A case report describing diverticulosis of the appendix presenting as acute appendicitis A a S a b a A R A A K A A D D C 1 a w u o [ t t A i f d D h 2 c CASE REPORT – OPEN ACCESS International Journal[.]
Trang 1International Journal of Surgery Case Reports 29 (2016) 155–157
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j o u r n al ho m e p a g e :w w w c a s e r e p o r t s c o m
Sarah L Khana,∗, Madhu Siddeswarappab,1, Mohammad Farrukh Khanb
a Drexel University College of Medicine, Philadelphia, PA 19129, USA
b Department of Surgery, Mercy Hospital of Philadelphia, Philadelphia, PA 19143, USA
a r t i c l e i n f o
Article history:
Received 17 August 2016
Accepted 30 October 2016
Available online 15 November 2016
Keywords:
Acute appendicitis
Appendix
Diverticulosis
Diverticulosis of the appendix
Case report
a b s t r a c t
INTRODUCTION:Diverticulosisoftheappendix(DA)isarareclinicalfindingwhichisoftenconfusedwith acuteorchronicappendicitisandisusuallyonlyidentifiedduringorafterappendectomy.Thesymptoms
ofDAcanlastforuptotwoweeksandlaboratorystudiestendtoreflectamorechronicinflammation DistinguishingthetwoentitiesisimportantasDAhasahigherriskforperforationandmaybeassociated withanunderlyingmalignancy
PRESENTATIONOFCASE:A54 yearoldAfrican Americanmalepresentedwiththree daysofright sidedabdominalpain,nausea,andvomiting.PhysicalexamandabdominalCTimagingwereconcerning forearlyacuteappendicitis.Thepatientwastakenemergentlytotheoperatingroomforlaparoscopic appendectomy.ExtensiveadhesionswerefoundaroundtheAppendixwhichwasgrosslyabnormalwith multiplediverticula.Thepatienthadanuneventfulrecovery
DISCUSSION:PatientswithDAareoftenmisdiagnosedwithchronicoracuteappendicitisbasedontheir presentingsymptomsandimaging.Whileappendectomyisthedefinitivetreatment,diagnosingDA beforesurgeryisimportantindeterminingthepatient’srisksandpotentialcomplications
CONCLUSION:DiverticulosisoftheAppendixisarareclinicalentitywhichisoftenmisdiagnosed.Better imagingtechniquesandhigherindicesofclinicalsuspicionareneededtomaketheappropriatediagnoses beforepatientsaretakenforsurgery
©2016TheAuthor(s).PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.Thisisanopen accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/)
1 Introduction
Diverticulosisoftheappendix(DA)isarareanatomical
vari-antfoundin0.004%to2.1%ofappendectomies[1].AlthoughDA
wasfirstdescribedin1893,itremainsalittlestudiedandpoorly
understoodclinical entity [6] Its symptomsare similarto and
oftenmistaken for those of earlyacute or chronicappendicitis
[8,10].Whileappendectomyiscurativeforboth,itisimportant
todistinguishDAfromappendicitisasitisfourtimesmorelikely
toperforateand maybea signof anunderlyingneoplasm [2]
AbdominalCTandsonographymayaidindiagnosis,buttheir
util-ityishighlytechnicianandradiologistdependent[7].Giventhese
factors,DA remainsa largely incidentalfindingwithout aclear
diagnosticalgorithm
∗ Corresponding author.
E-mail address: slk325@drexel.edu (S.L Khan).
1 Present Address: Department of Surgery, Duke University Medical Center,
Durham, NC 27710, USA
2 Presentation of case
A54 yearoldAfrican AmericanmalewithahistoryofCOPD andhypertensionpresentedtotheEmergencyDepartmentwitha three dayhistoryofrightsidedabdominalpain,nausea,and vom-iting.Hehadsimilarsymptomsoneweekpriorandwassenthome fromtheEmergencyDepartmentafteraCTscanrevealedanormal appendix.Hispastmedicalhistorywassignificantforhypertension andchronicobstructivepulmonarydisease.Hehadnoprevious surgeries
Examination revealed diffuse abdominal tenderness to pal-pation across all quadrants without rebound or guarding All laboratorystudieswerewithinnormal limitsincluding awhite blood cellcountof 7300g/dL.AnabdominalCTscan revealeda mildlydilatedfluid filledAppendixwithmildwallthickeningand enhancementandminimaladjacentinflammation,whichwas con-cerningforearlyacuteappendicitis
Thepatientwastakenemergentlytotheoperatingroomfor laparoscopicappendectomyperformedbytheattendingsurgeon withtheassistanceofaseniorresidentphysicianandtwostudents During theprocedure, extensive adhesions were foundaround theAppendixsuggestiveofchronicappendicealinflammation.The adhesionswerelysedandtheAppendixidentifiedand removed http://dx.doi.org/10.1016/j.ijscr.2016.10.074
2210-2612/© 2016 The Author(s) Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd This is an open access article under the CC BY-NC-ND license ( http://
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(Fig.1).TheAppendixwasnotedtobegrosslyabnormalwith
mul-tiplediverticula(Fig.2).Noothergrosspathologywasnotedand
theabdomenwasclosed.Thepatienthadanuneventfulrecovery
Pathology of the removed Appendix revealed budding like
lesionsprotrudingfromtheappendicealwallsuggestiveoffocal
diverticularprotrusionwithfibrousobliteration.Therewasfocal
serositiswithoutinflammationoftheappendicealmucosaorwall
3 Discussion
Appendicealdiverticulaareeithercongenitaloracquired[10]
Congenitaldiverticulaareoutpouchingsoftheentireappendiceal
wallandaccountfor3%ofalldiagnosedcasesofdiverticulosisof
theappendix(DA)[1,7,8].Acquired,orpseudodiverticula,account
fortheremainingmajorityofcases.Thesearisefromtheherniation
oftheappendicealmucosaandsubmucosathroughdefectsinthe
muscularisnearpenetratingarteries[7].Theyarebelievedtoarise
fromsustainedcontractionoftheAppendixbehind an
obstruc-tionleadingtoluminaldistension,inflammation,andperforation
[2,3,7].Sourcesofobstructionmayinclude,butarenotlimitedto
inflammation,fecaliths,calculi,andneoplasms[3,4]
DAasdescribedinthecaseaboveisoftenmisdiagnosedasacute
appendicitis[3].Featuresthatshouldraisetheclinicalsuspicionfor
DAincludeaprolongedcourse–uptotwoweeks–ofright sided
lowerabdominalpainwhichmaybeprecededbyachronic
his-toryofmultiplepreviouspainepisodes [10].Laboratorystudies
tendtosupportahistoryofchronicinflammationwith
compara-tivelylowerwhitebloodcellcountsandhigherCRPlevels[3,5,9]
Furthermore,patientspresentingwithDAareoftenolderthan30
yearswhichisoutsideofthetypicalagerangeforappendicitis[1]
Menaremorecommonlyaffectedthanwomen [1,3].Whileboth abdominalCTandUShavebeenshowntoaidinthedifferentiation
ofDAand acuteappendicitis,theirutilityishighly technician dependentandlimitedbyagenerallylowindexofsuspicionforDA [3].Thedefinitivetreatmentforbothconditionsisappendectomy [2,10]
FurthercomplicatingthedifferentiationofDAandacute appen-dicitisarethevariouscasesinwhichappendicealdiverticulamay present witheithera normal appearing orinflamed appendix Eachofthefourpossibleclinicalscenarioshasbeenclassifiedbased
ontheappearanceoftheAppendixandthediverticula [7].Class
1featuresanon inflamedAppendixwithdiverticulitis;-Class2, bothappendicitisanddiverticulitis;-Class3,appendicitiswitha non inflameddiverticulum;-andfinally,Class4,anon inflamed Appendixwithanon inflameddiverticulum[2,7]
Althoughthis andpreviousreportshaveoutlinedtheclinical featuresthatdistinguishDAfromacuteappendicitis,early diag-nosisofDAremainschallenging.DiagnosingDAbeforesurgeryis importantin determiningthepatient’s risk ofappendiceal per-foration,post operative complicationssuchasabscess,andthe potentialforaneoplasticcauseoftheinitialobstruction[2,3,10]
Atthistime,diagnosisshouldbeguidedbysymptomatologyand laboratoryfindingswithconfirmationafterpromptappendectomy Furtherworkisneededtoimproveourabilitytoradiologically con-firmsuspectedcasesofDA
4 Conclusion
WepresentedacaseinwhichapatientwithDAwas misdiag-nosedwithearlyacuteappendicitis.Thiscaseprovidesanexample
ofthesymptomatology,inconsistentradiographicalfindings,and atypicalpatientdemographicsthatshouldraisethesuspicionfor
DA Although the definitive treatment for both DA and acute appendicitisis appendectomy,theyeach haveunique risksand complicationswhichmakepreoperativediagnosisavaluablestep
inthepatient’shospitalcourse.ImprovingourabilitytoidentifyDA beforesurgerywillrequirehigherindicesofclinicalsuspicionbased
onpatientpresentationandbetterradiographicdifferentiationof thetwoclinicalentities
Conflict of interest
Noneof theauthorsreporta conflictof interestin this case report
Funding
Nofundingwasreceivedforthisstudy
Ethical approval
Allidentifyinginformationhasbeenremovedfromthecase
Consent
Noidentifyinginformationhasbeengiven,officialconsenthas notbeenobtainedasthepatienthasbeenlosttofollowup
SCARE guidelines
ThisworkwasreportedinlinewiththeSCAREcriteriaandthe correspondingchecklistwascompletedbytheauthors.(R.A.Agha, A.J.Fowler,A.Saetta,I.Barai,S.Rajmohan,D.P.OrgillandS.C.A.R.E fortheGroup,TheSCAREstatement:concensus-basedsurgicalcase reportguidelines,Int.J.Surg.2016.)
Trang 3S.L Khan et al / International Journal of Surgery Case Reports 29 (2016) 155–157 157
SarahLKhanperformeddatacollection,analysis,andwriting
MadhuSiddeswerappaandM.FarrukhKhandidanalysisand
writ-ing
Registration of research studies
N/A
Guarantor
S.Khan
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