Calcified mucocele of the appendix

CALCIFIED

MUCOCELE J.

PEYTON

BARNES,

Houston,

M cified more author

1JCOCELES rather

of

rare

diagnosed

mucoceIe rare

the are

appendix very

preoperativeIy. of

and this

has seen

and the

appendix

is the only

are

seIdom A is

one that

caIeven the

so far. CASE

OF THE APPENDIX

REPORT

Mrs. A. B. C., age seventy-nine, a white, widow, first consulted the writer on October I 5, 1943. Her chief compIaint was attacks of pain in the right upper quadrant which were very severe. The pain radiated to the right back. These attacks began some twenty years ago, but only in the past few years has she required hypodermics in order to obtain relief. The attacks were usuahy associated with a good deal of nausea but no vomiting, except rareIy. She had a good deal of indigestion, gas on the stomach and belching, but this was mostly during an attack. Previous clinica history revealed that the patient had the usua1 childhood diseases and had typhoid fever in rgr I. She was in bed three months with this but remembers no definite complications. She has had much troubIe with constipation all her life. She has never been jaundiced and has had no operations. She had eight children and two miscarriages; most of the eight children are Iiving and well at present. Examination revealed the folIowing: temperature gg’r., p&e 84, bIood pressure 140/80. The lungs were negative. The heart was not enlarged and the rate was not excessive. No murmurs or arrythmias were noted. The pulse was of good voIume, regular and the peripheral arteries were not excessively thick or stiff. The abdomen was somewhat distended. Definite tenderness with shght rigidity was noted over the gahbladder area. A tender, paIpabIe mass was felt in the gaIIbIadder area. Murphy’s sign for gahbladder disease was positive. The liver and spleen apparentIy. were not enlarged. In the right lower quadrant there was a very hard, rounded mass which was freely movable within certain limits. It was not 323

M.D.

Texas dehniteIy associated with the kidney. Its extreme hardness was noteworthy. Thinking perhaps it was an inspissated intraceca1 mass, she was sent home to take a Iaxative that night, to be folIowed with an enema the next morning after which she was to come back for a re-check. The mass was unchanged in any respect fohowing the procedure first mentioned. The pelvic exammation was negative in every way. An x-ray study was done at St. Joseph’s Infirmary by Dr. C. P. Harris and was as follows: November I, 1943: Mrs. SaIlie C. Gallbadder and gastrointestina1 series: “Preliminary Roentgenograms: No shadows were seen suggestive of opaque urinary calculi. There is a round caIcific density in the right Iower quadrant which measures about 5 cm. in diameter. (Fig. I .) “Cholecystograms (oral method): There was no evidence of concentration of the dye in the gallbladder, and gallstones were revealed within the gallbIadder. “Barium Meal Examination: The barium meal passed through the oesophagus normahy. There was a fairly large diaphragmatic hernia through the oesophageal hiatus of the diaphragm. The stomach and duodenum filled normally and showed no evidence of an organic Iesion. There was a diverticuIum at about the junction of the duodenum and jejunum, which measured about z cm. in size. (Fig. 2.) “Six-Hour Examination: The barium mea1 was distributed in the Iower iIeum and proximal portion of the colon. (Fig. 3.) “ Twenty-four Hour Examination: The head of the barium mea1 had reached the rectum. There was a residue in the proximal portion of the coIon, and the rounded calcific mass in the region of the cecum appeared to be more opaque than prior to administration of the barium meal. (Fig. 4.) “Barium Enema Examination: The coIon fiIIed aImost compIeteIy and multiple diverticuIa were present in the sigmoid. The cecum and ascending portion of the coIon were markedIy diIated and the round mass previously described apparently communicated with the coIon. (Figs. 3 and 6.)

324

AmericanJournal of Surgery

Barnes-MucoceIe

FIG. I. Scout Mm showing right Iower quadrant.

of Appendix

round calcific

2

FIG. z. Note diaphragmatic hernia and large diverticulum FIG. 3. Barium meal indicates mass near cecum.

“Conclusions: (I) Non-functioning gallbIadder which contains gaIlstones. (2) Diaphragmatic hernia through the oesophagea1 opening of the diaphragm. (3) A diverticulum was present on the iIeum at junction of the duodenum and jejunum. This diverticuIum emptied normaIly. (4) The colon showed multiple diverticulae in the sigmoid region, and the

of duodenum

density in

3 near duodenojejunal

juncture.

cecum and ascending portion of the colon were diIated. There was a round, dense shadow at the Iower margin of the cecum which became more opaque after administration of the barium mea1. Thik shadow is not defkiteIy identified. It is possibIe that it does not communicate with the cecum.” She was advised that the main source of

VOL. LXXVI,

Barnes-Mucocele

No. 3

FIG. 4. Mass Figure I.

I

appears

of Appendix

slightly

FIGS. 5 and 6. Note dilatation of cecum and ascending possibIy present between mass and colon.

more opaque

American Journal of Surgery

than

colon. RoentgenoIogist

325

in

6 thought

a communication

was

326

American

Journal

Barnes-Mucocele

of Surgery

FIG.

7.

The

round

mass

SEPTEMBER, 1948

of Appendix

as seen when

cut

open;

the

wa1l.shad to be cut with a smaIl saw. troubIe was the diseased gaIIbIadder and that it should be removed. She was also advised that no diagnosis of the ileocecal tumor had been made, and that as it did not appear to be troubling her much its remova was not seriousIy contempIated. The diaphragmatic hernia and the diverticuIum of the jejunum aIso were not considered for surgicaI treatment, due respect being had for her age and genera1 condition and for the fact that the hernia and diverticuIum apparentIy were giving her IittIe if any trouble. She entered St. Joseph’s Infirmary November 17, 1943. At that time her physical findings were as reported. Her bIood showed: hemoglobin, SahIi, 75 per cent; erythrocytes, 4,240,ooo; Ieukocytes, 8,700; smaI1 Iymphocytes, 33 per cent; poIymorphonucIears, 63 per cent; basophiIes, 2 per cent; urinaIysis: YeIIow, clear, acid, specific gravity, 1.015; aIbumin, negative; sugar, negative; casts, none; mucus, one pIus. Epithelium, few, pus, occasiona1; bacteria none. Operation was done November 18, 1943, using cycIopropane anesthesia. An upper oblique incision was used, cutting the aponeurosis of the externa1 oblique transverseIy and spIitting the interna oblique and transverse in the Iine of their fibers. The right rectus was cut transverseIy. The gaIIbIadder was very contracted, adherent and diffrcuIt to dissect

but was found fiIIed with stones on final remova1. RemovaI was done from within out, carefuIIy ligating the cystic duct and artery. After this the ileocecal mass was brought up. Even then it was hard to ascertain its origin. It was attached to the cecum exactly where the appendix normaIIy arises. It sheIIed out fairIy easiIy with IittIe bIeeding and was as hard as a rock. There was some mutinous materia1 on its outer surface; this mutinous materia1 had exactIy the same general physica appearance and characteristics as the mutinous material found in the more common pseudomucinous cyst of the ovary. None of this material was found eIsewhere in the abdomen. The ovaries were entireIy atrophied and showed no signs of any disease whatever, there was no cyst, even a smaI1 one, in either ovary. No appendix couId be found after the remova of this tumor mass, no opening into the cecum or iIeum couId be determined, as apparently this mass was compIeteIy seaIed off from the gastrointestinaI tract. A free graft of omentum was tacked over the site of removal and, after pIacing a single Penrose drain in the foramen of Winslow, the abdomen was closed in Iayers. The pathological report on November 19, 1943, by Dr. A. H. Braden was as foIIows: “A gaIIbIadder that measures g X 435 cm. It has a thickened waI1 and contains muItipIe calculi. the Iargest of which measures I cm. across,

VOL. LXXVI,

No. 3

Barnes-MucoceIe

The mucosa shows extensive inff ammation and necrosis. “A mass removed from the region between the cecum and the ileum measures 9 cm. across and 6 cm. in diameter. The waII shows extensive calcification and the cavity is filled with thick, mutinous materia1. (Fig. 7.) “Diagnosis: ChoIecystitis; cholelithiasis; caIcihed mucocele of the appendix.”

of Appendix

American

journal

of Surgery

327

The patient made an uneventfu1 recovery, but did deveIop an auricuIar fibrihation on the second postoperative day. This was controhed by digitahs. She went home on the seventh day and got out of bed the same day without iI effects. She celebrated her eightieth birthday two weeks after the operation and has been we11 ever since.