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An Unusual Cause of Right Upper Quadrant Pain
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Bilal Hameed, Uma Mahadevan, and Kay Washington, Section Editors
An Unusual Cause of Right Upper Quadrant Pain Q3
Nazar Hafiz,1 Kevin G. Greene,2 and Seth D. Crockett1 1 Division of Gastroenterology and Hepatology, and 2Department of Pathology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
Question: A 32-year-old man with a 2-year history of pain localized to the right upper quadrant was referred to our clinic for evaluation. Pain was reported as dull and constant that was exacerbated by eating. He also reported occasional nausea and vomiting, especially with severe pain. In addition, he reported diarrhea, having 5-6 bowel movements per day that were loose in consistency. He denied blood in stools. Laboratory testing was normal, including white blood cell count, liver function tests, electrolytes, and celiac serology. Previous endoscopic and radiographic tests performed by the referring physician including upper endoscopy, colonoscopy, computed tomography of the abdomen and pelvis (CT A/P), and magnetic resonance cholangiopancreatography were all unremarkable, apart from a retrocecal appendix noted on imaging. Of note, he had undergone an elective cholecystectomy 4 months prior for suspected biliary colic, but his symptoms persisted, and even worsened after this surgery. Physical examination was notable only for tenderness in the right upper quadrant with positive Murphy’s sign (despite prior cholecystectomy). Given the persistent and bothersome right upper quadrant pain, a decision was made to pursue repeat cross-sectional imaging of the abdomen and pelvis. CT A/P images with views of the right upper quadrant area are shown in Figure A (axial), Figure B (coronal), and Figure C (sagittal). What is the cause of this patient’s abdominal pain? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Q1
Conflicts of interest The authors disclose no conflicts.
Q2
Funding Dr Crockett’s effort was supported, in part by a grant from the National Institutes of Health (KL2-RR025746). © 2017 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2016.12.042
Gastroenterology 2017;-:e1–e2 DIS 5.4.0 DTD YGAST60910 proof 30 June 2017 3:19 pm ce
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Answer to: Image 5: Anomalously Located and Elongated Appendix With Inflammatory Changes
Repeat CT A/P demonstrated that the cecum was located in the right upper quadrant with an elongated retrocecal appendix without obvious inflammatory changes (Figure B, white arrows). However, the tip of the appendix seemed to abut the inferior surface of the liver (Figure A, C, white arrows). After a review of the findings and consultation with a colorectal surgeon, the patient decided to pursue elective laparoscopic appendectomy. During the surgery, an elongated appendix was found in a retrocecal position adjacent to the patient’s liver. The pathology specimen showed a 14 cm in length 0.6 cm in diameter intact vermiform appendix with attached mesoappendix. The serosa was smooth and focally erythematous. Microscopic examination showed lymphoid hyperplasia (Figure D, cross-section) and focal mild acute inflammation of appendiceal crypts and surface epithelium (Figure E), characterized by neutrophilic infiltrates (Figure F, arrow). Transmural acute inflammation was not identified. The patient returned to clinic 2 weeks after the appendectomy and reported complete resolution of his pain symptoms. We attributed his chronic right upper quadrant pain to an anomalously located and elongated appendix with inflammatory changes. The length of the appendix averages 8-9 mm, but has been reported to be >20 cm in rare cases.1 The origin is relatively constant, typically arising from the posteromedial cecal border or from the cecal fundus. From there, the appendix can have a variable course, but is typically located in the right lower quadrant. The appendiceal tip may be found in a variety of locations, with the most common being retrocecal (but intraperitoneal) in approximately 60% of individuals, pelvic in 30%, and retroperitoneal in 10%.1 Several previous case reports have been published of atypical presentations of appendicitis attributed to anomalously located and elongated appendices, but most are in children and in the context of acute appendicitis.2,3 This patient did not have the typical acute presentation of appendicitis or classic findings of acute appendicitis, but did have chronic pain likely attributable to the aberrantly located and inflamed appendix. Reviewing cross-sectional imaging with critical eye was important in this case, because the subtle finding in the area of this patients pain led ultimately to successful intervention and resolution of his symptoms.
References 1. 2. 3.
Richmond B. Sabiston textbook of surgery, 20th edition. Philadelphia: Elsevier, 2017. Alzaraa A, Chaudhry S. An unusually long appendix in a child: a case report. Cases J 2009;2:7398. Kim I, Chitnis A, Sabri S, et al. An unusually long retrocaecal appendix. Postgrad Med J 2016;92:624.
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Bilal Hameed, Uma Mahadevan, and Kay Washington, Section Editors
An Unusual Cause of Right Upper Quadrant Pain Q3
Nazar Hafiz,1 Kevin G. Greene,2 and Seth D. Crockett1 1 Division of Gastroenterology and Hepatology, and 2Department of Pathology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
Question: A 32-year-old man with a 2-year history of pain localized to the right upper quadrant was referred to our clinic for evaluation. Pain was reported as dull and constant that was exacerbated by eating. He also reported occasional nausea and vomiting, especially with severe pain. In addition, he reported diarrhea, having 5-6 bowel movements per day that were loose in consistency. He denied blood in stools. Laboratory testing was normal, including white blood cell count, liver function tests, electrolytes, and celiac serology. Previous endoscopic and radiographic tests performed by the referring physician including upper endoscopy, colonoscopy, computed tomography of the abdomen and pelvis (CT A/P), and magnetic resonance cholangiopancreatography were all unremarkable, apart from a retrocecal appendix noted on imaging. Of note, he had undergone an elective cholecystectomy 4 months prior for suspected biliary colic, but his symptoms persisted, and even worsened after this surgery. Physical examination was notable only for tenderness in the right upper quadrant with positive Murphy’s sign (despite prior cholecystectomy). Given the persistent and bothersome right upper quadrant pain, a decision was made to pursue repeat cross-sectional imaging of the abdomen and pelvis. CT A/P images with views of the right upper quadrant area are shown in Figure A (axial), Figure B (coronal), and Figure C (sagittal). What is the cause of this patient’s abdominal pain? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Q1
Conflicts of interest The authors disclose no conflicts.
Q2
Funding Dr Crockett’s effort was supported, in part by a grant from the National Institutes of Health (KL2-RR025746). © 2017 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2016.12.042
Gastroenterology 2017;-:e1–e2 DIS 5.4.0 DTD YGAST60910 proof 30 June 2017 3:19 pm ce
59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174
Answer to: Image 5: Anomalously Located and Elongated Appendix With Inflammatory Changes
Repeat CT A/P demonstrated that the cecum was located in the right upper quadrant with an elongated retrocecal appendix without obvious inflammatory changes (Figure B, white arrows). However, the tip of the appendix seemed to abut the inferior surface of the liver (Figure A, C, white arrows). After a review of the findings and consultation with a colorectal surgeon, the patient decided to pursue elective laparoscopic appendectomy. During the surgery, an elongated appendix was found in a retrocecal position adjacent to the patient’s liver. The pathology specimen showed a 14 cm in length 0.6 cm in diameter intact vermiform appendix with attached mesoappendix. The serosa was smooth and focally erythematous. Microscopic examination showed lymphoid hyperplasia (Figure D, cross-section) and focal mild acute inflammation of appendiceal crypts and surface epithelium (Figure E), characterized by neutrophilic infiltrates (Figure F, arrow). Transmural acute inflammation was not identified. The patient returned to clinic 2 weeks after the appendectomy and reported complete resolution of his pain symptoms. We attributed his chronic right upper quadrant pain to an anomalously located and elongated appendix with inflammatory changes. The length of the appendix averages 8-9 mm, but has been reported to be >20 cm in rare cases.1 The origin is relatively constant, typically arising from the posteromedial cecal border or from the cecal fundus. From there, the appendix can have a variable course, but is typically located in the right lower quadrant. The appendiceal tip may be found in a variety of locations, with the most common being retrocecal (but intraperitoneal) in approximately 60% of individuals, pelvic in 30%, and retroperitoneal in 10%.1 Several previous case reports have been published of atypical presentations of appendicitis attributed to anomalously located and elongated appendices, but most are in children and in the context of acute appendicitis.2,3 This patient did not have the typical acute presentation of appendicitis or classic findings of acute appendicitis, but did have chronic pain likely attributable to the aberrantly located and inflamed appendix. Reviewing cross-sectional imaging with critical eye was important in this case, because the subtle finding in the area of this patients pain led ultimately to successful intervention and resolution of his symptoms.
References 1. 2. 3.
Richmond B. Sabiston textbook of surgery, 20th edition. Philadelphia: Elsevier, 2017. Alzaraa A, Chaudhry S. An unusually long appendix in a child: a case report. Cases J 2009;2:7398. Kim I, Chitnis A, Sabri S, et al. An unusually long retrocaecal appendix. Postgrad Med J 2016;92:624.
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