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Appendiceal endometriosis presenting as a cecal mass.

INTRODUCTION

Tumors of the appendix are rare entities that are difficult to diagnose preoperatively. Appendiceal masses can present as acute appendicitis. An appendiceal tumor could be a carcinoid, adenocarcinoma, lymphoma, or cystadenoma (2). Therefore, complete surgical resection of the mass and histologic examination of the specimen is central to correctly diagnosing and properly treating appendiceal intussusception, which was first reported in 1858 by McKidd (3). It remains a rare (0.01% incidence) but well-described entity (1,4). Its presentation includes vague intermittent abdominal pain with gastrointestinal symptoms such as episodic diarrhea (1).

When the appendix is involved in endometriosis (proliferation of endometrial glands outside the uterine cavity), the endometriosis deposits can lead to hyperperistalsis and intussusception of the appendix, wholly or partially (1).

The cause of endometriosis is unclear, but several theories postulate direct intraperitoneal shedding of glands through the fallopian tubes and possible lymphovascular spread (5). The common presentation of endometriosis includes pelvic pain, dysmenorrhea, and infertility, although it can be asymptomatic in some individuals. Endometriosis affects the pelvic reproductive organs and associated peritoneum, followed less frequently by the bowel and bladder (5).

CASE REPORT

A 44-year-old woman came to our medical center with a diagnosis of biliary dyskinesia from an outside institution. However, her symptoms were not consistent with that diagnosis. She had right lower quadrant pain that was intermittent, with no past medical or surgical history of such pain. She was taking only a calcium supplement and a multivitamin. For the past 6 years, she had experienced vague alternating episodes of constipation and diarrhea, with occasional fevers. But she reported no jaundice, no hematochezia, and no weight loss. Her symptoms were not related to meals. We found that her initial vital signs and the results of her laboratory tests and physical examination were within normal limits. Her prior workup had included normal laboratory test results and a normal abdominal ultrasound study; her prior hepatobiliary iminodiacetic (HIDA) scan had revealed a reduced ejection fraction of 7%.

We felt that her symptoms were not consistent with biliary dyskinesia, so we ordered a computed tomography (CT) scan to delineate the cause of her pain (Figure A, B). The CT scan revealed an apparent mass causing a filling defect of the cecum near the appendiceal orifice. A subsequent colonoscopy showed that the appendix was partially intussuscepted, with mucosal thickening at the appendiceal orifice. Because a mucinous cystadenoma or cystadenocarcinoma was a possibility, we deferred a biopsy.

[FIGURE A-D OMITTED]

The patient underwent a laparoscopic ileocecectomy and a cholecystectomy with intraoperative cholangiography. During the operation, we noted a firm mass at the cecum; in addition, the appendix was partially intussuscepted (Figure C). The specimen was sent for frozen-section analysis, which pointed to a presumptive diagnosis of endometriosis.

The final histopathologic review of the mass was diagnostic of transmural appendiceal endometriosis (Figure D). The patient recovered uneventfully and was discharged home. She has since been seen in our clinic and is free of symptoms. She was referred to our gynecology colleagues for management of her endometriosis.

DISCUSSION

In patients with endometriosis, ectopic endometrial tissue typically appears in the pelvis and reproductive organs, but can appear on the bowel and appendix (6). Appendiceal endometriosis is rare (accounting for only 3% of intestinal endometriosis cases) (6), but it can mimic appendicitis, perforation, intussusception, or lower gastrointestinal (GI) bleeding (7). Frequently, such symptoms occur at the time of menses (8). But our patient had intermittent subacute abdominal pain that did not coincide with her menses. Our gross inspection of the appendix and cecum did not reveal evidence of endometriosis, but rather a firm white mass suggestive of a malignancy. In patients with appendiceal endometriosis, such a lack of a clear pathologic finding is not uncommon; often, the subsequent histologic examination reveals the true diagnosis, with endometrial stroma and glands present in the surgical specimen (9).

In our patient, the appendiceal intussusception found on the CT scan appeared as a cecal mass, more consistent with her symptoms than biliary dyskinesia. It is important to remember that endometriosis can be one of the many causes of an appendiceal mass or a cecal mass, especially in pre-menopausal women. Appropriate treatment includes resection--both to establish a definitive diagnosis and to alleviate symptoms (10). Given the nature of endometriosis, patients like ours should be encouraged to follow up with a gynecologist and should be offered hormonal medical therapy as an adjunct for symptom control.

REFERENCES

(1.) Ijaz S, Lidder S, Mohamid W, Carter M, Thompson H. Intussusception of the appendix secondary to endometriosis: a case report. Journal of Medical Case Reports. 2008; 2:12

(2.) Murphy E.M.A, Farquharson SM, Moran BJ. Management of an unexpected appendiceal neoplasm. British Journal of Surgery. 2006. 93:783-792

(3.) McKidd J. Case of invagination of cecum and appendix. Edinburgh Medical Journal. 1858. 4:793

(4.) Gupta P, Chwals W, Guandalini S. Intussusception of the appendix: another poorly recognized cause of rectal bleeding. Journal of Pediatric Gastroenterology & Nutrition. 2000; 30(3):320-323

(5.) Slaughter K, Gala RB. Endometriosis for the colorectal surgeon. Clin Colon Rectal Surg. 2010. 23(2):72-79

(6.) Shome GP, Nagaraju M, Munis A, Wiese D. Appendiceal endometriosis presenting as massive lower intestinal hemorrhage. Am J Gastroenterol. 1995; 90(10):1881-3

(7.) Khoo JJ, Ismail MSA, Tiu CC. Endometriosis of the appendix presenting as acute appendicitis. Singapore Medical Journal. 2004; 45(9)435

(8.) Idetsu A, Ojima H, Saito K, Yamauchi H, Yamaki E, Hosouchi Y, Nishida Y, Kuwano H. Laparoscopic appendectomy for appendiceal endometriosis presenting as acute appendicitis: report of a case. Surg Today. 2007; 37:510-513

(9.) Terada T. Endometriosis of the vermiform appendix presenting as a tumor. Gastroenterology Research. 2009; 2(6):353-355

(10.) Singh KK, Lessells AM, Adam DJ, Jordan C, Miles WFA, Macintyre IMC, Greig JD. Presentation of endometriosis to general surgeons: a 10-year experience. BJS, 1995; 82:1349-1351

Authors: N Ehsani, J Rose, M Probstfeld

Location: Tucson Medical Center, Arizona, USA
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Author:Ehsani, N.; Rose, J.; Probstfeld, M.
Publication:Journal of Surgical Case Reports
Article Type:Case study
Geographic Code:1USA
Date:Apr 1, 2012
Words:986
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