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The relationship between appendicitis and right ovarian retention cysts
THE RELATIONSHIP
APPENDICITIS
BETWEEN
AND RIGHT OVARIAN MANDEL
WEINSTEIN,
RETENTION
CYSTS*
M.D.
LONG ISLAND CITY, NEW YORK
W
HEN operating for appendicitis in the female, the writer has been impressed with the frequent co-
be impossibIe. Nor does it matter as Iong as the correct treatment is recognized: nameIy, to operate upon the patient. Sigmoid (Displaced
Flexure Upward)
Mewappendix Ap endicubOvarian (&do’s Ligment) Vermiform
Appendix
(Displaced
Downwards)
FIG.
existence of right,ovarian cysts as compared to left-sided cysts. This combined pathology has occurred so often, that a study was made of 167 femaIe patients operated upon for appendicitis at one institution over a period of two and a haIf years. Cases of suppurative and perforated appendicitis are not inckded in this study for obvious reasons. CompIicating the pathoIogicaI appendix, there were 23 right ovarian cysts (I 3.7 %), in contradistinction to 4 Ieft ovarian cysts (2.4 per cent). In many instances, an ovarian cyst was detected or suspected before operation, where the signs of appendicitis were not pronounced enough to prevent careful examination. Bonney’ beIieves that since the diseased appendix may lie in cIose proximity to the right adnexa, accurate diagnosis may
I.
At the outset, Iet it be stated that a carefuI attempt was made to ehminate other pathoIogica1 processes as the cause of ovarian cysts. Cases of apparent inffammatory adnexa1 disease have been excIuded, as we11 as every type of ovarian tumor other than simpIe retention cyst. The Iatter consist of Graafian foIIicuIar and corpus Iutein cysts. ANATOMIC
EVIDENCE
Under normal conditions, the tip of the appendix usuaIIy Iies in the peIvis with the right tube and ovary, (Graves5). In cases of ptosis or cecum mobile, the appendix may Iie compIeteIy in the peIvis, even as Iow as the floor of DougIas’ pouch. The appendicuIo-ovarian Iigament, aIso termed CIado’s Iigament, (Campbe11,2 De Lee3) is a proIongation of peritoneum in the femaIe
* Submitted for publication December
270
3
I, 1930.
NEW
SERIES VOL. XIII, No. 1
Weinstein-Appendicitis
extending from the mesoappendix to the broad Iigament and the right ovary. Herein is contained the appendicuIo-ovarian artery which forms an anastomosis between the appendicuIar and ovarian vessels, thus conferring a greater vascularity upon the femaIe appendix, a suggestive reason for its greater immunity against appendicitis in femaIes. Communications have been described as existing between the appendicuIar Iymphatits and those of the broad Iigament of the uterus as we11 as the iIiac nodes. Deaver4 states that the Iymphatics may empty into those of the ovary by passing aIong the appendicuIo-ovarian Iigament. In this fashion a lymphatic communication is established between the appendix and the right ovary. More recent observations, however, have faiIed to confirm the existence of any direct connection between these structures, (PiersoI,s KaufmarY). PathoIogicaI conditions of the broad Iigament, ovaries, and iIiac nodes associated with acute appendicitis may perhaps be due to a dissemination of the infection through the subperitoneal Iymphatic network by way of the appendiculo-ovarian Iigament. Graves5 beheves that this inffammatory extension from an acuteIy inflamed appendix may cause such serious damage to the genita1 organs in young girIs, that among other Iesions chronic thickening of the cortex of the ovaries may resuIt. If the attack occurs before puberty, or in young chiIdren, fuI1 genita1 deveIopment may be curtaiIed, resuIting in infantiIism with its symptoms of amenorrhea, dysmenorrhea, neurosis, and steriIity. PATHOLOGICAL
SEQUENCE
The underIying causes of retention cysts are numerous. The commonest cause, interstitia1 oophoritis, may be acute or chronic, (NeIson’). Acute oophoritis is usuaIIy secondary to an acute perioophoritis which in turn foIIows in the path of acute peIvic peritonitis, as in acute gonorrhea. Or it may be primarily interstitia1 as a compIication of mumps, acute fevers,
& Cysts
American
JOUI~~I of surgery
27 I
Iymphangitis of acute septic puerpera1 or surgica1 infection. Chronic oophoritis may be the residuum
FIG.
2.
from any of the foregoing acute states, or may be chronic from the beginning. The condition is essentiaIIy inflammatory in origin, whether the peIvis is the seat of gross inflammatory Iesions or not. The essential lesion consists in a scIerosing process invoIving the interstitia1 tissues. This Ieads to hardening of the tunica albuginea and inability of the Graafian foIIicIes to rupture when mature. The foIIicuIar membrane undergoes hypersecretion simiIar to that of any serous membrane ,that is subjected to the chronic irritation of infection. The resuIt is a retention cyst of any size. And a right retention cyst in the presence of appendix infection, suggests the appendix as the etioIogica1 factor. SYMPTOMATOLOGY
No age is exempt from the presence of ovarian retention cysts. Patients in the age of puberty as we11 as women advanced in years may be afXicted. Our average age incidence was twenty-seven years. Nine
272
Amrric~n Journnl of Surgery
Weinstein-Appendicitis
patients or 39 per cent were single, and 14 or 61 per cent were married. Of course, many cysts are not detected preoperatively in unmarried women, unless quite large in size. Scant flow, irregular menses, premenstrual and co-menstrual pain, and metrorrhagia may yield a clue. When a satisfactory bimanual examination is possible, right adnexal tenderness, and in further advanced cases, an ovarian mass may be elicited, in addition to the signs and symptoms of appendicitis. Ross9 reported a case of a twelve-year old girl who had an ovarian cyst; the right ovary twisted on its pedicIe 235 turns. The appendix was found in a state of chronic inflammation and was likewise removed. He was of the opinion that a twist of the pedicle of the ovarian cyst had been occasioned by the active peristal-
& Cysts
AUGUST, ,031
sis of the bowel produced, by an acute exacerbation of a chronic appendicitis. CONCLUSION
I. A statistical analysis of 167 cases of appendicitis in the female is presented, 23 of which showed upon operation, right ovarian retention cysts in contradistinction to only 4 left-sided cysts. 2. An anatomic relationship exists between the appendix and right ovary, whether due to the normal proximity of the organs or to lymphatic and vascular pathways. 3. Chronic oophoritis resuhing from appendiceal infection causes a sclerosing of the tunica albuginea, failure of the follicles to rupture when mature, hypersecretion of the follicular membrane, and the resultant retention cysts.
REFERENCES
BONNEY, V. GynecoIogicaI transactions in chronic appendicitis. &it. M. J., 2: 1066, 1927. Textbook of Surgical Anatomy, 2. C AMPBELL, W. Phila., Saunders, 191 I. 3. DE LEE, J. B. PrincipIes and Practices of Obstetrics. Ed. 3, PhiIa., Saunders, 1924, 510. 4. DEAVER, J. Surgical Anatomy of the Human Body. Phila., Blakiston, 1926, 3: 442. 5. GRAVES. GynecoIogy. Ed. 4, Phila., Saunders, 1928.
6. KAUFMAN, E. PathoIogy. PhiIa., BIakiston’s Son 8; Co. VoI. II, pp. 838. 7_ NELSON, T. Loose Leaf Living Surgery. Chapt. x, VoI. 7, p. 280. 8. PIERSOL, G. A. Human Anatomy. Phila., Lippincott Co., 191 I, pp. 978. 9. Ross. Transactions of the PhiIadeIphia Academy of Surgery Meeting, October 4th, 1909.
I.
REFERENCES
38. VIRCHOW. Quoted by Saint.32 39. WHEELER, W.
I. DE C. MuItipIe
coIon. Brit. J. Surg., 14: 58-66,
poIypi
of the
1926. *Continued
OF
DR.
KILFOY*
40. WARWICK, M. IntestinaI poIyposis and its reIation to maIignancy. Minnesota Med., 5: 9437, 1922. 41. YOEMANS, F. The carcinomatous degeneration of recta1 adenomas. Report of 7 cases. J. A. M. A., 89: 852-854, 1927. from p. 290.
APPENDICITIS
BETWEEN
AND RIGHT OVARIAN MANDEL
WEINSTEIN,
RETENTION
CYSTS*
M.D.
LONG ISLAND CITY, NEW YORK
W
HEN operating for appendicitis in the female, the writer has been impressed with the frequent co-
be impossibIe. Nor does it matter as Iong as the correct treatment is recognized: nameIy, to operate upon the patient. Sigmoid (Displaced
Flexure Upward)
Mewappendix Ap endicubOvarian (&do’s Ligment) Vermiform
Appendix
(Displaced
Downwards)
FIG.
existence of right,ovarian cysts as compared to left-sided cysts. This combined pathology has occurred so often, that a study was made of 167 femaIe patients operated upon for appendicitis at one institution over a period of two and a haIf years. Cases of suppurative and perforated appendicitis are not inckded in this study for obvious reasons. CompIicating the pathoIogicaI appendix, there were 23 right ovarian cysts (I 3.7 %), in contradistinction to 4 Ieft ovarian cysts (2.4 per cent). In many instances, an ovarian cyst was detected or suspected before operation, where the signs of appendicitis were not pronounced enough to prevent careful examination. Bonney’ beIieves that since the diseased appendix may lie in cIose proximity to the right adnexa, accurate diagnosis may
I.
At the outset, Iet it be stated that a carefuI attempt was made to ehminate other pathoIogica1 processes as the cause of ovarian cysts. Cases of apparent inffammatory adnexa1 disease have been excIuded, as we11 as every type of ovarian tumor other than simpIe retention cyst. The Iatter consist of Graafian foIIicuIar and corpus Iutein cysts. ANATOMIC
EVIDENCE
Under normal conditions, the tip of the appendix usuaIIy Iies in the peIvis with the right tube and ovary, (Graves5). In cases of ptosis or cecum mobile, the appendix may Iie compIeteIy in the peIvis, even as Iow as the floor of DougIas’ pouch. The appendicuIo-ovarian Iigament, aIso termed CIado’s Iigament, (Campbe11,2 De Lee3) is a proIongation of peritoneum in the femaIe
* Submitted for publication December
270
3
I, 1930.
NEW
SERIES VOL. XIII, No. 1
Weinstein-Appendicitis
extending from the mesoappendix to the broad Iigament and the right ovary. Herein is contained the appendicuIo-ovarian artery which forms an anastomosis between the appendicuIar and ovarian vessels, thus conferring a greater vascularity upon the femaIe appendix, a suggestive reason for its greater immunity against appendicitis in femaIes. Communications have been described as existing between the appendicuIar Iymphatits and those of the broad Iigament of the uterus as we11 as the iIiac nodes. Deaver4 states that the Iymphatics may empty into those of the ovary by passing aIong the appendicuIo-ovarian Iigament. In this fashion a lymphatic communication is established between the appendix and the right ovary. More recent observations, however, have faiIed to confirm the existence of any direct connection between these structures, (PiersoI,s KaufmarY). PathoIogicaI conditions of the broad Iigament, ovaries, and iIiac nodes associated with acute appendicitis may perhaps be due to a dissemination of the infection through the subperitoneal Iymphatic network by way of the appendiculo-ovarian Iigament. Graves5 beheves that this inffammatory extension from an acuteIy inflamed appendix may cause such serious damage to the genita1 organs in young girIs, that among other Iesions chronic thickening of the cortex of the ovaries may resuIt. If the attack occurs before puberty, or in young chiIdren, fuI1 genita1 deveIopment may be curtaiIed, resuIting in infantiIism with its symptoms of amenorrhea, dysmenorrhea, neurosis, and steriIity. PATHOLOGICAL
SEQUENCE
The underIying causes of retention cysts are numerous. The commonest cause, interstitia1 oophoritis, may be acute or chronic, (NeIson’). Acute oophoritis is usuaIIy secondary to an acute perioophoritis which in turn foIIows in the path of acute peIvic peritonitis, as in acute gonorrhea. Or it may be primarily interstitia1 as a compIication of mumps, acute fevers,
& Cysts
American
JOUI~~I of surgery
27 I
Iymphangitis of acute septic puerpera1 or surgica1 infection. Chronic oophoritis may be the residuum
FIG.
2.
from any of the foregoing acute states, or may be chronic from the beginning. The condition is essentiaIIy inflammatory in origin, whether the peIvis is the seat of gross inflammatory Iesions or not. The essential lesion consists in a scIerosing process invoIving the interstitia1 tissues. This Ieads to hardening of the tunica albuginea and inability of the Graafian foIIicIes to rupture when mature. The foIIicuIar membrane undergoes hypersecretion simiIar to that of any serous membrane ,that is subjected to the chronic irritation of infection. The resuIt is a retention cyst of any size. And a right retention cyst in the presence of appendix infection, suggests the appendix as the etioIogica1 factor. SYMPTOMATOLOGY
No age is exempt from the presence of ovarian retention cysts. Patients in the age of puberty as we11 as women advanced in years may be afXicted. Our average age incidence was twenty-seven years. Nine
272
Amrric~n Journnl of Surgery
Weinstein-Appendicitis
patients or 39 per cent were single, and 14 or 61 per cent were married. Of course, many cysts are not detected preoperatively in unmarried women, unless quite large in size. Scant flow, irregular menses, premenstrual and co-menstrual pain, and metrorrhagia may yield a clue. When a satisfactory bimanual examination is possible, right adnexal tenderness, and in further advanced cases, an ovarian mass may be elicited, in addition to the signs and symptoms of appendicitis. Ross9 reported a case of a twelve-year old girl who had an ovarian cyst; the right ovary twisted on its pedicIe 235 turns. The appendix was found in a state of chronic inflammation and was likewise removed. He was of the opinion that a twist of the pedicle of the ovarian cyst had been occasioned by the active peristal-
& Cysts
AUGUST, ,031
sis of the bowel produced, by an acute exacerbation of a chronic appendicitis. CONCLUSION
I. A statistical analysis of 167 cases of appendicitis in the female is presented, 23 of which showed upon operation, right ovarian retention cysts in contradistinction to only 4 left-sided cysts. 2. An anatomic relationship exists between the appendix and right ovary, whether due to the normal proximity of the organs or to lymphatic and vascular pathways. 3. Chronic oophoritis resuhing from appendiceal infection causes a sclerosing of the tunica albuginea, failure of the follicles to rupture when mature, hypersecretion of the follicular membrane, and the resultant retention cysts.
REFERENCES
BONNEY, V. GynecoIogicaI transactions in chronic appendicitis. &it. M. J., 2: 1066, 1927. Textbook of Surgical Anatomy, 2. C AMPBELL, W. Phila., Saunders, 191 I. 3. DE LEE, J. B. PrincipIes and Practices of Obstetrics. Ed. 3, PhiIa., Saunders, 1924, 510. 4. DEAVER, J. Surgical Anatomy of the Human Body. Phila., Blakiston, 1926, 3: 442. 5. GRAVES. GynecoIogy. Ed. 4, Phila., Saunders, 1928.
6. KAUFMAN, E. PathoIogy. PhiIa., BIakiston’s Son 8; Co. VoI. II, pp. 838. 7_ NELSON, T. Loose Leaf Living Surgery. Chapt. x, VoI. 7, p. 280. 8. PIERSOL, G. A. Human Anatomy. Phila., Lippincott Co., 191 I, pp. 978. 9. Ross. Transactions of the PhiIadeIphia Academy of Surgery Meeting, October 4th, 1909.
I.
REFERENCES
38. VIRCHOW. Quoted by Saint.32 39. WHEELER, W.
I. DE C. MuItipIe
coIon. Brit. J. Surg., 14: 58-66,
poIypi
of the
1926. *Continued
OF
DR.
KILFOY*
40. WARWICK, M. IntestinaI poIyposis and its reIation to maIignancy. Minnesota Med., 5: 9437, 1922. 41. YOEMANS, F. The carcinomatous degeneration of recta1 adenomas. Report of 7 cases. J. A. M. A., 89: 852-854, 1927. from p. 290.