Case Report

 

Stump appendicitis: A rare but important entity


G. Roche-Nagle C. Gallagher C. Kilgallen1 M. Caldwell

Department of Surgery, 1Department of Pathology, Sligo General Hospital, Sligo, Ireland

Correspondence to: G. Roche-Nagle, Department of Surgery, Sligo General Hospital, The Mall, Sligo, Ireland Email: grnagle@rcsi.ie

 

 

Introduction

Case Report

References

 

A case of right lower quadrant pain in a 35-year-old male who underwent an appendicectomy 14 years previously is presented. Recurrent appendicitis with perforation was noted in an appendiceal stump on exploratory laparotomy. Although rare, inlammation of the appendiceal stump can occur and is still an important clinical entity. It is difficult to diagnose pre-operatively. A wide spectrum of causes in the differential diagnosis of right lower quadrant pain of the abdomen and a previous appendicectomy in a patient’s history may delay the diagnosis. Knowledge of the condition should permit the physician to make an early diagnosis and, thus, limit the resultant morbidity

Keywords: Appendicitis, appendectomy, stump appendicitis, morbidity Surgeon, 1 February 2005, 53-54

 

INTRODUCTION

The first accurate description of the clinical and pathologic features of appendicitis is attributed to Reginald Fitz, who, in 1886, was among the first to advocate appendicectomy as the appropriate treatment for this entity.1 Appendicitis is one of the most common conditions treated by the general surgeon. The more common complications of appendicectomy include superficial wound infections, post-operative adhesions, and intramural abscess formation. Although stump appendicitis is an exceedingly rare condition, there are several isolated case reports in the surgical literature. In addition, the rapid development of laparoscopic appendicectomy has prompted the recognition of stump appendicitis as an entity that may be increasing in prevalence.2,3

 

CASE REPORT

A 35-year-old man presented with a 12-hour history of “cramping” epigastric pain, radiating to the right iliac fossa (RIF). It was constant in nature but variable in intensity. The pain was rated 8/10 in severity on a linear pain analogue scale. The patient had also begun to vomit over the previous eight hours. The vomitus was bilious in content and the patient could tolerate neither food nor fluids as he was extremely nauseated. He had passed a normal bowel motion e the patient treated conservatively. Because of persistent clinical signs and symptoms, computed tomography was performed and revealed some mild thickening of the small bowel and pericaecal fat infiltration. Approximately 30 hours after admission, the patient underwent exploratory laparotomy via a lower midline incision. This revealed a perforated appendiceal stump (Figure 1). The stump was 3-4cm long. The appendiceal stump was ligated, and the patient continued on intravenous antibiotics for 48 hours. He made a good recovery and was discharged on day eight post-operatively. Histopathological examination confirmed the presence of an appendix stump with acute suppurative appendicitis and perforation. The tissue adjacent to the perforation showed marked acute inflammation and necrosis.

REFERENCES

1. Fitz RH. Perforating inflammation of the vermiform appendix, with special reference to its early recognition and treatment. Trans Assoc Am Phys 1886;1:107.

2. Devereaux DA, McDermott

JP, Caushaj PF. Recurrent appendicitis following laparoscopic appendicectomy. Report of a case. Dis Colon Rectum 1994; 37(7): 719-20.

3. Greenberg JJ and Esposito TJ.

Appendicitis after laparoscopic appendicectomy: a warning. J Laparoendosc Surg 1996;6: 185-87.

4. Baumgardner LO. Rupture of appendiceal stump three months after uneventful appendicectomy with repair and recovery. Ohio State Medical Journal 1949;45: 476-77.

5. Greene JM, Peckler D, Schumer

W, Greene EL. Incomplete surgical removal of the appendix: its complications. J Int Coll Surg 1958;29:141-46.

6. Harris CR. Appendiceal stump abscess ten years after appendicectomy. Am J Emerg Med 1989;7(4):411-12.

7. Siegel SA. Appendiceal stump abscess: a report of a stump abscess twenty-three years postappendicectomy. Am J Surg 1954; 63:630-32.

8. Feigin E, Carmon M, Szold A,

Seror D. Acute stump appendicitis. Lancet 1993;341: 757.

Indexed 8 bits

° 2005 Surgeon 3: 1; 53-54

The Royal Colleges of Surgeons of Edinburgh and Ireland 53

re.5-8 Incomplete reporting of this complication makes the exact incidence unknown. Greene et al (1958) reported three cases of stump appendicitis between 13 and 20 years post-appendicectomy.5 They emphasised the importance of locating the junction of the base of the appendix with the caecum by dissecting and ligating the recurrent branch of the appendiceal artery as well as the artery itself, as the former marks the true base of the appendix. The known interval between appendicectomy and onset of stump appendicitis can range from weeks up to 23 years.7

 

In the literature, the suggested causes of stump appendicitis include insufficient inversion of the stump, a remnant of excessive length or insufficient laparoscopic appendicectomy.2,3,9 Different methods of dealing with the appendiceal stump have been discussed in the literature.5,6,9,10 The ligated stump can be inverted or not. Stump inversion is performed to prevent contamination of the peritoneal cavity. If separation of the ligature occurs, bowel contaminates the peritoneal cavity and the patient develops either generalised peritonitis or a periappendicular abscess. Since the common use of laparoscopy in surgical management, stump burial technique has become disputed. Angled scopes may provide a good visualisation and a sufficient amputation. Prospective trials have shown no advantages gained by inverting the appendiceal stump.11

Despite the newer technology, pre-operative diagnosis of appendiceal stump pathology remains extremely difficult. Delayed operation causes peritonitis and is associated with increased morbidity and mortality. The general practitioner, as well as the surgeon, faced with a patient with abdominal pain and a past appendicectomy, will justifiably consider other causes of right lower quadrant pain, thus leading to a delay in referral and treatment. Where possible, stump resection alone for cases of acute stump appendicitis should be favoured.

 

Copyright 18 December 2004

 

REFERENCES

1. Fitz RH. Perforating inflammation of the vermiform appendix, with special reference to its early recognition and treatment. Trans Assoc Am Phys 1886;1:107.

2. Devereaux DA, McDermott JP, Caushaj PF. Recurrent appendicitis following laparoscopic appendicectomy. Report of a case. Dis Colon Rectum 1994; 37(7): 719-20.

 

3. Greenberg JJ and Esposito TJ. Appendicitis after laparoscopic appendicectomy: a warning. J Laparoendosc Surg 1996;6:185-87.

 

4. Baumgardner LO. Rupture of appendiceal stump three months after uneventful appendicectomy with repair and recovery. Ohio State Medical Journal 1949;45:476-77.

 

5. Greene JM, Peckler D, Schumer W, Greene EL. Incomplete surgical removal of the appendix: its complications. J Int Coll Surg 1958;29:141-46.

 

6. Harris CR. Appendiceal stump abscess ten years after appendicectomy. Am J Emerg Med 1989;7(4):411-12.

 

7. Siegel SA. Appendiceal stump abscess: a report of a stump abscess twenty-three years post-appendicectomy. Am J Surg 1954; 63:630-32.

 

8. Feigin E, Carmon M, Szold A, Seror D. Acute stump appendicitis. Lancet 1993;341: 757.

 

9. Berne TV, Ortega A. Appendicitis and appendiceal abscess. In: Nyhus LM, Baker RJ, Fischer JE editors. Mastery of surgery. Boston : Little Brown; 1997. p.1407-11.

 

10. Mangi AA, Berger DL. Stump appendicitis. Am Surg 2000;66:739-41.

 

11. Fitzgibons RJ, Ulualp KM. Laparoscopic appendicectomy. In: Nyhus LM, Baker RJ, Fischer JE editors. Mastery of surgery. Boston : Little Brown;1997. p1412-19.