AA Mangi

AK Al Dabbagh

DG Addiss

Donal P O'Leary

Eddie Myers

Ian Wilson

Joe Coyle

MJ Truty

MK Liang

P Nahon

U De

WL Battle

English

PubMed

Springer - Publisher Connector

Case report of recurrent acute appendicitis in a residual tip

CASE REPORT Open Access
Case report of recurrent acute appendicitis in a
residual tip
Donal P O’Leary*, Eddie Myers, Joe Coyle, Ian Wilson
Abstract
Introduction: Residual appendicitis involving the stump of the appendix has been well described in the literature
in the past.
Case report: We report the case of a 43 year old male with acute onset of abdominal pain who had undergone
an appendicectomy ten years previously. Ultrasound revealed the presence of an inflamed tubular structure.
Subsequent laparotomy and histology confirmed that this structure was an inflamed residual appendiceal tip.
Conclusion: Residual tip appendicitis has not been reported in the literature previously and should be considered
in the differential diagnosis of localised peritonitis in a patient with a history of a previous open appendicectomy.
Introduction
Acute appendicitis is a common surgical emergency
requiring intervention. The lifetime risk of developing
appendicitis is approximately seven per cent [1]. Despite
advances in both minimally invasive surgery and radiol-
ogy, it’s accurate diagnosis remains challenging in some
instances [2]. This is especially the case following a pre-
vious appendicectomy, where inflammation of residual
appendiceal tissue is a possibility.
Case Report
We report the case of a 43 year old male who presented
with sudden onset of severe abdominal pain. His symp-
toms were consistent with acute cholecystitis. He was
unable to speak English and communicated via an inter-
preter. On examination a Battle’s incision was noted. He
claimed that this was due to a previous cholecystectomy
completed ten years previous in his home country. He
demonstrated signs of localised peritonitis in the right
upper quadrant. Inflammatory markers were elevated. A
clinical diagnosis of acute cholecystitis was made and
broad spectrum antibiotics commenced. An ultrasound
was performed and this confirmed the presence of a
non-inflamed gallbladder which did not contain gall-
stones. However, it did reveal an inflamed tubular, non-
compressible, non-peristalting, blind-ending structure
intimately related to the liver suggesting sub-hepatic
appendicitis (Figure 1).
Laparoscopy revealed dense adhesions throughout the
abdominal cavity and the presence of purulent intra-
abdominal fluid. We proceeded to a laparotomy through
a midline incision. Following extensive adhesiolysis the
caecum was identified, however only a non-inflamed
appendiceal stump remained. Further dissection revealed
evidence of pus in the right sub-hepatic space. The pus
was originating from a tubular structure which was
adherent to the lateral abdominal wall. An intra-opera-
tive diagnosis of residual tip appendicitis was made. The
tubular structure, measuring 2.5 cms in length, was
removed and was confirmed histologically as appendici-
tis with evidence of acute inflammatory changes. The
patient made an uneventful recovery and was discharged
home six days post-operatively.
Discussion
Appendicectomy is usually performed either via open or
laparoscopic surgery. At open surgery the conventional
incisions are of either the Gridiron or Lanz variety. A
Battle’s incision, which employs a vertical para-median
incision with temporary retraction of the rectus muscle
medially, was initially described in 1895 [3]. In the mod-
ern era it is rarely employed. In this setting with a bat-
tle’s incision and limited clinical information, recurrent
appendicitis formed part of the differential diagnosis,
* Correspondence: olearypeter83@hotmail.com
Department of Surgery, Saint Luke’s Hospital, Kilkenny, Ireland
O’Leary et al. Cases Journal 2010, 3:14
http://www.casesjournal.com/content/3/1/14
© 2010 O’Leary et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
although the location of signs was atypical for stump
appendicitis.
There are thirty seven cases of residual appendicitis in
the English literature. The majority of these case reports
involve stump appendicitis. Stump appendicitis remains,
however, an under reported condition. It occurs when
there is incomplete resection of the inflamed appendix.
The reported interval between operations varies between
two months and 50 years [4,5]. In our case of inflamed
residual appendiceal tip, presentation was ten years post
appendicectomy.
Residual appendicitis may be diagnosed using radiolo-
gical imaging. Ultrasound imaging is useful and was
diagnostic in this case. A pre-operative ultrasound,
which was done primarily to confirm the presence of a
gallbladder, visualised a sub-hepatic appendicitis. Com-
puted tomography (CT) is also useful in diagnosing resi-
dual appendicitis. CT features of stump appendicitis are
similar to those of acute appendicitis. They include peri-
caecal inflammatory changes, abscess formation, fluid in
the right paracolic gutter, caecal wall thickening, and an
ileocecal mass. Barium studies have also been reported
as being diagnostic in diagnosing stump appendicitis [6].
There are also reported cases of stump appendicitis
being diagnosed using colonoscopy [7].
The surgical treatment of residual appendicitis is most
commonly reported as an open operation but cases have
been successfully treated using laparoscopic interven-
tion. This case required a laparotomy as there were
dense adhesions from previous surgery and the exact
source of purulent fluid was not evident laparoscopi-
cally. Residual appendicitis has been reported most fre-
quently in cases of appendicitis treated with
laparoscopic surgery. There is a high morbidity rate in
this setting due to a combination of delayed diagnosis
and a high rate of stump perforation [8]. The rate of
perforation of stump appendicitis at the time of opera-
tion has been reported as sixty-eight per cent in one
review of the literature [9].
Conclusion
Residual tip appendicitis has not been reported in the
literature previously and should be considered in the
differential diagnosis of localised peritonitis in a patient
with a history of a previous open appendicectomy.
Consent
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images. A copy of the written consent is available for
review by the journal’s Editor-in-Chief.
Authors’ contributions
EM - Assistant surgeon, JC - Radiologist who conducted ultrasound, IW -
Consultant who operated on patient. All authors read and approved the
final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 14 October 2009
Accepted: 9 January 2010 Published: 9 January 2010
References
1. Addiss DG, Shaffer N, Fowler BS, Tauxe RV: The epidemiology of
appendicitis and appendectomy in the United States. Am J Epidemiol
1990, 132(5):910-25.
2. Al Dabbagh AK, Thomas NB, Haboubi N: Stump appendicitis, a diagnostic
dilemma. Tech Coloproctol 2008.
3. Battle WL: Modified incision for removal of the vermiform appendix. The
British Medical Journal 1895, 2:1360.
4. Baldisserotto M, Cavazzola S, Cavazzola LT, et al: Acute oedematous stump
appendicitis diagnosed preoperatively on sonography. AJR 200(175):503-
4.
5. Mangi AA, Berger DL: Stump appendicitis. Am Surg 2000, 66(8):739-41.
6. De U, De KK: Stump appendicitis. J Ind Med Assoc 2004, 102(6):329.
7. Nahon P, Nahon S, Hoang JM, Traissac L, Delas N: Stump appendicitis
diagnosed by colonoscopy. Am J Gastroenterol 2002, 97(2):1564-5.
8. Truty MJ, Stulak JM, Utter PA, et al: Appendicitis after appendectomy. Arch
Surg 2008, 143(4):413-15.
9. Liang MK, Lo HG, Marks JL: Stump Appendicitis: A Comprehensive
Review of Literature. The American Surgeon 2006, 72(2):162-166.
doi:10.1186/1757-1626-3-14
Cite this article as: O’Leary et al.: Case report of recurrent acute
appendicitis in a residual tip. Cases Journal 2010 3:14.
Figure 1 Ultrasound showing an inflamed tubular structure.
O’Leary et al. Cases Journal 2010, 3:14
http://www.casesjournal.com/content/3/1/14
Page 2 of 2


Crossref

al: Acute oedematous stump appendicitis diagnosed preoperatively on sonography.

Appendicitis: A Comprehensive Review of Literature. The American Surgeon

De KK: Stump appendicitis.

Delas N: Stump appendicitis diagnosed by colonoscopy.

DL: Stump appendicitis. Am Surg

et al: Appendicitis after appendectomy. Arch Surg

Haboubi N: Stump appendicitis, a diagnostic dilemma. Tech Coloproctol

Modified incision for removal of the vermiform appendix.

Tauxe RV: The epidemiology of appendicitis and appendectomy in the United States.

file:///data/remote/core/dit/data/Springer-OA/pdf/acb/aHR0cDovL2xpbmsuc3ByaW5nZXIuY29tLzEwLjExODYvMTc1Ny0xNjI2LTMtMTQucGRm.pdf

Case report of recurrent acute appendicitis in a residual tip

Abstract

Similar works

Full text

Available Versions

Springer - Publisher Connector

Springer - Publisher Connector

Crossref