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Recurrent (stump) appendicitis: a case series
American Journal of Emergency Medicine 33 (2015) 480.e1–480.e2
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Recurrent (stump) appendicitis: a case series☆ Abstract Stump appendicitis is a rare but serious postoperative complication of an appendectomy. In the emergency department, diagnosticians are likely to rule out appendicitis when a surgical history of an appendectomy is reported. We describe 2 patients in this case series who presented to the emergency department with right lower quadrant abdominal pain and a history of previous appendectomy. Both patients were identified with a remnant appendiceal stump and stump appendicitis. Upon admission to a surgical service, a nonoperative approach in management allowed each patient to stabilize and be discharged after treatment with antibiotics. The purpose of this article is to raise awareness about the diagnosis of stump appendicitis, as well as to discuss the treatments for it. Approximately 250 000 appendectomies are performed annually in the United States [1]. Rose [2] first described stump appendicitis in 1945. Since then, approximately 61 reported cases are cited in literature [1]. Stump appendicitis is a disease in which a remnant of the appendix becomes inflamed, causing a clinical presentation that is indistinguishable to that of appendicitis. The reported incidence is 1 in 50 000 [3], although the true incidence is probably higher [4]. The following review of 2 cases of stump appendicitis will optimally raise awareness of this entity and serve as a foundation to discuss the current available treatments. A 33-year-old woman presented complaining of abdominal pain. Vital signs were as follows: blood pressure, 113/80 mm Hg; heart rate, 98; respiratory rate, 18; and temperature, 100.0°F. She described the pain as being sharp, severe, constant, and in the right lower quadrant. Having begun the night prior, it became progressively worse and was not relieved by anything. It worsened with movement. The pain radiated to her lower back and right groin. She had anorexia without nausea, vomiting, or diarrhea. She reported that the pain was similar to when she had appendicitis that was operatively treated 6 months prior. Her examination revealed tenderness and guarding at McBurney’s point. Pelvic examination revealed a brown discharge that was sent for culture. Her white blood cell count was 18 000/mm 3 (normal, 4000-10 000). A computed tomography (CT) was performed in consideration of a possible tubo-ovarian abscess, right-sided diverticulitis, or a small bowel obstruction. The CT demonstrated phlegmonous changes surrounding the staple line consistent with stump appendicitis. She was started on antibiotics and admitted to a surgical service. After a 2-day hospitalization, she was discharged on oral antibiotics.
☆ The authors have no outside support information, conflicts, or financial interest to disclose; and this work has not been presented elsewhere.
0735-6757/© 2014 Elsevier Inc. All rights reserved.
A 34-year-old female patient presented with a chief concern of abdominal pain. Vital signs were as follows: blood pressure, 110/74 mm Hg; heart rate, 87; respiratory rate, 18; and temperature 96.2°F. Her pain began the night before, was gradual in onset, and fluctuated in intensity. She described it as moderate, diffuse, and radiating to the upper back. It was not relieved or worsened by anything. She had nausea and anorexia without vomiting or diarrhea. She reported having appendectomy 5 years prior. Her examination revealed mild tenderness diffusely throughout the abdomen with moderate tenderness found in the epigastric area. Bowel sounds were diminished. Her white blood cell count was 9200/mm 3 with abnormally high neutrophil (76%; normal, 40%-70%). A CT showed inflammation of an appendiceal stump as well as stump distention and wall enhancement. Mild periappendiceal fat stranding was noted. Surgical clips were present in the distal portion of the appendiceal stump. Findings were consistent with stump appendicitis. She was admitted to a surgical service for intravenous antibiotics, pain control medication, and a clear liquid diet. She was discharged home 2 days later with pain medication and a 10-day course of antibiotics. Stump appendicitis clinically presents very similarly to acute appendicitis. Signs and symptoms include acute sharp pain in the right lower quadrant, nausea, vomiting, fever, leukocytosis, and neutrophilia. Of concern for practicing clinicians is their unfamiliarity of the complication of stump appendicitis after appendectomy. The diagnosis of stump appendicitis can be delayed because of the surgical history of an appendectomy despite the classic presentation of acute appendicitis. Stump appendicitis is defined as a rare complication of previous appendectomy caused by infection of the residual portion of the appendix left in place. In most cases, an appendiceal stump greater than 3 mm can be cause for reinflammation [5]. During a surgical appendectomy, there may be misidentification of the complete appendix structure with failure to identify the base of the appendix or the cecal appendiceal junction. Stump appendicitis can occur anytime after the original appendectomy (reports range from 4 days to 40 years postappendectomy) [5]. It is important to recognize and diagnose stump appendicitis to prevent unnecessary testing, consultations, or further complications from a delayed diagnosis. Imaging modalities have been used to diagnose stump appendicitis. Ultrasound is recommended as the first-line imaging modality [6]; however, CT is more commonly performed and may secure the diagnosis of stump appendicitis [7]. In our 2 cases, CT scans proved effective in determining the diagnosis. Currently, there is no standardized approach in the management of stump appendicitis. One reported treatment is a completion of the appendectomy or resection of the appendiceal stump by open or laparoscopic surgery followed by postoperative antibiotic treatment [5]. A nonoperative treatment can also be successful. If this approach
480.e2
R.E. Rios et al. / American Journal of Emergency Medicine 33 (2015) 480.e1–480.e2
is elected, the patient may undergo interval stump appendectomy 6 weeks following resolution of inflammation. This decreases the potential morbidity of wound and surgical site infections and essentially eliminates repeat bouts of stump appendicitis in the future. Additionally, these patients should be referred to gastroenterology for colonoscopy following resolution of symptoms to ensure that cecal pathology or mass is not responsible for the inflammatory process. Although controversial, recent research claims that antibiotics alone as first-line therapy for acute appendicitis show improvement of condition in patients [8]. This conservative approach of nonsurgical treatment is associated with overall fewer complications, wound infection, and abdominal/pelvic abscess; lower morbidity; and shorter hospital stay compared with immediate appendectomy [9]. In our 2 cases, both patients were successfully treated nonoperatively and discharged home after 48 hours.
Rolando E. Rios, MD Kara Mia V. Villanueva MSII Department of Emergency Medicine Lehigh Valley Hospital/USF Morsani College of Medicine CC & I-78, Allentown, PA 18103 Joseph J. Stirparo, MD Department of Surgery Lehigh Valley Hospital/USF Morsani College of Medicine CC & I-78, Allentown, PA 18103
Kathleen E. Kane, MD Department of Emergency Medicine Lehigh Valley Hospital/USF Morsani College of Medicine CC & I-78, Allentown, PA 18103 Corresponding author. Department of EM Lehigh Valley Hospital, Research offices Tel.: + 1 610 402 7666 Email address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.08.050
References [1] Subramanian A, Liang MK. A 60-year literature review of stump appendicitis: the need for a critical view. Am J Surg 2013;203:503–7. [2] Rose TF. Recurrent appendiceal abscess. Med J Aust 1945;32:352–9. [3] Liang MK, Lo HG, Marks JL. Stump appendicitis. A comprehensive review of literature. Am Surg 2006;72:162–6. [4] Mangi AA, Berger DL. Stump appendicitis. Am Surg 2000;66:739–41. [5] Roberts K, Starker L, Duffa A, Bell R, Bohkari J. Stump appendicitis: a surgeon’s dilemma. JSLS 2011;15(3):373–8. [6] Ismail I, Iusco D, Jannaci M, et al. Prompt recognition of stump appendicitis is important to avoid serious complications. A case report. Cases J 2009;2:7415. [7] Burt BM, Javid PJ, Ferzoco SJ. Stump appendicitis in a patient with prior appendectomy. Dig Dis Sci 2005;50:2163–4. [8] Tannoury J, Abboud B. Treatment options of inflammatory appendiceal masses in adults. World J Gastroenterol 2013;19:3942–50. [9] Hansson J, Körner U, Ludwigs K, Johnsson E, Jönsson C, Lundholm K. Antibiotics as first-line therapy for acute appendicitis: evidence for a change in clinical practice. World J Surg 2012;36:2028–36.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Recurrent (stump) appendicitis: a case series☆ Abstract Stump appendicitis is a rare but serious postoperative complication of an appendectomy. In the emergency department, diagnosticians are likely to rule out appendicitis when a surgical history of an appendectomy is reported. We describe 2 patients in this case series who presented to the emergency department with right lower quadrant abdominal pain and a history of previous appendectomy. Both patients were identified with a remnant appendiceal stump and stump appendicitis. Upon admission to a surgical service, a nonoperative approach in management allowed each patient to stabilize and be discharged after treatment with antibiotics. The purpose of this article is to raise awareness about the diagnosis of stump appendicitis, as well as to discuss the treatments for it. Approximately 250 000 appendectomies are performed annually in the United States [1]. Rose [2] first described stump appendicitis in 1945. Since then, approximately 61 reported cases are cited in literature [1]. Stump appendicitis is a disease in which a remnant of the appendix becomes inflamed, causing a clinical presentation that is indistinguishable to that of appendicitis. The reported incidence is 1 in 50 000 [3], although the true incidence is probably higher [4]. The following review of 2 cases of stump appendicitis will optimally raise awareness of this entity and serve as a foundation to discuss the current available treatments. A 33-year-old woman presented complaining of abdominal pain. Vital signs were as follows: blood pressure, 113/80 mm Hg; heart rate, 98; respiratory rate, 18; and temperature, 100.0°F. She described the pain as being sharp, severe, constant, and in the right lower quadrant. Having begun the night prior, it became progressively worse and was not relieved by anything. It worsened with movement. The pain radiated to her lower back and right groin. She had anorexia without nausea, vomiting, or diarrhea. She reported that the pain was similar to when she had appendicitis that was operatively treated 6 months prior. Her examination revealed tenderness and guarding at McBurney’s point. Pelvic examination revealed a brown discharge that was sent for culture. Her white blood cell count was 18 000/mm 3 (normal, 4000-10 000). A computed tomography (CT) was performed in consideration of a possible tubo-ovarian abscess, right-sided diverticulitis, or a small bowel obstruction. The CT demonstrated phlegmonous changes surrounding the staple line consistent with stump appendicitis. She was started on antibiotics and admitted to a surgical service. After a 2-day hospitalization, she was discharged on oral antibiotics.
☆ The authors have no outside support information, conflicts, or financial interest to disclose; and this work has not been presented elsewhere.
0735-6757/© 2014 Elsevier Inc. All rights reserved.
A 34-year-old female patient presented with a chief concern of abdominal pain. Vital signs were as follows: blood pressure, 110/74 mm Hg; heart rate, 87; respiratory rate, 18; and temperature 96.2°F. Her pain began the night before, was gradual in onset, and fluctuated in intensity. She described it as moderate, diffuse, and radiating to the upper back. It was not relieved or worsened by anything. She had nausea and anorexia without vomiting or diarrhea. She reported having appendectomy 5 years prior. Her examination revealed mild tenderness diffusely throughout the abdomen with moderate tenderness found in the epigastric area. Bowel sounds were diminished. Her white blood cell count was 9200/mm 3 with abnormally high neutrophil (76%; normal, 40%-70%). A CT showed inflammation of an appendiceal stump as well as stump distention and wall enhancement. Mild periappendiceal fat stranding was noted. Surgical clips were present in the distal portion of the appendiceal stump. Findings were consistent with stump appendicitis. She was admitted to a surgical service for intravenous antibiotics, pain control medication, and a clear liquid diet. She was discharged home 2 days later with pain medication and a 10-day course of antibiotics. Stump appendicitis clinically presents very similarly to acute appendicitis. Signs and symptoms include acute sharp pain in the right lower quadrant, nausea, vomiting, fever, leukocytosis, and neutrophilia. Of concern for practicing clinicians is their unfamiliarity of the complication of stump appendicitis after appendectomy. The diagnosis of stump appendicitis can be delayed because of the surgical history of an appendectomy despite the classic presentation of acute appendicitis. Stump appendicitis is defined as a rare complication of previous appendectomy caused by infection of the residual portion of the appendix left in place. In most cases, an appendiceal stump greater than 3 mm can be cause for reinflammation [5]. During a surgical appendectomy, there may be misidentification of the complete appendix structure with failure to identify the base of the appendix or the cecal appendiceal junction. Stump appendicitis can occur anytime after the original appendectomy (reports range from 4 days to 40 years postappendectomy) [5]. It is important to recognize and diagnose stump appendicitis to prevent unnecessary testing, consultations, or further complications from a delayed diagnosis. Imaging modalities have been used to diagnose stump appendicitis. Ultrasound is recommended as the first-line imaging modality [6]; however, CT is more commonly performed and may secure the diagnosis of stump appendicitis [7]. In our 2 cases, CT scans proved effective in determining the diagnosis. Currently, there is no standardized approach in the management of stump appendicitis. One reported treatment is a completion of the appendectomy or resection of the appendiceal stump by open or laparoscopic surgery followed by postoperative antibiotic treatment [5]. A nonoperative treatment can also be successful. If this approach
480.e2
R.E. Rios et al. / American Journal of Emergency Medicine 33 (2015) 480.e1–480.e2
is elected, the patient may undergo interval stump appendectomy 6 weeks following resolution of inflammation. This decreases the potential morbidity of wound and surgical site infections and essentially eliminates repeat bouts of stump appendicitis in the future. Additionally, these patients should be referred to gastroenterology for colonoscopy following resolution of symptoms to ensure that cecal pathology or mass is not responsible for the inflammatory process. Although controversial, recent research claims that antibiotics alone as first-line therapy for acute appendicitis show improvement of condition in patients [8]. This conservative approach of nonsurgical treatment is associated with overall fewer complications, wound infection, and abdominal/pelvic abscess; lower morbidity; and shorter hospital stay compared with immediate appendectomy [9]. In our 2 cases, both patients were successfully treated nonoperatively and discharged home after 48 hours.
Rolando E. Rios, MD Kara Mia V. Villanueva MSII Department of Emergency Medicine Lehigh Valley Hospital/USF Morsani College of Medicine CC & I-78, Allentown, PA 18103 Joseph J. Stirparo, MD Department of Surgery Lehigh Valley Hospital/USF Morsani College of Medicine CC & I-78, Allentown, PA 18103
Kathleen E. Kane, MD Department of Emergency Medicine Lehigh Valley Hospital/USF Morsani College of Medicine CC & I-78, Allentown, PA 18103 Corresponding author. Department of EM Lehigh Valley Hospital, Research offices Tel.: + 1 610 402 7666 Email address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.08.050
References [1] Subramanian A, Liang MK. A 60-year literature review of stump appendicitis: the need for a critical view. Am J Surg 2013;203:503–7. [2] Rose TF. Recurrent appendiceal abscess. Med J Aust 1945;32:352–9. [3] Liang MK, Lo HG, Marks JL. Stump appendicitis. A comprehensive review of literature. Am Surg 2006;72:162–6. [4] Mangi AA, Berger DL. Stump appendicitis. Am Surg 2000;66:739–41. [5] Roberts K, Starker L, Duffa A, Bell R, Bohkari J. Stump appendicitis: a surgeon’s dilemma. JSLS 2011;15(3):373–8. [6] Ismail I, Iusco D, Jannaci M, et al. Prompt recognition of stump appendicitis is important to avoid serious complications. A case report. Cases J 2009;2:7415. [7] Burt BM, Javid PJ, Ferzoco SJ. Stump appendicitis in a patient with prior appendectomy. Dig Dis Sci 2005;50:2163–4. [8] Tannoury J, Abboud B. Treatment options of inflammatory appendiceal masses in adults. World J Gastroenterol 2013;19:3942–50. [9] Hansson J, Körner U, Ludwigs K, Johnsson E, Jönsson C, Lundholm K. Antibiotics as first-line therapy for acute appendicitis: evidence for a change in clinical practice. World J Surg 2012;36:2028–36.