved arrows) and appendolith (straight arrow) along the posteromedial cecum (C) at the anatomical cecal apex secure the diagnosis of stump appendicitis. obscured by surrounding phlegmon and abscess, CT did show an arrowhead sign and an appendolith, individual specific CT signs of appendicitis that, when combined, are pathognomonic for appendicitis. 1,2 Compare the findings of stump appendicitis (Figure 1) with a normally invaginated appendiceal stump at CT (Figure 2).
This case also highlights the difficulty of accurately diagnosing postpartum fever and abdominal pain. The differential diagnosis includes both conditions seen in the general population and conditions specific to the puerperium. The latter group includes endometritis, ovarian vein thrombophlebitis, wound infection or abscess (after cesarean
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of ovarian vein thrombosis mimicking the CT appearance of appendicitis. 12 In our case, the CT findings could not have been confused for ovarian vein thrombophlebitis. In summary, stump appendicitis is a rare occurrence that is not often considered in the differential diagnosis of acute fight lower quadrant abdominal pain. It can, however, occur as a late complication of appendectomy, even up to 34 years after surgery. In a postappendectomy patient who presents with acute fight lower quadrant findings mimicking appendicitis, CT can assist in making an accurate preoperative diagnosis.
REFERENCES
FIGURE 2. Normal appendiceal stump. A small mound of soft tissue (arrows) along the cecal wall is a characteristic finding in patients whose appendiceal stump was invaginated. section or deep laceration repair), and vaginal hematoma. ~° Endometritis is the most common cause of puerperal fever, usually associated with a boggy and tender uterine fundus and malodorous cervical discharge. Our case was not typical for endometritis. Although uncommon, ovarian vein thrombophlebitis is a right-sided process 90% of the time. ~1 The clinical picture can be very similar or identical to typical appendicitis, and CT and magnetic resonance imaging both can diagnose ovarian vein thrombophlebitis. Appendicitis, however, is best diagnosed using CT, with reported accuracies reaching 98%? There has been a case report, however,
1. Rao PM, Rhea JT, Novelline RA, et al: Helical CT technique for the diagnosis of appendicitis: Prospective evaluation of a focused appendix CT technique. Radiology 1997;202:139-144 2. Rao PM, Wittenberg J, McDowell RK, et al: Appendicitis: Use of arrowhead sign for diagnosis at CT. Radiology 1997;202:363-366 3. Street D, Balazs BI, Owens LJ, et al: Simple ligation vs stump inversion in appendectomy. Arch Surg 1988; 123:689-690 4. Thomas SE, Denning DA, Cummings MH: Delayed pathology of the appendiceal stump: A case report of stump appendicitis and review. Am Surg 1994;60:842-844 5. Devereaux DA, McDermott JP, Caushaj PF: Recurrent appendicitis following laparoscopic appendectomy. Report of a case. Dis Colon Rectum 1994;37:719-720 6. Filippi de la Palavesa MM, Vaxmann D, Campos M, et al: Appendiceal stump abscess. Abdom Imaging 1996;21:65-66 7. Wright TE, Diaco JF: Recurrent appendicitis after laparoscopic appendectomy. Int Surg 1994;79:251-252 8. Scott-Conner CEH, Hall TJ, Anglin BL, Muakkassa FF: Laparoscopic appendectomy. Am J Surg 1993; 165:670-675 9. Harris CR: Appendiceal stump abscess ten years after appendectomy. Am J Emerg Med 1989;7:411-412 10. Calhoun BC, Brost B: Emergency management of sudden puerperal fever. Obstet Gynecol Clin North Am 1995;22:357-367 11. Simmons GR, Piwnica-Worms DR, Goldhaber SZ: Ovarian vein thrombosis. Am Heart J 1993;126:641-647 12. Van Hoe L, Baert AL, Marchal G, et al: Thrombosed ovarian vein collateral mimicking acute appendicitis on CT. J Comput Assist Tomogr 1994; 18:643-646
CASE REPORT A 39-year-old woman (gravida 3, para 2, therapeutic abortion l) who was l 1 days postpartum from a normal, spontaneous vaginal delivery, presented to our emergency department (ED) with the chief complaint of bilateral (right greater than left) lower abdominal pain. She also complained of mild nausea, emesis, and low-grade fever. She denied urinary tract symptoms, excessive vaginal bleeding or discharge, or change in bowel habits. Her medical and surgical histories included an appendectomy at 5 years of age, a partial small bowel and colonic resection for focal ischemia, peptic ulcer disease, and polysubstance abuse. Upon presentation to our ED the patient appeared to be in moderate distress. Vital signs included a temperature of up to 100.4°F, blood pressure of 130/80 mm Hg, pulse rate of 96 beats/min, and respiratory rate of 20 breaths/min. Physical examination of the abdomen revealed well-healed midline and right lower abdominal surgical scars. There was mild to moderate right-greater-than-left lower abdominal quadrant tenderness to palpation, with mild guarding, rebound, and shake tenderness. Psoas and Rovsing signs were both present. Pelvic examination was remarkable only for mild right adnexal tenderness without uterine abnormality detected. The uterus was 12-week size with a mildly tender, firm fundus. Rectal examination found no tenderness and hemoccult negative stools. Pertinent laboratory values included normal electrolyte and blood cell panels except for a white blood cell count of 19,400/pL; urinalysis was unremarkable. The initial clinical impression was postpartum endometritis for which the patient was placed on clindamycin and gentamicin. The atypical presentation and worsening symptoms over the next 2 days prompted a pelvic ultrasound examination, which showed an enlarged but normal postpartum uterus and a small amount of endometrial cavity fluid. Both ovaries were uuremarkable. At this point, because of the possibility of ovarian vein thrombosis, an abdominopelvic CT examination was performed with oral and
From the *Department of Radiology and 1-Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA. Manuscript received March 18, 1997; accepted April 2, 1997. Address repdnt requests to Dr Rao, Department of Radiology, Massachusetts General Hospital, 32 Fruit St, Boston, MA 02114. Key Words:Appendicitis, appendix, computed tomography (CT). Copyright © 1998 by W.B. Saunders Company 0735-6757/98/1603-002558.00/0
intravenous contrast media. The scans showed fight paracolic gutter fluid and a pericecal phlegmon and abscess (Figures 1A,B,C). Two and one half centimeters below the ileocecal valve, along the posteromedial cecal wall, at the expected location of the appendiceal orifice, an 8-rnm by 16-mm oval calcification was noted, as was the CT arrowhead sign of appendicitis (Fig 1D).2 The CT scan was interpreted as diagnostic of appendicitis, in this case, stump appendicitis. At surgery, a periappendiceal stump abscess with cecal perforation was found, and distal ileal and fight colonic resection was performed with primary anastamosis of ileum to mid-transverse colon. Findings were confirmed at pathology. The patient did well postoperatively on a 6-day course of antibiotics, and was discharged on postoperative day 7.
DISCUSSION Appendectomy is a common and safe surgical procedure, whether by laparotomy or by laparoscopic means) In the perioperative period, complications are uncommon but include superficial wound infection, abscess formation, antt bowel obstruction. Remote complications are also uncommon and include infection, hemorrhage, malignancy, intussusception, fistula formation, and recurrent (stump) appendicitis. 4 We are aware of 14 cases of stump appendicitis reported in the medical literature to date, although other unreported cases have likely occurred. Time intervals from initial appendectomy to stump appendicitis have ranged from 3 months to 21 years. 4 All cases have occurred in patients who underwent simple ligation of the appendix without invagination of the stump. Four recently reported cases involved initial laparoscopic appendectomy. 5-7 It is possible that simple ligation with failure to amputate the appendix close to its origin from the cecum is a prerequisite for developing stump appendicitis. It has also been postulated that during laparoscopic appendectomy, difficulty retracting a long appendix can leave a long appendiceal stump. 8 Before the advent of CT, definitive preoperative diagnosis of stump appendicitis was not possible. CT was used in four documented cases of stump appendicitis, and findings have included an irregular ileocecal mass (2 cases), a large pelvic abscess (1 case), and pericecal fat infiltration around a retrocecal tubular structure (1 case). 4,6,7,9 Only in the latter case, in which the appendiceal stump actually resembled a short but distended appendix, were the CT findings diagnostic of stump appendicitis. 4 In the case reported here, the clinical presentation, although typical for appendicitis, was clouded by the patient's postpartum state, prior bowel surgery, and prior appendectomy 34 years earlier. The longest previously reported time lag between appendectomy and stump appendicitis was 21 years. 4 Although the appendiceal stump was 309
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AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 16, Number 3 • May 1998
FIGURE 1. Stump appendicitis at CT. (A) Free fluid (F) along the fight paracolic gutter, posterior to the ascending colon (AC) and lateral to the right kidney (K). (B) The fatty ileocecal valve (arrow) at the junction of the terminal ileum (I) and cecum (C) is an important landmark for identifying the appendiceal origin. (C) Large phlegmordabscess (P) between the cecum (C), fight psoas muscle (PS), and right iliac crest (I). (D) The arrowhead sign (curved arrows) and appendolith (straight arrow) along the posteromedial cecum (C) at the anatomical cecal apex secure the diagnosis of stump appendicitis. obscured by surrounding phlegmon and abscess, CT did show an arrowhead sign and an appendolith, individual specific CT signs of appendicitis that, when combined, are pathognomonic for appendicitis. 1,2 Compare the findings of stump appendicitis (Figure 1) with a normally invaginated appendiceal stump at CT (Figure 2).
This case also highlights the difficulty of accurately diagnosing postpartum fever and abdominal pain. The differential diagnosis includes both conditions seen in the general population and conditions specific to the puerperium. The latter group includes endometritis, ovarian vein thrombophlebitis, wound infection or abscess (after cesarean
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of ovarian vein thrombosis mimicking the CT appearance of appendicitis. 12 In our case, the CT findings could not have been confused for ovarian vein thrombophlebitis. In summary, stump appendicitis is a rare occurrence that is not often considered in the differential diagnosis of acute fight lower quadrant abdominal pain. It can, however, occur as a late complication of appendectomy, even up to 34 years after surgery. In a postappendectomy patient who presents with acute fight lower quadrant findings mimicking appendicitis, CT can assist in making an accurate preoperative diagnosis.
REFERENCES
FIGURE 2. Normal appendiceal stump. A small mound of soft tissue (arrows) along the cecal wall is a characteristic finding in patients whose appendiceal stump was invaginated. section or deep laceration repair), and vaginal hematoma. ~° Endometritis is the most common cause of puerperal fever, usually associated with a boggy and tender uterine fundus and malodorous cervical discharge. Our case was not typical for endometritis. Although uncommon, ovarian vein thrombophlebitis is a right-sided process 90% of the time. ~1 The clinical picture can be very similar or identical to typical appendicitis, and CT and magnetic resonance imaging both can diagnose ovarian vein thrombophlebitis. Appendicitis, however, is best diagnosed using CT, with reported accuracies reaching 98%? There has been a case report, however,
1. Rao PM, Rhea JT, Novelline RA, et al: Helical CT technique for the diagnosis of appendicitis: Prospective evaluation of a focused appendix CT technique. Radiology 1997;202:139-144 2. Rao PM, Wittenberg J, McDowell RK, et al: Appendicitis: Use of arrowhead sign for diagnosis at CT. Radiology 1997;202:363-366 3. Street D, Balazs BI, Owens LJ, et al: Simple ligation vs stump inversion in appendectomy. Arch Surg 1988; 123:689-690 4. Thomas SE, Denning DA, Cummings MH: Delayed pathology of the appendiceal stump: A case report of stump appendicitis and review. Am Surg 1994;60:842-844 5. Devereaux DA, McDermott JP, Caushaj PF: Recurrent appendicitis following laparoscopic appendectomy. Report of a case. Dis Colon Rectum 1994;37:719-720 6. Filippi de la Palavesa MM, Vaxmann D, Campos M, et al: Appendiceal stump abscess. Abdom Imaging 1996;21:65-66 7. Wright TE, Diaco JF: Recurrent appendicitis after laparoscopic appendectomy. Int Surg 1994;79:251-252 8. Scott-Conner CEH, Hall TJ, Anglin BL, Muakkassa FF: Laparoscopic appendectomy. Am J Surg 1993; 165:670-675 9. Harris CR: Appendiceal stump abscess ten years after appendectomy. Am J Emerg Med 1989;7:411-412 10. Calhoun BC, Brost B: Emergency management of sudden puerperal fever. Obstet Gynecol Clin North Am 1995;22:357-367 11. Simmons GR, Piwnica-Worms DR, Goldhaber SZ: Ovarian vein thrombosis. Am Heart J 1993;126:641-647 12. Van Hoe L, Baert AL, Marchal G, et al: Thrombosed ovarian vein collateral mimicking acute appendicitis on CT. J Comput Assist Tomogr 1994; 18:643-646