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A complicated case of appendicitis
Clinical Radiology (1986) 37, 407-409 © 1986 Royal College of Radiologists
0009-9260/86/683407$02.00
A Complicated Case of Appendicitis ANGELA JONES
Department of Radiodiagnosis, Bristol Royal Infirmary, Bristol A case is presented of acute appendicitis in a 50-year-old man with unsuspected carcinoma of the right colon. This association is emphasised as acute appendicitis is an important marker of colonic carcinoma in the older age group. The value of doing routine barium enema examination in these patients after appendicectomy is discussed. Further unusual features of this carcinoma were radiographically visible calcification and spread into the right kidney.
showed amorphous calcification related to the lower pole of the kidney, explaining these findings (Fig. 2). Intravenous urography confirmed a large mass at the right lower pole with calyceal displacement (Fig. 2b). Arteriography showed that the tumour had a pathological circulation with arterial supply from renal capsular vessels and also the right colic branch of the superior mesenteric artery (Fig. 3). Barium enema showed an obstructing circumferential lesion at the hepatic flexure (Fig. 4). Right nephrectomy and hemicolectomy was performed. Histological investigation showed a moderately well differentiated adenocarcinoma of the bowel invading the lower pole of the kidney, with large areas of necrosis.
DISCUSSION U n c o m p l i c a t e d acute a p p e n d i c i t i s is a disease of the y o u n g . W h e n it occurs in m i d d l e age or later its associat i o n with m o r e serious u n d e r l y i n g disease is o f t e n n o t a p p r e c i a t e d . A case history is p r e s e n t e d to illustrate the diagnostic difficulties that arise f r o m the failure to recognise acute a p p e n d i c i t i s as a m a r k e r illness.
CASE R E P O R T A 50-year-old man presented in January 1984 with a 24 h history of acute abdominal pain. The history and physical examination indicated a diagnosis of acute appendicitis. An inflamed appendix which was adherent to the rectum was removed that evening. Histology showed supparative appendicitis with necrosis. The patient made an uneventful recovery and was discharged 10 days later. Five months later he presented again, this time with a small stitch abscess, which was drained. He also complained of pain in the right loin which had been increasing in severity but which had been present before his original admission. Intravenous urography was performed and he was discharged on the basis of a normal report, despite weightloss being evident at follow-up. After a further 4 months he still had pain. He also had night sweats and had lost 6.4 kg. Abdominal ultrasound revealed a collection of fluid anteriorly in the abdomen, situated just cephalad to the appendicectomy scar. Adjacent to this were several loops of fluid-filled bowel with slight bowel wall thickening. The lower pole of the right kidney was ill-defined with markedly increased echogenicity and acoustic shadowing centrally (Fig. la). Abdominal radiographs
Fig. 1 - Ultrasound scan of the right kidney. Echogenicity with acoustic shadowing is increased at the lower pole.
T w o p r o b l e m s are illustrated by this case history. First the site of the p r i m a r y t u m o u r a n d its dtrection ot s p r e a d were c o n f u s e d . T h e i n t r a v e n o u s u r o g r a p h i c a n d ultras o u n d a p p e a r a n c e of a right r e n a l mass c o n t a i n i n g a m o r p h o u s calcification a n d causing d i s t o r t i o n of the a n a t o m y m a d e the diagnosis of r e n a l cell c a r c i n o m a most likely, as 10% of such t u m o u r s show calcification ( D a n i e l et al., 1972). Metastases to the k i d n e y a c c o u n t for 0 . 4 % of all r e n a l masses, with a similar p r o p o r t i o n showing calcification ( D a n i e l et al., 1972). Calcification in p r i m a r y c o l o n i c c a r c i n o m a o n the o t h e r h a n d is rare, usually p u n c t a t e , a n d visible o n l y o n histological e x a m i n a t i o n of m u c i n secreting t u m o u r s ( F l e t c h e r et al., 1967). U s u a l l y , it occurs in those of relatively y o u n g e r age t h a n is g e n e r a l in colonic m a l i g n a n c y ( F l e t c h e r et al., 1967). T h e p a t h o l o g i c a l circulation was partly s u p p l i e d
Fig. 2 - Intravenous urogram. A large mass displaces the right lower pole calyces. There is calcification at the periphery of the mass (arrow).
408
CLINICAL RADIOLOGY
v~
(a) (b) Fig. 3 (a) Right renal artenogram. A pathologicalcirculationis supplied by renal capsularvessels. (b) Superior mesentenc arterlogram. A branch of the right colic artery supplies the tumour circulation (arrow).
Z
Fig. 4 - Barium enema 'spot' film of hepatic flexure. A cxrcumferential mass is seen with little barium passing beyond it into the caecum•
from renal capsular arteries and the right colic branch of the superior mesenteric artery. Renal celt carcinomas are known to receive extensive collateral supply from adjacent vessels once they have breached the renal capsule (Boijsen, 1983). In this case, the reverse had occurred in that an extra-renal neoplasm invading the kidney had acquired a blood supply from the renal arteries. The second and more important problem illustrated by the present case is that the diagnosis was delayed because the history was interrupted by a genuine illness of acute appendicitis. This illness and the effects of surgery were considered adequate explanation for the patients loin pain and slight weight-loss when he presented for the second time. The significance of acute appendicitis as a marker illness in patients of this age is not widely recognised. However, there is an association with right colonic malignant tumours (Miln and McLaughlin, 1969; Waller and Glasgow, 1977). These tumours may cause appendicitis due to direct obstruction by the tumour itself or by inflammation at the base of the appendix, or by back pressure due to more distal obstruction (Miln and McLaughlin, 1969). Appendicitis is uncommon in patients over 50 years of age. Miln and McLaughlin (1969) report only 15 cases in a series of 329 over a 2-year period, and three of these had underlying malignant disease. It has, however, increased in frequency recently in our hospital, doubling from 20 cases in 1973 to 40 in 1983, although the rate of admission for appendicitis generally has remained unchanged in this period. A large retrospective review of patients having surgery for right-sided colonic neoplasm (Mayo, 1947) found that 15% had had previous appendicectomy, mostly
A COMPLICATED CASE OF APPENDICITIS
within the preceding 2 years and after the onset ot symptoms. A review of caecal carcinomas by Costello and Saxton (1951) revealed that 31 of their 122 patients had initially suspected appendicitis. In 16 of these patients there was a delay in diagnosis varying from 1-36 months. The prognosis of caecal malignancies presenting as appendicitis is poor, partly due to the delay in diagnosis and resection and partly because of the subsequent factor of multiple operations (Patterson, 1956). The most important feature in the diagnosis is a suspicion of underlying malignancy. Palpation and inspection of the caecum at the time of appendicectomy may not be enough. In the case presented by Waller and Glasgow (1977), the caecal carcinoma responsible was only revealed by mucosal biopsies. Further clues may be available from the history. If the patient is anaemic this should not be dismissed as being 'due to his age' (Patterson, 1956). It is suggested that all patients over 50 years with appendicitis should be followed up and a barium enema examination made to prevent delay in diagnosis, unless laparotomy and thorough examination of the bowel including mucosal biopsy has been performed. In our hospital this would add about 40 patients to a workload of approximately 1750 barium enemas, or an increase of 2.3%. This is less than the present annual rate of increase.
409
This case history is reported in detail because of the importance of the possible significance of acute appendicitis in patients over the age of 50 years, and because of the rarity of carcinoma of the colon mimicking renal cell carcinoma. REFERENCES Boijsen, E. (1983). Vascular and interventional radiology. InAbrams Angiography. 3rd edn, ed. Abrams, H. L. Vol. 2, p. 1629. Little, Brown & Co., Boston. Costello, O. & Saxton, J. (1951). Appendicitis and cancer. Postgraduate Medicine, 9, 482-486. Daniel, W. W., Hartman, G. W., Witten, D. M., Farrow, G. M. & Kelalis, P. P. (1972). Calcified renal masses: a review of ten years experience at the Mayo Clinic. Radiology, 103, 503-508. Fletcher, B. D., Morreels, C. L., Christian, W. H. & Brogdon, B. G. (1967). Calcified adenoma of the colon. American Journal of Roentgenology, 101, 301-305. Mayo, C. W. (1947). Carcinoma of the right (proximal) portion of the colon. Surgical Clinics of North America, 27, 875--884. Miln, D. C. & McLaughlin, I. S. (1969), Carcinoma of proximal large bowel associated with acute appendicitis. British Journal of Surgery, 56, 143--4. Patterson, H. A. (1956). The management of caecal carcinoma discovered unexpectedly at operation for acute appendicitis. Annals of Surgery, 143, 670-681. Waller, D. G. & Glasgow, M. (1977). Acute appendicitis in association with non-obstructive carcinoma of the caecum. Postgraduate Medical Journal, 53, 234-236.
0009-9260/86/683407$02.00
A Complicated Case of Appendicitis ANGELA JONES
Department of Radiodiagnosis, Bristol Royal Infirmary, Bristol A case is presented of acute appendicitis in a 50-year-old man with unsuspected carcinoma of the right colon. This association is emphasised as acute appendicitis is an important marker of colonic carcinoma in the older age group. The value of doing routine barium enema examination in these patients after appendicectomy is discussed. Further unusual features of this carcinoma were radiographically visible calcification and spread into the right kidney.
showed amorphous calcification related to the lower pole of the kidney, explaining these findings (Fig. 2). Intravenous urography confirmed a large mass at the right lower pole with calyceal displacement (Fig. 2b). Arteriography showed that the tumour had a pathological circulation with arterial supply from renal capsular vessels and also the right colic branch of the superior mesenteric artery (Fig. 3). Barium enema showed an obstructing circumferential lesion at the hepatic flexure (Fig. 4). Right nephrectomy and hemicolectomy was performed. Histological investigation showed a moderately well differentiated adenocarcinoma of the bowel invading the lower pole of the kidney, with large areas of necrosis.
DISCUSSION U n c o m p l i c a t e d acute a p p e n d i c i t i s is a disease of the y o u n g . W h e n it occurs in m i d d l e age or later its associat i o n with m o r e serious u n d e r l y i n g disease is o f t e n n o t a p p r e c i a t e d . A case history is p r e s e n t e d to illustrate the diagnostic difficulties that arise f r o m the failure to recognise acute a p p e n d i c i t i s as a m a r k e r illness.
CASE R E P O R T A 50-year-old man presented in January 1984 with a 24 h history of acute abdominal pain. The history and physical examination indicated a diagnosis of acute appendicitis. An inflamed appendix which was adherent to the rectum was removed that evening. Histology showed supparative appendicitis with necrosis. The patient made an uneventful recovery and was discharged 10 days later. Five months later he presented again, this time with a small stitch abscess, which was drained. He also complained of pain in the right loin which had been increasing in severity but which had been present before his original admission. Intravenous urography was performed and he was discharged on the basis of a normal report, despite weightloss being evident at follow-up. After a further 4 months he still had pain. He also had night sweats and had lost 6.4 kg. Abdominal ultrasound revealed a collection of fluid anteriorly in the abdomen, situated just cephalad to the appendicectomy scar. Adjacent to this were several loops of fluid-filled bowel with slight bowel wall thickening. The lower pole of the right kidney was ill-defined with markedly increased echogenicity and acoustic shadowing centrally (Fig. la). Abdominal radiographs
Fig. 1 - Ultrasound scan of the right kidney. Echogenicity with acoustic shadowing is increased at the lower pole.
T w o p r o b l e m s are illustrated by this case history. First the site of the p r i m a r y t u m o u r a n d its dtrection ot s p r e a d were c o n f u s e d . T h e i n t r a v e n o u s u r o g r a p h i c a n d ultras o u n d a p p e a r a n c e of a right r e n a l mass c o n t a i n i n g a m o r p h o u s calcification a n d causing d i s t o r t i o n of the a n a t o m y m a d e the diagnosis of r e n a l cell c a r c i n o m a most likely, as 10% of such t u m o u r s show calcification ( D a n i e l et al., 1972). Metastases to the k i d n e y a c c o u n t for 0 . 4 % of all r e n a l masses, with a similar p r o p o r t i o n showing calcification ( D a n i e l et al., 1972). Calcification in p r i m a r y c o l o n i c c a r c i n o m a o n the o t h e r h a n d is rare, usually p u n c t a t e , a n d visible o n l y o n histological e x a m i n a t i o n of m u c i n secreting t u m o u r s ( F l e t c h e r et al., 1967). U s u a l l y , it occurs in those of relatively y o u n g e r age t h a n is g e n e r a l in colonic m a l i g n a n c y ( F l e t c h e r et al., 1967). T h e p a t h o l o g i c a l circulation was partly s u p p l i e d
Fig. 2 - Intravenous urogram. A large mass displaces the right lower pole calyces. There is calcification at the periphery of the mass (arrow).
408
CLINICAL RADIOLOGY
v~
(a) (b) Fig. 3 (a) Right renal artenogram. A pathologicalcirculationis supplied by renal capsularvessels. (b) Superior mesentenc arterlogram. A branch of the right colic artery supplies the tumour circulation (arrow).
Z
Fig. 4 - Barium enema 'spot' film of hepatic flexure. A cxrcumferential mass is seen with little barium passing beyond it into the caecum•
from renal capsular arteries and the right colic branch of the superior mesenteric artery. Renal celt carcinomas are known to receive extensive collateral supply from adjacent vessels once they have breached the renal capsule (Boijsen, 1983). In this case, the reverse had occurred in that an extra-renal neoplasm invading the kidney had acquired a blood supply from the renal arteries. The second and more important problem illustrated by the present case is that the diagnosis was delayed because the history was interrupted by a genuine illness of acute appendicitis. This illness and the effects of surgery were considered adequate explanation for the patients loin pain and slight weight-loss when he presented for the second time. The significance of acute appendicitis as a marker illness in patients of this age is not widely recognised. However, there is an association with right colonic malignant tumours (Miln and McLaughlin, 1969; Waller and Glasgow, 1977). These tumours may cause appendicitis due to direct obstruction by the tumour itself or by inflammation at the base of the appendix, or by back pressure due to more distal obstruction (Miln and McLaughlin, 1969). Appendicitis is uncommon in patients over 50 years of age. Miln and McLaughlin (1969) report only 15 cases in a series of 329 over a 2-year period, and three of these had underlying malignant disease. It has, however, increased in frequency recently in our hospital, doubling from 20 cases in 1973 to 40 in 1983, although the rate of admission for appendicitis generally has remained unchanged in this period. A large retrospective review of patients having surgery for right-sided colonic neoplasm (Mayo, 1947) found that 15% had had previous appendicectomy, mostly
A COMPLICATED CASE OF APPENDICITIS
within the preceding 2 years and after the onset ot symptoms. A review of caecal carcinomas by Costello and Saxton (1951) revealed that 31 of their 122 patients had initially suspected appendicitis. In 16 of these patients there was a delay in diagnosis varying from 1-36 months. The prognosis of caecal malignancies presenting as appendicitis is poor, partly due to the delay in diagnosis and resection and partly because of the subsequent factor of multiple operations (Patterson, 1956). The most important feature in the diagnosis is a suspicion of underlying malignancy. Palpation and inspection of the caecum at the time of appendicectomy may not be enough. In the case presented by Waller and Glasgow (1977), the caecal carcinoma responsible was only revealed by mucosal biopsies. Further clues may be available from the history. If the patient is anaemic this should not be dismissed as being 'due to his age' (Patterson, 1956). It is suggested that all patients over 50 years with appendicitis should be followed up and a barium enema examination made to prevent delay in diagnosis, unless laparotomy and thorough examination of the bowel including mucosal biopsy has been performed. In our hospital this would add about 40 patients to a workload of approximately 1750 barium enemas, or an increase of 2.3%. This is less than the present annual rate of increase.
409
This case history is reported in detail because of the importance of the possible significance of acute appendicitis in patients over the age of 50 years, and because of the rarity of carcinoma of the colon mimicking renal cell carcinoma. REFERENCES Boijsen, E. (1983). Vascular and interventional radiology. InAbrams Angiography. 3rd edn, ed. Abrams, H. L. Vol. 2, p. 1629. Little, Brown & Co., Boston. Costello, O. & Saxton, J. (1951). Appendicitis and cancer. Postgraduate Medicine, 9, 482-486. Daniel, W. W., Hartman, G. W., Witten, D. M., Farrow, G. M. & Kelalis, P. P. (1972). Calcified renal masses: a review of ten years experience at the Mayo Clinic. Radiology, 103, 503-508. Fletcher, B. D., Morreels, C. L., Christian, W. H. & Brogdon, B. G. (1967). Calcified adenoma of the colon. American Journal of Roentgenology, 101, 301-305. Mayo, C. W. (1947). Carcinoma of the right (proximal) portion of the colon. Surgical Clinics of North America, 27, 875--884. Miln, D. C. & McLaughlin, I. S. (1969), Carcinoma of proximal large bowel associated with acute appendicitis. British Journal of Surgery, 56, 143--4. Patterson, H. A. (1956). The management of caecal carcinoma discovered unexpectedly at operation for acute appendicitis. Annals of Surgery, 143, 670-681. Waller, D. G. & Glasgow, M. (1977). Acute appendicitis in association with non-obstructive carcinoma of the caecum. Postgraduate Medical Journal, 53, 234-236.