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Acute suppurative appendicitis complicating ileocolic intussusception due to a caecal lipoma
European Journal of Radiology Extra 60 (2006) 113–115
Acute suppurative appendicitis complicating ileocolic intussusception due to a caecal lipoma Ian Hagan a,∗ , Conor Corr a , Neil Shepherd b,1 , Garrett McGann a a
b
Department of Radiology, Cheltenham General Hospital, Sandford Rd., Cheltenham, Gloucestershire GL53 7AN, UK Department of Histopathology, Cheltenham General Hospital, Sandford Rd., Cheltenham, Gloucestershire GL53 7AN, UK Received 30 April 2006; accepted 14 September 2006
Abstract We present a case of acute suppurative appendicitis caused by intussusception of a caecal lipoma involving the appendiceal orifice. The relationship between these disorders is discussed together with the salient radiological and histopathological features. As well as illustrating a unique cause of appendicitis this case demonstrates the great value of computed tomography as a diagnostic tool in assessing both the cause and complications of intussusception in adults. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Intussusception; Lipoma; Appendicitis
1. Introduction Appendicitis is a common surgical emergency with a peak incidence in the second decade but occurring in all age groups. The aetiology of this condition remains a matter of some debate but many cases involve a degree of obstruction of the appendiceal lumen, most commonly due to lymphoid hyperplasia or a faecolith. It can be diagnosed with a high degree of sensitivity and specificity using CT [1–3], though this is usually reserved for adult cases where there are atypical clinical features and the diagnosis is uncertain. We present a case of appendicitis with an unusual underlying cause, both of which were eloquently demonstrated by CT. 2. Patient A 66-year-old man with chronic renal failure, congestive cardiac failure and type 2 diabetes mellitus was admitted with ∗
Corresponding author. Tel.: +44 845 4223001. E-mail addresses: ian [email protected] (I. Hagan), [email protected] (C. Corr), [email protected] (N. Shepherd), [email protected] (G. McGann). 1 Tel.: +44 8454 222222. 1571-4675/$ – see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2006.09.008
a 3 day history of right iliac fossa pain. Examination revealed a low grade pyrexia of 37.8 ◦ C and signs of local peritonism in the right iliac fossa. Blood tests showed a moderately elevated C reactive protein of 83 mg/l. The clinical differential diagnosis included appendicitis, caecal diverticulitis, perforated caecal tumour, epiploic appendagitis and omental infarction. CT of the abdomen and pelvis was performed without intravenous contrast in view of the pre-existing renal failure. The CT demonstrated an ileocolic intussusception with a large caecal lipoma acting as a lead point (Fig. 1) but without any significant small bowel dilatation to indicate obstruction. In addition the appendix was noted to be distended with periappendiceal inflammatory changes, particularly around the tip of the appendix, in keeping with acute appendicitis (Fig. 2). Caecal diverticula were also evident but without any associated inflammatory changes. The patient was treated with intravenous antibiotics and surgery was delayed for 36 h while optimisation of the previously described severe comorbid medical conditions was undertaken. At laparotomy the appendix was found to be inflamed with a small amount of adjacent free fluid. The ileocolic intussusception documented on the CT had resolved spontaneously and a limited right hemicolectomy with endto-end anastomosis was performed to remove the caecal
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Fig. 1. Coronal reformatted CT image demonstrating ileocolic intussusception due to caecal lipoma. A mass of fat attenuation (arrows) acting as a lead point is seen in the ascending colon just proximal to the hepatic flexure (HF). Invagination of terminal ileum (TI) and surrounding mesenteric fat into ascending colon is clearly seen.
lipoma and appendix. Following surgery the patient was transferred to the Intensive Care Unit but over the next 24 h developed sepsis and multi-organ failure unresponsive to treatment and subsequently died. Fig. 3. Limited right hemicolectomy specimen. The appendix (long arrow) and caecal lipoma (short arrows) cut away from the appendiceal orifice (AO) are clearly demonstrated. The close proximity of the site of attachment of the lipoma (arrowheads) to the appendiceal orifice can be appreciated.
Histopathological assessment of the right hemicolectomy specimen (Fig. 3) confirmed the presence of a large polypoid caecal submucosal lipoma with variable inflammatory changes in the overlying mucosa and features of mucosal prolapse, perhaps related to intussusception. Furthermore, the caecal lipoma was seen to be partially obstructing the orifice of the appendix, which itself showed changes of acute suppurative appendicitis. It was therefore concluded that the appendicitis was likely to be secondary to obstruction of the appendiceal orifice by the caecal lipoma, this obstruction having been compounded by the lipoma forming a lead point for ileocolic intussusception.
3. Discussion Fig. 2. Curved multiplanar reformatted image demonstrating distended appendix (arrows) with inflammatory changes in periappendiceal fat, in association with intussuscepting lipoma (L). Several caecal diverticula (arrowheads) are visible in the ascending colon but without any associated pericolic inflammation.
Intussusception is a common surgical emergency in the paediatric setting but is much less common in adults. While paediatric intussusception is usually idiopathic, adults with intussusception are much more likely to have a pathological
I. Hagan et al. / European Journal of Radiology Extra 60 (2006) 113–115
‘lead point’ such as a polyp or tumour causing the intussusception, although estimates of the prevalence of such lead points in adult intussusception vary [4,5]. CT is the diagnostic procedure of choice [6] and may demonstrate the lead point, as in this case. Complications of intussusception relate to the mechanical effects of this condition on the bowel and its blood supply. Hence invagination of the proximal segment of bowel (the intussusceptum) into the distal segment (the intussuscipiens) may cause bowel obstruction at this level, but this was not a significant feature of this case. The mesenteric vessels drawn into the intussusception may also be compressed, leading to vascular compromise and ultimately infarction, gangrene and bowel perforation. The mucosal changes overlying the caecal lipoma in this case may in part have reflected a degree of mucosal ischaemia but otherwise vascular compromise was not a major feature. The appendix can be related to intussusception in many ways. It may act as a lead point for intussusception in various pathological states such as appendicitis, appendiceal endometriosis and appendiceal neoplasia [7,8], and even when normal [9]. In addition, the vessels of the delicate mesoappendix may be compromised in ileocolic intussusception and infarction and gangrene of the appendix in this scenario has been reported [10–12]. In this case there was no evidence of infarction of the appendix. Rather, the pathological changes were of acute suppurative appendicitis and to the best of our knowledge this is the first report of this condition occurring as a complication of ileocolic intussusception. We believe that this occurred because the caecal lipoma, which subsequently acted as a lead point for the intussusception, partially obstructed the appendiceal orifice in the resting state and this progressed to complete occlusion of the orifice when intussusception supervened. In addition the presence of chronic renal failure and diabetes rendered the patient more susceptible to infection.
115
As well as illustrating a unique cause of appendicitis, this case emphasizes the utility of CT as a diagnostic tool in evaluating both the cause and complications of adult intussusception. Such information allows optimal surgical planning which is particularly important in patients with significant comordibity for whom surgery is a high risk procedure. This case also supports the use of preoperative CT in older patients presenting with symptoms and signs suggestive of appendicitis who may have another surgical condition masquerading as appendicitis or – as in this case – causing it.
References [1] See TC, Ng CS, Watson CJE, Dixon AK. Appendicitis: spectrum of appearances on helical CT. Br J Radiol 2002;75:775–81. [2] Ege G, Akman H, Sahin A, Bugra D, Kuzucu K. Diagnostic value of unenhanced helical CT in adult patients with suspected acute appendicitis. Br J Radiol 2002;75:721–5. [3] Macari M, Balthazar EJ. The acute right lower quadrant: CT evaluation. Radiol Clin North Am 2003;41:1117–36. [4] Agha FP. Intussusception in adults. AJR Am J Roentgenol 1986;146:531–7. [5] Huang BY, Warshauer DM. Adult intussusception: diagnosis and clinical relevance. Radiol Clin North Am 2003;41:1137–51. [6] Gayer G, Zissin R, Apter S, Papa M, Hertz M. Adult intussusception: a CT diagnosis. Br J Radiol 2002;75:185–90. [7] Bellows CF, Haque S, Jaffe BM. Two unusual cases of adult intussusception. Dig Surg 2002;19:241–4. [8] Misdraji J, Graeme-Cook FM. Miscellaneous conditions of the appendix. Semin Diagn Pathol 2004;21:151–63. [9] Patton KR, Ferrera PC. Intussusception of a normal appendix. Am J Emerg Med 2000;18:115–7. [10] Toonder FG, Palmieri AJ. Ileocecal intussusception with haemorrhagic infarction of the appendix. Rocky Mt Med J 1973;70:40–2. [11] Varty K, Rance CH. Intussusception complicated by gangrene, demarcation and separation of the appendix. Aust N Z J Surg 1993;63: 913–4. [12] McCafferty H. Isolated gangrene of the appendix complicating intussusception. Br J Clin Pract 1983;37:401–3.
Acute suppurative appendicitis complicating ileocolic intussusception due to a caecal lipoma Ian Hagan a,∗ , Conor Corr a , Neil Shepherd b,1 , Garrett McGann a a
b
Department of Radiology, Cheltenham General Hospital, Sandford Rd., Cheltenham, Gloucestershire GL53 7AN, UK Department of Histopathology, Cheltenham General Hospital, Sandford Rd., Cheltenham, Gloucestershire GL53 7AN, UK Received 30 April 2006; accepted 14 September 2006
Abstract We present a case of acute suppurative appendicitis caused by intussusception of a caecal lipoma involving the appendiceal orifice. The relationship between these disorders is discussed together with the salient radiological and histopathological features. As well as illustrating a unique cause of appendicitis this case demonstrates the great value of computed tomography as a diagnostic tool in assessing both the cause and complications of intussusception in adults. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Intussusception; Lipoma; Appendicitis
1. Introduction Appendicitis is a common surgical emergency with a peak incidence in the second decade but occurring in all age groups. The aetiology of this condition remains a matter of some debate but many cases involve a degree of obstruction of the appendiceal lumen, most commonly due to lymphoid hyperplasia or a faecolith. It can be diagnosed with a high degree of sensitivity and specificity using CT [1–3], though this is usually reserved for adult cases where there are atypical clinical features and the diagnosis is uncertain. We present a case of appendicitis with an unusual underlying cause, both of which were eloquently demonstrated by CT. 2. Patient A 66-year-old man with chronic renal failure, congestive cardiac failure and type 2 diabetes mellitus was admitted with ∗
Corresponding author. Tel.: +44 845 4223001. E-mail addresses: ian [email protected] (I. Hagan), [email protected] (C. Corr), [email protected] (N. Shepherd), [email protected] (G. McGann). 1 Tel.: +44 8454 222222. 1571-4675/$ – see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2006.09.008
a 3 day history of right iliac fossa pain. Examination revealed a low grade pyrexia of 37.8 ◦ C and signs of local peritonism in the right iliac fossa. Blood tests showed a moderately elevated C reactive protein of 83 mg/l. The clinical differential diagnosis included appendicitis, caecal diverticulitis, perforated caecal tumour, epiploic appendagitis and omental infarction. CT of the abdomen and pelvis was performed without intravenous contrast in view of the pre-existing renal failure. The CT demonstrated an ileocolic intussusception with a large caecal lipoma acting as a lead point (Fig. 1) but without any significant small bowel dilatation to indicate obstruction. In addition the appendix was noted to be distended with periappendiceal inflammatory changes, particularly around the tip of the appendix, in keeping with acute appendicitis (Fig. 2). Caecal diverticula were also evident but without any associated inflammatory changes. The patient was treated with intravenous antibiotics and surgery was delayed for 36 h while optimisation of the previously described severe comorbid medical conditions was undertaken. At laparotomy the appendix was found to be inflamed with a small amount of adjacent free fluid. The ileocolic intussusception documented on the CT had resolved spontaneously and a limited right hemicolectomy with endto-end anastomosis was performed to remove the caecal
114
I. Hagan et al. / European Journal of Radiology Extra 60 (2006) 113–115
Fig. 1. Coronal reformatted CT image demonstrating ileocolic intussusception due to caecal lipoma. A mass of fat attenuation (arrows) acting as a lead point is seen in the ascending colon just proximal to the hepatic flexure (HF). Invagination of terminal ileum (TI) and surrounding mesenteric fat into ascending colon is clearly seen.
lipoma and appendix. Following surgery the patient was transferred to the Intensive Care Unit but over the next 24 h developed sepsis and multi-organ failure unresponsive to treatment and subsequently died. Fig. 3. Limited right hemicolectomy specimen. The appendix (long arrow) and caecal lipoma (short arrows) cut away from the appendiceal orifice (AO) are clearly demonstrated. The close proximity of the site of attachment of the lipoma (arrowheads) to the appendiceal orifice can be appreciated.
Histopathological assessment of the right hemicolectomy specimen (Fig. 3) confirmed the presence of a large polypoid caecal submucosal lipoma with variable inflammatory changes in the overlying mucosa and features of mucosal prolapse, perhaps related to intussusception. Furthermore, the caecal lipoma was seen to be partially obstructing the orifice of the appendix, which itself showed changes of acute suppurative appendicitis. It was therefore concluded that the appendicitis was likely to be secondary to obstruction of the appendiceal orifice by the caecal lipoma, this obstruction having been compounded by the lipoma forming a lead point for ileocolic intussusception.
3. Discussion Fig. 2. Curved multiplanar reformatted image demonstrating distended appendix (arrows) with inflammatory changes in periappendiceal fat, in association with intussuscepting lipoma (L). Several caecal diverticula (arrowheads) are visible in the ascending colon but without any associated pericolic inflammation.
Intussusception is a common surgical emergency in the paediatric setting but is much less common in adults. While paediatric intussusception is usually idiopathic, adults with intussusception are much more likely to have a pathological
I. Hagan et al. / European Journal of Radiology Extra 60 (2006) 113–115
‘lead point’ such as a polyp or tumour causing the intussusception, although estimates of the prevalence of such lead points in adult intussusception vary [4,5]. CT is the diagnostic procedure of choice [6] and may demonstrate the lead point, as in this case. Complications of intussusception relate to the mechanical effects of this condition on the bowel and its blood supply. Hence invagination of the proximal segment of bowel (the intussusceptum) into the distal segment (the intussuscipiens) may cause bowel obstruction at this level, but this was not a significant feature of this case. The mesenteric vessels drawn into the intussusception may also be compressed, leading to vascular compromise and ultimately infarction, gangrene and bowel perforation. The mucosal changes overlying the caecal lipoma in this case may in part have reflected a degree of mucosal ischaemia but otherwise vascular compromise was not a major feature. The appendix can be related to intussusception in many ways. It may act as a lead point for intussusception in various pathological states such as appendicitis, appendiceal endometriosis and appendiceal neoplasia [7,8], and even when normal [9]. In addition, the vessels of the delicate mesoappendix may be compromised in ileocolic intussusception and infarction and gangrene of the appendix in this scenario has been reported [10–12]. In this case there was no evidence of infarction of the appendix. Rather, the pathological changes were of acute suppurative appendicitis and to the best of our knowledge this is the first report of this condition occurring as a complication of ileocolic intussusception. We believe that this occurred because the caecal lipoma, which subsequently acted as a lead point for the intussusception, partially obstructed the appendiceal orifice in the resting state and this progressed to complete occlusion of the orifice when intussusception supervened. In addition the presence of chronic renal failure and diabetes rendered the patient more susceptible to infection.
115
As well as illustrating a unique cause of appendicitis, this case emphasizes the utility of CT as a diagnostic tool in evaluating both the cause and complications of adult intussusception. Such information allows optimal surgical planning which is particularly important in patients with significant comordibity for whom surgery is a high risk procedure. This case also supports the use of preoperative CT in older patients presenting with symptoms and signs suggestive of appendicitis who may have another surgical condition masquerading as appendicitis or – as in this case – causing it.
References [1] See TC, Ng CS, Watson CJE, Dixon AK. Appendicitis: spectrum of appearances on helical CT. Br J Radiol 2002;75:775–81. [2] Ege G, Akman H, Sahin A, Bugra D, Kuzucu K. Diagnostic value of unenhanced helical CT in adult patients with suspected acute appendicitis. Br J Radiol 2002;75:721–5. [3] Macari M, Balthazar EJ. The acute right lower quadrant: CT evaluation. Radiol Clin North Am 2003;41:1117–36. [4] Agha FP. Intussusception in adults. AJR Am J Roentgenol 1986;146:531–7. [5] Huang BY, Warshauer DM. Adult intussusception: diagnosis and clinical relevance. Radiol Clin North Am 2003;41:1137–51. [6] Gayer G, Zissin R, Apter S, Papa M, Hertz M. Adult intussusception: a CT diagnosis. Br J Radiol 2002;75:185–90. [7] Bellows CF, Haque S, Jaffe BM. Two unusual cases of adult intussusception. Dig Surg 2002;19:241–4. [8] Misdraji J, Graeme-Cook FM. Miscellaneous conditions of the appendix. Semin Diagn Pathol 2004;21:151–63. [9] Patton KR, Ferrera PC. Intussusception of a normal appendix. Am J Emerg Med 2000;18:115–7. [10] Toonder FG, Palmieri AJ. Ileocecal intussusception with haemorrhagic infarction of the appendix. Rocky Mt Med J 1973;70:40–2. [11] Varty K, Rance CH. Intussusception complicated by gangrene, demarcation and separation of the appendix. Aust N Z J Surg 1993;63: 913–4. [12] McCafferty H. Isolated gangrene of the appendix complicating intussusception. Br J Clin Pract 1983;37:401–3.