E Topal, N Topal, H Özgüc
appendectomy, appendicitis, stump appendicitis
E Topal, N Topal, H Özgüc. A Rare Cause Of Acute Abdomen: Stump Appendicitis. The Internet Journal of Emergency Medicine. 2005 Volume 3 Number 1.
We report a stump appendicitis case of a 18-years-old man two mounts after laparoscopic appendectomy diagnosed by CT scan and succesfully treated by laparoscopically. Although the signs and symptoms do not differ from acute appendicitis, the diagnosis is often not considered because of the past surgical history. This clinical condition should considered in differential diagnosis of acute abdominal pain and surgery should not be delayed.
Stump appendicitis is a rare and serious clinical entity (1). It is an acute inflammation of residual part of appendix remaining after an appendectomy has been performed. The incidence of this condition may be increasing, possibly because of widespread use of laparascopic appendectomy(2). It has been associated with the length of the stump and the utilization of laparoscopic surgery. Although the signs and symptoms do not differ from acute appendicitis, the diagnosis is often not considered because of the past surgical history (3). Ultrasonography (US) and computed tomography (CT) are helpful in detecting pericecal changes (4). We report a case with stump appendicitis who performed laparoscopic re-resection 2 months after first laparoscopic appendectomy.
A 18 year old male was admitted with diffuse abdominal pain, nausea, vomiting lasting 18 hours. There was no medical history except a laparascopic appendectomy 6 mounths ago in our hospital. On physical examination he had temperature 39 0 C (axillary), blood presure pf 110/70 mmHg, pulse rate 100/min. His abdomen was tender and there was diffuse rebound and defense. On laboratory tests there was 20.600/mm 3 white blood cell count. In evaluation of records relating to the first operation, pathologic examination had confirmed removal of suppurative appendicitis. The specimen had measured 8x1
Abdominal US examination performed 3-5 MHz convex transducer. There was 2,5 cm in thicknes free fluid between intestinal ans and thickned intestinal ans about 2 cm in length at right lower quadrant(Figure 1). Abdominal CT examination after oral and intravenous contrast media administration indicated a tubulary mass about 1,5 cm in length and inflammatory changes of surrounding fat(Figure 2).
The patients underwent laparascopic exploration. Purulent material between intestinal ans at right lower quadrant and inflammated appendiceal stump 3 cm in size were noted. Appendiceal stump was resected by using endo GIA 45 mm(Tyco Healthcare, USSC, Norwalk, Connecticut,USA) and peritoneal cavity irrigated. Pathologic examination confirmed acute suppurative appendicitis involving a 3 cm appendix stump. The patient was discharged postoperative 4th day. He is in good general health after 9mounths.
Stump appendicitis was first described by Baumgartner in 1949. Since then sporadic cases have reported in the literature. It may subacuteor acutein nature.(5). Patients who had undergone appendectomy operation are not considered to have a disease based on appendiceal stump. Delayed operation causes peritonitis and increases morbidity and mortality (1). The interval of onset ranges from few mounts to 20 years (2,4). Stump appendicitis may ocur either open or laparoscopic appendectomy (1,3). A stump longer than 5 mm may cause such complications and also serves as a reservoir fort he fecalith that may result with a stump perforation (1). In literature causes of stump appendicitis are insufficient inversion of stump, remmant of excessive length and insufficient laparascopic appendectomy (1,3). In our case there was history of laparoscopic appendectomy 6mounths ago and appendicecal remmant length was 3 cm in size.
The imaging findings are nonspesific. US and CT useful for detecting peritoneal fluid and pericecal abcess. CT is more helpful to show periferal fat inflammation (4). We also detected a tubulary mass representing thickned stump on US and CT.
There is no consensus regarding treatment of the stump appendicitis. In 1934 Mayo reported simple ligation of the stump but several studies demonsrated the complication such as intussusception, intramural abscesses and post operative adhesions. Inversion of the stump theoretically decreases contamination of the peritoneal cavity by the infected stump, decreases the formation of adhesions and minimizes bleeding from the stump. Despite these arguments there are no data to support either simple ligation or or inversion (5). Options for treatment stump appendicitis have ranged from laparoscopic appendectomy to more aggressive operation such as ileocolic resection with ostomy. Our case succesfully treated with laparoscopic stump appendectomy. In literature, laparoscopic surgical treatment for stump appendicitis has rarely been reported(6,7). Probably, these cases are under-reported.
In conclusion, the precence of appendectomy history does not excluded the possibility of appendicitis. Stump appendicitis should be take in to consideration in the differential diagnosis of right lower quadrant abdominal pain. CT scan and diagnostic laparoscopy are excellent diagnostic modalities. Completion of laparoscopic stump appendectomy can be done in patient who diagnosed early.
Halil Ozguc, MD Department of Surgery Uludag University Medical School 16059-Bursa/TURKEY Tel:00902244428400 Fax:00902244428398 E-mail: firstname.lastname@example.org