A 44-year-old woman presents to the emergency department (ED) with a 12-hour history of acute-onset abdominal pain accompanied by nausea, vomiting, fever, sweats, and chills. The pain is localized in the right lower quadrant and is described as dull and burning. The patient denies any trauma, melena, hematochezia, or hematemesis. She has a past medical history of endometriosis, colitis, and irritable bowel syndrome. She has a history of multiple intra-abdominal surgeries, including a total abdominal hysterectomy, a bilateral salpingo-oophorectomy, and a laparoscopic appendectomy.
On the physical examination, the patient is alert and cooperative though ill-appearing. She has a temperature of 102.6°F (39.2°C), a blood pressure of 130/89 mm Hg, a heart rate of 92 bpm, an oxygen saturation of 98% while breathing room air, and a respiratory rate of 22 breaths/min. Her abdomen is tender in both lower quadrants, with the tenderness being greater on the right side. Guarding and rebound tenderness are present at the McBurney point, and positive psoas and obturator signs are noted. There is no tenderness in the right upper quadrant, with a negative Murphy sign. Hypoactive bowel sounds are auscultated. Her lungs are clear to bilateral auscultation, and her heart rate, rhythm, and heart sounds are normal.
Laboratory tests performed in the ED show an elevated white blood cell (WBC) count of 22.5 x 109/L with a left shift (89% segmented neutrophils). Her hemoglobin is 16.0 g/dl; her hematocrit is elevated at 47.2%; and her urinalysis, amylase and lipase levels, and complete metabolic panel are all within normal limits.
Despite the absence of right upper quadrant tenderness, a right upper quadrant ultrasound is initially performed and is noted to be negative for cholelithiasis. An upright abdominal radiograph shows increased stool in the descending colon but no evidence of dilated bowel loops, air-fluid levels, or free air. A contrast-enhanced computed tomography (CT) scan of the abdomen is obtained (Image 1).
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What is the diagnosis?
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HINT
This is an uncommon complication of appendectomy.
Authors:
Jason Romesburg, DO,
Medicine Intern,
New Hanover Regional Medical Center,
Wilmington, NC
Khursheed Imam, MD,
Staff Radiologist,
Center for Advanced Imaging,
Roanoke, VA
eMedicine Editors:
Brady Pregerson, MD,
Depts. of Emergency Medicine,
Cedars-Sinai Medical Center,
Los Angeles, CA,
Tri-City Medical Center,
Oceanside, CA
Rick G. Kulkarni, MD,
Assistant Professor,,
Yale School of Medicine,
Section of Emergency Medicine,
Department of Surgery,
Attending Physician,
Medical Director,
Department of Emergency Services,
Yale-New Haven Hospital, CT
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Stump appendicitis: The CT scan (Image 1) shows a blind-end tubular structure dilated to 13 mm in diameter in the expected location of the appendix. The structure measures 1.8 cm in length and extends to the surgical clips in the pelvis. The structure has thickened walls and adjacent fatty inflammatory changes. There is also mild thickening of the cecal tip. These CT findings, combined with the patient’s clinical presentation, are consistent with appendicitis of the patient’s remnant stump.
Appendectomy is one of the most commonly performed surgeries in the United States, with more than 250,000 procedures performed annually. Stump appendicitis is an uncommon complication of the procedure that develops with acute inflammation of the residual appendix in a patient who has had a prior appendectomy. The complication typically occurs in patients in whom the appendix was not completely removed in the initial procedure. In 36 reports of this rare condition, the disease occurred anywhere from 2 months up to 50 years after the initial appendectomy, with 1 year being the median interval.1 The clinical presentation is similar to initial appendicitis, with right lower quadrant pain, anorexia, vomiting, and fever. Right lower quadrant tenderness, often accompanied by a positive psoas sign, obturator sign, or Rovsing sign, may be noted on the physical exam. The WBC count is usually elevated, with the mean being 14.9 x 109/L.1 Stump appendicitis is not usually considered as the etiology for right lower quadrant pain in patients with a prior history of appendectomy; as a result, a delay in treatment may occur, which may explain why the rate of perforation for stump appendicitis approaches 70%.1
Some reports have suggested that the laparoscopic appendectomy technique is associated with an increased incidence of stump appendicitis, because it may be easier to incorrectly identify the appendiceal base; however, the most recent comprehensive review of the literature on stump appendicitis by Liang et al reveals that only 34% of stump appendicitis cases follow laparoscopic appendectomy, and 66% of cases follow open resection.1 Irrespective of the technique, not adequately identifying the base of the appendix and failing to amputate the entire appendix can lead to stump appendicitis. Methods for identifying the base of the appendix that decrease the likelihood of leaving residual appendiceal tissue include tracing the taenia coli of the cecum to the appendix or dissecting and ligating the recurrent branch of the appendiceal artery, which marks the true base of the appendix.1
A CT scan with oral and intravenous (IV) contrast can diagnose stump appendicitis. The findings may include pericecal inflammatory changes, abscess formation, fluid in the right paracolic gutter, or cecal wall thickening. A cecal arrowhead sign, indicating inflammation at the base of the appendix, may be visualized. A specific diagnosis can be made if inflammatory changes surround the visualized stump, as in this case. When the diagnosis is made, the patient should proceed to the operating room for a complete appendectomy.
Clinicians and radiologists should consider the diagnosis of stump appendicitis when examining patients who are status post-appendectomy and present with appendicitis-like symptoms consistent with an acute infectious etiology in the right lower quadrant. A CT scan of the abdomen should be considered, to allow for earlier diagnosis of this uncommon complication, as well as to avoid the relatively higher rate of perforation and increased morbidity associated with a late diagnosis. The patient in this case was taken to the operating room and had an uneventful completion of her appendectomy with removal of the remaining, infected stump.
References
Liang MK, Lo HG, Marks JL. Stump appendicitis: a comprehensive review of literature. Am Surg 2006 Feb;72(2):162-6. [MEDLINE: 16536249]
Uludag M, Isgor A, Basak M. Stump appendicitis is a rare delayed complication of appendectomy: A case report. World J Gastroenterol 2006 Sep 7;12(33):5401-3. [MEDLINE: 16981278]
