Case Study: Recurrent and cyclic appendicitis in females: suspect pelvic endometriosis

Summary

Endometriosis is a well-recognized gynecological condition in the reproductive age group. Literature on appendiceal endometriosis, which is a rare condition, is inadequate. The presentation to general surgeons may be atypical and pose diagnostic difficulty. Thus, a thorough history, gynecological assessment, radiology and serology may be very useful, and a definitive diagnosis is likely to be established only by the histological examination of the appendicectomy specimen. Here we shall discuss the case of a 32-year-old female.

Background

Endometriosis is the presence of endometrial glands and stroma outside the uterine cavity and musculature. It has been found in about 4% of women during tubal ligation, but also in up to 50% of teens who have intractable dysmenorrhea , and it results in pelvic pain in up to 50% of these patients . According to the Journal of Medical Case Reports, “Recent studies reported the prevalence of appendiceal endometriosis to be around 0.8%. Appendiceal endometriosis not only may cause symptoms of acute appendicitis but also is known to cause cyclic and chronic right lower quadrant pain, melena, lower intestinal hemorrhage, cecal intussusceptions and intestinal perforation, especially during pregnancy .” Here I shall describe a case of a woman with appendiceal endometriosis that presented as recurrent and periodical appendicitis. The pathology was detected incidentally during routine histopathology, and accordingly, hormone therapy was given.

Case Presentation

A 32-year-old female P1+0, presented with recurrent right iliac fossa pain for the last 8 months. Her previous childbirth was a normal vaginal delivery and was uneventful. The pain was related to her painful periods and was cyclical. No lump but tenderness was elicited at the McBurney’s point. There was no fever, but nausea and loss of appetite were present. No organomegaly was found.

Investigationsendometriosis1samanta

  1. Urine and stool chemical and microscopic examination: normal
  2. Urine microbiology: no growth
  3. USG lower abdomen: enlarged uterus, small cysts in both ovaries
  4. Blood routine tests: neutrophilic leucocytosis
  5. Serology CA-125: elevated (done post-operatively), WIDAL: not contributory
  6. Urine pregnancy test: negative

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Differential Diagnosisendometriosis2samanta

  1. Foreign bodies like stone, parasite or fecolith of the appendix
  2. Polyps and neoplasia
  3. Cecal intussusceptions
  4. Intestinal perforation
  5. Tuberculosis
  6. Crohn’s disease
  7. Infectious or ischemic enteritis or colitis

Treatment

Laparoscopic appendicectomy was performed, followed by hormone therapy after gynecological assessment.

Outcome and Follow-Up

Postoperatively, the patient recovered with no residual pain. Today, two years after the patient’s appendicectomy, her gynecologic record remains clear, and she recently has conceived without any complications.

Discussion

The appendix contained a small (2 mm) blackish nodule in the body. Appendiceal endometriosis was confirmed by histopathology. There were active endometrial glands and stroma on the serosal aspect as well as within the muscular layer. According to literature, about half of endometriosis of the appendix involves the body and half involves the tip of the appendix. According to the Journal of Medical Case Reports, “Muscular and seromuscular involvement occurs in two-thirds of patients, while the serosal surface is involved in only one-third of patients. The mucosa is not involved, but Langman et al. found that the submucosa was involved in one-third of patients with endometriosis of the appendix. In their series, the endometriotic foci were also found in the muscle, serosa and subserosa. There was no correlation between the location of the endometriotic foci and the patients’ symptoms. Therefore, mucosal or submucosal endometriosis is much more likely to mimic primary inflammatory diseases such as Crohn’s disease, infectious or ischemic enteritis or colitis, or mucosal prolapse than endometriosis of the outer bowel wall .” The present patient is categorized in the typical form of appendiceal endometriosis, since small nodules were present in the wall of the appendix while the endometrial glands were surrounded by endometrial stroma. Further studies, like elevated serum CA-125 level, supported the diagnosis of pelvic endometriosis in this patient, and hormone therapy was suggested.

Learning Points/Take Home Messages

With recurrent and cyclic appendicitis, appendicectomy alone may not treat completely!

About The Author

Dr-Swapan-Samanta-64x80
Dr. Samanta, MBBS, MD is currently a consultant at Suraksha diagnostic PVT. LTD. Kolkata, India for histopath, cytopath and hematology. His other interests are: oncopathology, bone marrow and neuropathology.

Sources:
Cramer DW, Missmer SA: The epidemiology of endometriosis. Ann N Y Acad Sci 2002. 955:11-22. http://www.ncbi.nlm.nih.gov/pubmed/11949940

Laskou S, Papavradmidis TS, Cheva A, Michalopoulos N, Koulouris C, Kesisoglou I, Papavramidis S: Acute appendicitis caused by endometriosis: a case report. Journal of Medical Case Reports 2011, 5:144, doi:10.1186/1752-1947-5-144 http://www.jmedicalcasereports.com/content/5/1/144

Berker B, Lashay N, Davarpanah R, Marziali M, Nezhat CH, Nezhat C: Laparoscopic appendectomy in patients with endometriosis. J Minim Invasive Gynecol 2005. 12: 206-209. http://www.ncbi.nlm.nih.gov/pubmed/15922976

Nakatani Y, Hara M, Misugi K, Korehisa H: Appendiceal endometriosis in pregnancy. Report of a case with perforation and review of the literature. Acta Pathol Jpn 1987, 37:1685-1690 http://www.ncbi.nlm.nih.gov/pubmed/3324642

Langman J, Rowland R, Vernon-Roberts B: Endometriosis of the appendix. Br J Surg 1981, 68:121-124. http://onlinelibrary.wiley.com/doi/10.1002/bjs.1800680218/abstract

Idetsu A, Ojima H, Saito K, et al. Laparoscopic appendectomy for appendiceal endometriosis presenting as acute appendicitis: report of a case. Surg Today 2007, 37:510-513 http://www.ncbi.nlm.nih.gov/pubmed/17522773

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One Comment

  1. upasana pandit
    Posted Sep 2013 at 1:59 pm | Permalink

    Very well written article on a very atypical presentation of Endometriosis

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