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Acute appendicitis and ectopic pregnancy? Which came first?
Journal of Visceral Surgery (2011) 148, e323
CORRESPONDENCE Acute appendicitis and ectopic pregnancy? Which came first? A 41-year-old female patient, with no unusual past history, was pregnant 5 weeks after her last period following in vitro fertilization (IVF); she presented with right lower quadrant abdominal pain, progressive over 48 hours, in association with a temperature of 37.8◦ , RLQ abdominal guarding, leukocytosis (WBC: 12,600), and an elevated CRP (4 mg/100 mL). Beta-HCG was greater than 100,000 IU/L. Three pelvic ultrasound examinations performed serially over 48 hours showed progression of an intrauterine pregnancy and an 8 mm diameter appendix with a fecolith as well as pelvic fluid suggestive of acute appendicitis (AA). The abdomen was explored through a MacBurney incision revealing an acutely inflamed appendix but also a low-volume hemoperitoneum. Appendectomy was performed. Persistent bleeding from a source which could not be identified through this exposure led us to perform a diagnostic laparoscopy; this led to the diagnosis of an unruptured ectopic pregnancy in the right tube (Fig. 1). A right salpingectomy was performed. The clinical diagnosis of acute appendicitis was confirmed by pathological exam. The appendiceal lumen was dilated and filled with polymorphonuclear WBC’s; the mucosa was acutely inflamed while the muscular wall was normal. The postoperative course was uncomplicated. Twenty-two cases of acute appendicitis with simultaneous tubal ectopic pregnancy have been described in the literature since 1960 [1,2], and three cases of appendicitis in association with heterotopic pregnancy [3]. A causal relation between ectopic pregnancy (EP) and AA has been postulated. EP could theoretically result in peri-appendicular inflammation thereby leading to bacterial colonization [4]. This hypothesis is believable in our case due to the precedent interventions of IVF which resulted in the ectopic pregnancy. In the opposite direction, an antecedent AA with spontaneous resolution could also conceivably result in peritubular inflammatory adhesions favoring the development of the ectopic pregnancy. It is of particular interest that 75% of tubal pregnancies involve the right tube [5]. Whatever the etiology, this case should incite the surgeon to vigilance in the management of appendicitis in the pregnant patient. Both acute appendicitis and ectopic pregnancy should be considered in the differential diagnosis and searched for; this is all the more so in the context of IVF. If the diagnosis of appendicitis is in doubt during an appendectomy through a MacBurney incision, the case can be ‘‘converted’’ to laparoscopy rather than enlarging the incision to a major laparotomy.
Figure 1. lopian.
Laparoscopic view: ectopic pregnancy in the right fal-
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Mir IS, Mohsin M, Malik A, Ahad B, Farooq SS. Successful laparoscopic management of concomitant ectopic pregnancy and acute appendicitis in a patient of failed tubal ligation: case report with a review of the literature. Case J 2008;1:412. [2] Hazebroek EJ, Boonstra O, van der Harst E. Concurrent tubal ectopic pregnancy and acute appendicitis. J Minim Invasive Gynecol 2008;15:97—8. [3] Radwan M, Maciolek-Blewniewska G, Malinowski A. Spontaneous heterotopic pregnancy and acute appendicitis treated by laparoscopy. Int J Gynaecol Obstet 2007;96:129. [4] Riggs JC, Schiavello HJ, Fixler RJ. Concurrent appendicitis and ectopic pregnancy. A case report. Reprod Med 2002;47:510—4. [5] Nguyen H, Le K, Le C, Nguyen H. Concurrent ruptured ectopic pregnancy and appendicitis. JABFP 2005;18:63—6.
1878-7886/$ — see front matter © 2011 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.jviscsurg.2011.06.002
P. David ∗ , E. Rosso , P. Pessaux , C. de Saint Roman , P. Bachellier Centre de chirurgie viscérale et de transplantation, hôpital de Hautepierre, avenue de Molière, 67098 Strasbourg cedex, France ∗ Corresponding author. E-mail address: [email protected] (P. David)
Available online 31 August 2011
CORRESPONDENCE Acute appendicitis and ectopic pregnancy? Which came first? A 41-year-old female patient, with no unusual past history, was pregnant 5 weeks after her last period following in vitro fertilization (IVF); she presented with right lower quadrant abdominal pain, progressive over 48 hours, in association with a temperature of 37.8◦ , RLQ abdominal guarding, leukocytosis (WBC: 12,600), and an elevated CRP (4 mg/100 mL). Beta-HCG was greater than 100,000 IU/L. Three pelvic ultrasound examinations performed serially over 48 hours showed progression of an intrauterine pregnancy and an 8 mm diameter appendix with a fecolith as well as pelvic fluid suggestive of acute appendicitis (AA). The abdomen was explored through a MacBurney incision revealing an acutely inflamed appendix but also a low-volume hemoperitoneum. Appendectomy was performed. Persistent bleeding from a source which could not be identified through this exposure led us to perform a diagnostic laparoscopy; this led to the diagnosis of an unruptured ectopic pregnancy in the right tube (Fig. 1). A right salpingectomy was performed. The clinical diagnosis of acute appendicitis was confirmed by pathological exam. The appendiceal lumen was dilated and filled with polymorphonuclear WBC’s; the mucosa was acutely inflamed while the muscular wall was normal. The postoperative course was uncomplicated. Twenty-two cases of acute appendicitis with simultaneous tubal ectopic pregnancy have been described in the literature since 1960 [1,2], and three cases of appendicitis in association with heterotopic pregnancy [3]. A causal relation between ectopic pregnancy (EP) and AA has been postulated. EP could theoretically result in peri-appendicular inflammation thereby leading to bacterial colonization [4]. This hypothesis is believable in our case due to the precedent interventions of IVF which resulted in the ectopic pregnancy. In the opposite direction, an antecedent AA with spontaneous resolution could also conceivably result in peritubular inflammatory adhesions favoring the development of the ectopic pregnancy. It is of particular interest that 75% of tubal pregnancies involve the right tube [5]. Whatever the etiology, this case should incite the surgeon to vigilance in the management of appendicitis in the pregnant patient. Both acute appendicitis and ectopic pregnancy should be considered in the differential diagnosis and searched for; this is all the more so in the context of IVF. If the diagnosis of appendicitis is in doubt during an appendectomy through a MacBurney incision, the case can be ‘‘converted’’ to laparoscopy rather than enlarging the incision to a major laparotomy.
Figure 1. lopian.
Laparoscopic view: ectopic pregnancy in the right fal-
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Mir IS, Mohsin M, Malik A, Ahad B, Farooq SS. Successful laparoscopic management of concomitant ectopic pregnancy and acute appendicitis in a patient of failed tubal ligation: case report with a review of the literature. Case J 2008;1:412. [2] Hazebroek EJ, Boonstra O, van der Harst E. Concurrent tubal ectopic pregnancy and acute appendicitis. J Minim Invasive Gynecol 2008;15:97—8. [3] Radwan M, Maciolek-Blewniewska G, Malinowski A. Spontaneous heterotopic pregnancy and acute appendicitis treated by laparoscopy. Int J Gynaecol Obstet 2007;96:129. [4] Riggs JC, Schiavello HJ, Fixler RJ. Concurrent appendicitis and ectopic pregnancy. A case report. Reprod Med 2002;47:510—4. [5] Nguyen H, Le K, Le C, Nguyen H. Concurrent ruptured ectopic pregnancy and appendicitis. JABFP 2005;18:63—6.
1878-7886/$ — see front matter © 2011 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.jviscsurg.2011.06.002
P. David ∗ , E. Rosso , P. Pessaux , C. de Saint Roman , P. Bachellier Centre de chirurgie viscérale et de transplantation, hôpital de Hautepierre, avenue de Molière, 67098 Strasbourg cedex, France ∗ Corresponding author. E-mail address: [email protected] (P. David)
Available online 31 August 2011