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CASE REPORT – OPEN ACCESSInternational Journal of Surgery Case Reports 4 (2013) 371– 374

Contents lists available at SciVerse ScienceDirect

International Journal of Surgery Case Reports

j ourna l ho me page: www.elsev ier .com/ locate / i j scr

n unsuspected clinical condition: Appendicitis of appendicularesidual, three cases report

ermán Míngueza,∗, Rubén Gonzaloa, Andrea Tamargoa, Estrella Turienzoa, Alicia Mesab,ino Vazqueza

General and Digestive Surgery Service, Hospital Universitario Central de Asturias, Calle de Celestino Villamil s/n, 33006 Oviedo, Asturias, SpainRadiology Service, Hospital Universitario Central de Asturias, Calle de Celestino Villamil s/n, 33006 Oviedo, Asturias, Spain

r t i c l e i n f o

rticle history:eceived 27 November 2012eceived in revised form 26 January 2013ccepted 30 January 2013vailable online 9 February 2013

eywords:tump appendicitisppendicular remanent

ncomplete appendectomy

a b s t r a c t

INTRODUCTION: Stump appendicitis is a rare complication of appendectomy unusually included in thedifferential diagnosis. This is found in appendectomized patients with similar symptoms to those of aprevious appendicitis.PRESENTATION OF CASE: We present three cases, two women and a man of 67, 30 and 24 years old,respectively. They underwent surgery at our centre and their appendectomies presented technical dif-ficulties: problems when identifying the appendicular base or the complete appendicular structure. Inthe first case, diagnosis and therapy were performed with laparoscopy. The second case was diagnosedby an abdominal ultrasound (US) which revealed a tubular structure with thickened walls. An abscesswas observed in the computed tomography (CT) scan for the third case and a laparotomy revealed theretained appendix.DISCUSSION: Although there are several factors that can contribute to this rare pathology, the main causeof stump appendicitis is the persistence of a large appendicular remnant. CT and US are very useful

diagnosis tools. Treatment consists to a completion appendectomy of the stump which can be carriedout by an open or a laparoscopic approach.CONCLUSION: In this rare pathology a prior history of appendicectomy can delay the diagnosis andincrease its associated morbidity and even mortality. In patients with abdominal pain in the right lowerquadrant and previous appendectomy, it is important to include this pathology in the differential diag-

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. Introduction

Although appendectomy is initially a simple technique it is notree of complications, one of them is appendicitis of appendicularemnant.

Inflammation of the appendicular stump is quite rare, through-ut the English medical literature there are only 63 cases described.

delayed identification of this condition implies an increase in theumber of complications that arise.

We describe three new cases of residual appendix appendicitis.

. Cases

.1. Case 1

A 67-year-old woman was admitted into emergency depart-

ent with a 12-h history of diffuse abdominal pain. Her most

utstanding medical history was a stable ischaemic cardiopathynd open appendectomy for gangrenous appendix 7 months ago.

∗ Corresponding author. Tel.: +34 661400524.E-mail address: dacusto generation@hotmail.com (G. Mínguez).

210-2612/$ – see front matter © 2013 Surgical Associates Ltd. Published by Elsevier Ltdttp://dx.doi.org/10.1016/j.ijscr.2013.01.026

treatment and thus avoid complications.013 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

At that time the patient had presented with an abscess adja-cent to appendix, making difficult to identify the appendicularbase.

Abdominal examination revealed diffuse tenderness, McBur-ney’s incision scar and increased peristalsis. Due to uncontrolledpain, it was decided to observe the patient for further assessment12 h later. Diffuse tenderness persisted at re-examination after 12 hin both iliac fosses, with tenderness and rebound in the right lowerquadrant (RLQ). Patient’s blood test showed 6900/�L leucocyteswith neutrophil (79%).

An abdominal CT was requested (Fig. 1A and B); it reported athickening of the caecum, inflammatory changes of the pericecal fatand a tubular structure. A small appendicular stump was suspectedalthough terminal ileitis was not rejected.

A laparoscopic exploration was performed and, having dividedadhesions around the pericecal area, a hard and inflamed 2 cmappendicular stump was excised and extracted (Fig. 2).

During postoperative recovery she presented with precordialpain treated with nitrates. An ECG did not reveal enzymatic alter-

ations until the 5th day and she was transferred to the cardiacdepartment. She had no abnormality at abdomen site and wasdischarged with the diagnosis of stump appendicitis and unstableangina on postoperative day 12.

. All rights reserved.

CASE REPORT – OPEN ACCESS372 G. Mínguez et al. / International Journal of Surgery Case Reports 4 (2013) 371– 374

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After the second surgery, the patient recovered well and left thehospital on the 10th day.

Pathology reports confirmed severe stump appendicitis in allthe three cases.

Fig. 1. (A and B) Case 1, abdominal CAT diagnosis: tubular structure, appare

.2. Case 2

A woman 30-year-old with a 12-h history of abdominal pain inLQ was admitted. She had undergone an open appendectomy 6onths before due to retrocecal appendicitis with multiple adhe-

ions to the cecum. The appendicular stump has not been invertedn prior surgery.

Abdominal examination showed a former McBurney’s scar, bothenderness and rebound in RLQ, 18,500 leucocytes/�L with neu-rophil (89%). An abdominal US revealed a tubular structure arisingn the caecum of retrocecal origin, with thickened walls and hyper-chogenity of local fat compatible with stump appendicitis (Fig. 3).

The patient underwent an urgent laparotomy. A retrocecalbscess was found close to a 3-cm appendicular stump. An appen-ectomy of the stump and abscess drainage was performed.ostoperative course was uneventful and she was discharged 6 daysfter admission.

.3. Case 3

A 24-year-old man was admitted to our centre with a compli-

ated appendicitis with abscess. A laparoscopic appendectomy andbscess drainage were performed and a retro-ileal appendix wasetermined.

Fig. 2. Appendicular stump, Case 1, after removal.

ppendicular stump 1, thickening of the caecum 2, pericecal fat thickening 3.

Twenty-four hours after surgery, despite antibiotic treat-ment, the patient had 38 ◦C temperature, pain in the inferiorhemiabdomen with rebound, tenderness, leucocytosis (leucocytes12,000 �L; neutrophils 87%) and increasing C reactive protein(CRP): 26.28 mg/L. An abdominal US revealed an enlarged smallbowel with liquid inside and decreasing peristalsis; thickened iliacfossa with hyperechogenity, neither free liquid nor collections.

A conservative approach was adopted with antibiotic treatment.Due to a lack of response, an abdominal CT was performed twodays later: a 9 cm × 3.5 cm × 5 cm collection was identified, locatedin the mesentery, between aorta, mesentery vessels and under theduodenum, associated with inflammatory changes in the local fatand a small amount of free liquid in the right parietocolic area andpelvis.

A median infraumbilical laparotomy was carried out: it wasidentified an abscess at the root of the mesentery that requireddrainage as well as an appendicular remnant that was removed.

Fig. 3. Abdominal ecography, Case 2: with tubular structure depending on caecum1. Hyperechogenicity of local fat, 2.

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CASE REPORTG. Mínguez et al. / International Journ

. Discussion

Appendectomy is one of the most frequent abdominal emer-ency surgeries.1 Complications in the procedure can be classifiednto two groups: the early ones: post-operative haemorrhage,

ound infection, intraabdominal abscesses and the later ones:dhesions, nerve entrapment signs, eventrations and stumpppendicitis.1,2 This last seems to be a rare event: around 70 casesave been described since the first published by Rose in 1945.3

his low frequency together to the fact that it is probably an underiagnosed entity make clear the lack of series to measure its real

ncidence. The described interval between the first surgery and theevelopment of the symptoms is between 4 days and 50 years.4 Inur third case, symptoms started 24 h after the first surgery.

The main cause for stump appendicitis is the persistence of aarge appendicular remnant, this should be <3 mm5 because anppendiceal stump larger than 5 mm is a possible reservoir forppendicolith and may get blocked, inflamed or damaged causingathology; other causes of stump appendicitis are an incompleteemoval of the appendix and the incomplete inversion of thetump.1,6 The presence of local inflammatory changes with severeedema, pericecal abscesses (first and third case), local peritonitis,dhesions, retrocecal or subserosal appendix localization (secondase) are related factors leading to a wrong identification of theppendiceal base which, at the same time, can lead to the incom-lete resection of the appendix.2,7

No an agreement on whether the stump inversion makes ushink that the ligation is the result of technical difficulties, but wean’t consider it the reason for an appendicitis of the remnat [5].

Although there has been an increasing incidence of this pathol-gy during the last years which can be linked to the increasing use ofaparoscopic approach, nothing can be proved. In that sense, mostf the referred cases presented an open approach (58.3% laparo-omy vs. 31.6% laparoscopy).2,4 This relationship is likely to beue to its own limitations: limited field of vision and a lack ofense of touch and depth. In our opinion the main factor coulde a wrong identification of the appendicular base; it would be

mproved following the colic tenias until getting to the appendicu-ar base and then ligating and resecting at this level.8 The fact of notaving identified the appendicular base indicates the conversion to

aparotomy.4

Stump appendicitis clinical presentation is similar to that of aevere appendicitis: all cases present abdominal pain (81% locatedn the RLQ with tenderness and rebound); nausea and vomitingre present in 90%; anorexia and temperature are also relatedactors9,10; leucocytosis appears in 85% of the patients. The sur-eon usually does not include this pathology in the differentialiagnosis, this issue cause a delayed identification and increasedate of complications, so stump perforation is found in 36% of casesnd gangrenous appendicitis in 6.6%, being associated or not to anbscess.4

Diagnosis by US is quite complicated. Our second case was diag-osed by this and a thickened appendicular stump which revealed

nflammatory changes in the pericecal fat was observed. Otherwise thickening of the caecum or free liquid can be seen.6 Abdomi-al CT provides the greatest amount of information, indirect signsf stump appendicitis are generally depicted: thickening of cae-um walls, inflammatory changes in the pericecal fat, presencef appendicolith, pericecal abscess and liquid in the parieto-olic area, etc. In some cases, the appendicular stump is directlyisualized.11

Despite all the diagnostic techniques, sometimes it is not possi-

le to reach a definite diagnosis; in those cases a laparoscopy givesn improved chance of examination while being also therapeutic.n the first case we confirmed the diagnosis with laparoscopy,nd resection of the stump after a proper identification of the

PEN ACCESSurgery Case Reports 4 (2013) 371– 374 373

appendicular base, plus drainage of the abscess, were performed.This is the initial treatment: appendectomy of the stump after aproper identification of the appendicular base. It can be performedin an open or laparoscopic intervention (there are as many as 8cases described using this option).8 More aggressive treatmentsare applied such as ileocecal resection when diagnosis is delayedand the pathology has more time to progress.

4. Conclusion

Appendicitis of the appendicular stump is a rare event that takesplace after inflammation of the large residual appendicular stump.This can be avoided by proper identification of the appendicularbase in the first surgery. Clinical findings are similar to that of theprevious appendicitis. A delayed diagnosis must be avoided and,in order to achieve this, imaging techniques such as US, CT andlaparoscopic examination should be used. This last one may alsobe therapeutic. When a patient present with symptoms of acuteappendicitis and had a prior history of difficult appendectomy, oneshould incorporate this diagnosis into the list of possible entities torule out.

Conflicts of interest

Authors state not to have any conflicts of interests.

Funding

None.

Ethical approval

Written informed consent was obtained from patients for pub-lication of this report and accompanying images. A copy of thewritten consent is available for review by the Editor-in-Chief ofthis journal on request.

Author contributions

Mínguez G., Gonzalo R. and Tamargo A. were designed and wrotethe paper, Mínguez G. reviewed the bibliography, Mesa A. con-tributed the radiology imaging, Turienzo E. corrected the paper,and Vazquez L. who is the chief surgeon of the service approvedthe final version of the paper for publication.

All authors read and approved the paper’s final version.

Acknowledgement

Maria Varela M.D. for written assistance.

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