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Endometriosis of the meso-appendix mimicking appendicitis: a case report.

Case presentation

A 33-year-old woman presented to us with a past history of infertility for which she had had several unsuccessful in vitro fertilisation attempts. No diagnostic laparoscopies were undertaken for infertility. She presented with gradual onset of peri-umbilical pain that localised to the right iliac fossa. Pain onset had been about 4 hours prior to presentation and was associated with nausea. On examination she was hot to touch but afebrile with guarding and rigidity localised to the right iliac fossa. The white blood cell count revealed a leucocytosis of 16 000. A pregnancy test and urine examination were both negative. A diagnosis of appendicitis was entertained; however, in light of her gynaecological history, a computed tomography (CT) scan was performed. The CT scan revealed a mildly enlarged appendix (measuring 8.2 mm in cross section), with rim enhancement and minimal surrounding fat stranding, with no other evident intra-abdominal pathology (Figs 1 and 2). The CT scan features were suggestive of that of an early appendicitis. At laparoscopic appendicectomy the appendix looked mildly inflamed (Figs 3 and 4). The rest of the abdomen was pristine except for a reddish brown area on the uterus which was suggestive of endometriosis and was biopsied. The postoperative course was unremarkable; the presenting pain improved drastically and the white blood cell count returned to normal. Histology of the biopsy from the uterus confirmed endometriosis. No signs of appendicitis were noted in the appendix; however, endometriosis was noted in the meso appendix.

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Discussion

Acute appendicitis is the leading cause of acute abdominal pain and abdominal surgery worldwide. The aetiology of acute appendicitis is due to obstruction of the lumen of the appendix, most commonly by a faecolith or lymphoid hyperplasia. Histological diagnosis for true appendicitis requires the presence of neutrophilic infiltration of the muscularis mucosa. [1] A host of conditions can mimic appendicitis, namely protozoan infections (amoebiasis, schistosomiasis, ascariasis, enterobiasis), tuber culosis, mucoceles and carcinoid tumours. Endometriosis ranks eighth among cond itions mimicking appendicitis. [2] The meso appendix is the part of the appendix that contains the blood vessels, nerves and lymphatics that supply and drain the appendix. It is also referred to as the mesentery of the appendix, and is usually uninvolved in appendicular pathologies.

Endometriosis is defined as the presence of endometrial glands and stroma outside the uterine cavity. [3] The exact aetiology and pathogenesis of endometriosis are unknown. The two main hypotheses proposed for the development of endometriosis are multipotential mesenchymal cells undergoing metaplasia into endometriosis and endometrial cells being implanted from retrograde men struation through the fallopian tubes. [4] Endometriosis is most commonly found in the gynaecological organs and pelvic peritoneum but may also involve the gastrointestinal system, greater omentum, surgical scars and the mesentery; it is rarely found at distant sites such as the kidney, lungs, skin and nasal cavity. [5] Gastrointestinal tract endometriosis occurs in 3-37% of all cases of endometriosis. Appendiceal endometriosis accounts for about 3% of all gastrointestinal endometriosis and <1% of all cases of endometriosis. [6]

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The diagnosis of endometriosis is made on histological evaluation with findings of endometrial glands and stroma. Intestinal endometriosis often affects the serosa and subserosal layers, but can occasionally be found in the muscularis propria, submucosa and mucosa. [7] Clinically, a third of patients with endometriosis may be asymptomatic; however, the majority are symptomatic with gynaecological symptoms ranging from chronic pelvic pain, dysmenorrhoea, dyspareunia, irregular or heavy menstrual periods and infertility. [8] Gastrointestinal endometriosis presents as rectal bleeding, abdominal cramps, change in bowel habits, and bowel obstruction. Appendiceal endo metriosis presents as acute right iliac fossa pain mimicking appendicitis, lower gastrointestinal bleeding or appendiceal intussusception. There are reports of meso appendiceal endometriosis presenting as appendiceal intussusception but none pre senting as acute appendicitis. [9] This case study, to our knowledge, is the first report of endometriosis of the meso-appendix presenting as acute appendicitis.

The reasons for endometriosis of the app endix or meso-appendix without patho logical signs of appendicitis and lumen obstruction presenting as typical acute appendicitis are not known; oedema and inflammation of the serosa and sur rounding peritoneum may be implicated. However, obstruction of the lumen from an endometrioma or haemorrhage of endometrium in the submucosa are poss ibilities for concomitant pathological findings of both appendicitis and endo metriosis of the appendix.

In a review [10] of 4 670 appendicectomy specimens, 14 cases of endometriosis of the appendix were identified. Of these, 5 (35.7%) had coexistent appendicitis and 7 (50.0%) had evidence of endometriosis only. [10]

Conclusion

The preoperative diagnosis of appendiceal endometriosis is almost impossible, but should be suspected in patients with infertility or cyclic right iliac fossa pain. The diagnosis should also be suspected on colonoscopy in patients with inverted appendices or a bulbous appendiceal orifice. The investigation of choice in patients suspected with endometriosis is laparoscopy, and if there is appendiceal involvement, an appendicectomy is warranted. A patient who has undergone appendicectomy with a histological diagnosis of endometriosis requires referral to a gynaecologist for further management.

True (A) or false (B):

Avoidable factors in maternal deaths

1. In the 2011-2013 Confidential Enquiry into Maternal Deaths in South Africa ~27% of deaths were judged to be avoidable and a further 32% possibly avoidable.

2. In the South African (SA) study published here, avoidable factors were identified in ~49% of deaths.

Teenagers' attitudes to contraception and sexual activity in Kwa-Zulu Natal, SA

3. The percentage of sexually active 13-17-year-olds was 29%.

4. The percentage of teenagers aware of emergency contraception was 35%.

5. Fewer females than males were aware that condoms were protective against sexually transmitted infections.

Endometriosis of the meso-appendix

6. Gastrointestinal endometriosis has been reported in up to 37% of cases of endometriosis.

Postpartum laparoscopic sterilisation

7. Postpartum sterilisation is defined as a sterilisation performed within 24 hours of delivery.

8. In the current study laparoscopic sterilisation was less time-consuming overall than open laparotomy.

9. In the obese patients studied (body mass index >30), open surgery was less time-consuming and involved fewer wound complications.

Eclampsia in rural KwaZulu-Natal, SA

10. The latest Saving Mothers Report of SA (2011-2013) shows that eclampsia accounts for >50% of deaths associated with hypertensive disorders of pregnancy (HDP).

11. HDP account for 40% of maternal deaths in SA, according to the 2011-2013 report.

12. In high-income countries, eclampsia is associated with a death rate of approximately 0.1%.

13. In the cases studied, at least one administrative failing was discovered in 60% of cases.

14. A study is quoted identifying a pre-eclampsia rate among all primigravidae in an SA urban setting of 14%.

Symptomatic pelvic organ prolapse

15. I n the developed world up to 4% of women will undergo a surgical procedure for pelvic prolapse or incontinence.

16. Up to 30% of prolapse procedures performed require repeat procedures.

17. The POP-Q system for describing prolapse, as recommended by the International Continence Society (ICS), is an acronym for the Pelvic Organ Prolapse Questionnaire.

18. Patients with rectocele may experience the need to pass a finger into the vagina and to push down to facilitate emptying of the bowel.

The retained surgical swab

19. A swaboma is the technical term for a retained surgical swab.

20. A retained surgical swab may remain undiagnosed for many years and the radio-opaque marker may disintegrate over time or may become folded, making detection difficult.

References

[1.] Smink DS, Soybel DI. Appendix and appendectomy. In: Zinner MJ, Stanley WA, eds. Maingot's Abdominal Operations. New York: McGraw-Hill, 2007:589-611.

[2.] Akbulut S, Tas M, Sogutcu N, et al. Unusual histopathological findings in appendectomy specimens: A retrospective analysis and literature review. World J Gastroenterol 2011;17(15):1961 1970. DOI:10.3748/wjg.v17.115.1961

[3.] Akbulut S, Dursun P, Kocbiyik A, Harman A, Sevmis S. Appendiceal endometriosis presenting as perforated appendicitis: Report of a case and review of the literature. Arch Gynecol Obstet 2009;280(3):495-497. DOI:10.1007/ s00404-008-0922-y

[4.] Akbulut S, Sevinc MM, Bakir S, Cakabay B, Sezgin A. Scar endometriosis in the abdominal wall: A predictable condition for experienced surgeons. Acta Chirurgica Belgica 2010;110(3):303-307. DOI:10.1080/00015458.2010.11680621

[5.] Tazaki T, Oue N, Ichikawa T, et al. A case of endometriosis of the appendix. Hiroshima J Med Sci 2010;59(2):39-42.

[6.] Gon S, Barui GN, Majumdar B, Baig SJ. Endometriosis of the appendix: A diagnostic dilemma. Indian J Surg 2010;72(1):315. DOI:10.1007/s12262-010-0087-3

[7.] Yantiss RK, Clement PB, Young RH. Neoplastic and pre neoplastic changes in gastrointestinal endometriosis: A study of 17 cases. Am J Surg Pathol 2000;24(4):513-524. DOI:10.1097/00000478-200004000-00005

[8.] Weed JC, Ray JE. Endometriosis of the bowel. Obstet Gynecol 1987;69(5):727-730.

[9.] Lauwers GY, Prendergast NC, Wahl SJ, Bagchi S. Invagination of vermiform appendix. Digestive Dis Sci 1993;38(3):565-568. DOI:1007/BF01316516

[10.] Chandrasegaram MD, Rothwell LA, An EI, Miller RJ. Pathologies of the appendix: A 10-year review of 4670 appendicectomy specimens. J Surg 2012;82:844-847. DOI:10.1111/j.1445-2197.2012.06185.x

S Mewa Kinoo, (1) FCS (SA), MMed; V V Ramkelawon, (2) FCS (SA); B Singh,1 FCS (SA), MD

(1) Department of General Surgery, Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa

(2) Ethekwini Hospital and Heart Centre, Durban, South Africa

Corresponding author: S Mewa Kinoo (smewakinoo@gmail.com)
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Article Details
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Title Annotation:CASE REPORT
Author:Kinoo, S. Mewa; Ramkelawon, V.V.; Singh, B.
Publication:South African Journal of Obstetrics and Gynaecology
Article Type:Case study
Geographic Code:6SOUT
Date:Sep 1, 2016
Words:1576
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