at SciVerse ScienceDirect

International Journal of Surgery 10 (2012) 425e428

REVIEW

Contents lists available

International Journal of Surgery

journal homepage: www.thei js .com

Review

Stump appendicitis: A review

Hala Kanona a, Ahmad Al Samaraee b,*, Colin Nice c, Vish Bhattacharya c

aCity General Hospital, Stoke-on-Trent, Staffordshire ST4 6QG, UKbGeneral Surgery, South Tyneside District Hospital, South Shields NE34 0PL, UKcQueen Elizabeth Hospital, Gateshead NE9 6SX, UK

a r t i c l e i n f o

Article history:Received 9 May 2012Received in revised form14 July 2012Accepted 15 July 2012Available online 27 July 2012

Keywords:Stump appendicitisAppendicitisRecurrent appendicitisAppendicular stump

* Corresponding author.E-mail address: ahmadas@doctors.org.uk (A. Al Sa

1743-9191/$ e see front matter � 2012 Surgical Assohttp://dx.doi.org/10.1016/j.ijsu.2012.07.007

a b s t r a c t

Acute appendicitis is perhaps the commonest cause of acute abdomen and surgical intervention in theform of open or laparoscopic appendicectomy. Stump appendicitis is an uncommon late complication ofappendicectomy; where inflammation occurs in the remaining appendicular stump. Delayed diagnosis ofthis condition may result in serious complications. This literature review has looked into the clinicalpresentation, diagnosis and treatment of Stump appendicitis.

� 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction

Acute appendicitis is perhaps the commonest cause of acuteabdomen that is responsible for over 40,000 hospital admissionsper year in England, and more than 2,00,000 operations per year inthe United States.1,2 The lifetime risk of having appendicitis is 8.6%for males and 6.7% for females; while the lifetime risk of appen-dicectomy is 12.0% for males and 23.1% for females.3 Short termcomplications of appendicectomy include; intra abdominal collec-tion, bleeding and wound infection. While late complicationsinclude; small bowel obstruction, hernia, and less commonly;stump appendicitis (SA).

Stump appendicitis was first described by Rose in 1945; it isdefined as the interval re-inflammation of any residual appendicealtissue after appendicectomy.4,5 Stump appendicitis is thought to beunderreported in literature, and its true incidence and exact causesremain unclear due to difficulty in making the diagnosis.6 Thisliterature review has looked into the clinical presentation, diag-nosis and treatment of SA.

2. Literature search methods

Electronic search of databases: Pubmed/Medline, Ovid, EMBASE, in addition tothe search engines Google/Google Scholar and Bing. The keywords used were:stump appendicitis, appendicitis, recurrent appendicitis and appendicular stump.

maraee).

ciates Ltd. Published by Elsevier Lt

The search was limited to articles published in English language only. Searches werescreened and those studies thought to be relevant had full text versions retrieved.The references of all retrieved texts were searched for further relevant studies.

3. Results

Literature review revealed (51) reported cases of SA (Table 1).The patients’ age rangewas (8e72 years); of which (67%)weremaleand (33%) were female. The commonest presenting symptom wasabdominal pain (right lower quadrant pain (59%), non specificabdominal pain (16%), and central abdominal pain radiating to theright lower quadrant (14%)). The initial appendicectomy operationwas open in (63%) and laparoscopic in (37%) of the patients. Thetime interval between the initial operation and re-operation wasbetween (9 weeks and 50 years). (47%) of the patients had preop-erative Computed Tomography (CT) scan. This was diagnostic of SAin about (27.5%) of the cases, the remainder showed non-specificinflammatory changes. On the other hand, (15.8%) of the patientshad preoperative abdominal Ultrasound Scan (USS), this wasdiagnostic in (37.5%) of the cases. Histopathological diagnosis of SAwas reported in (61%) of the reviewed cases only, none of whichsuggested Crohn’s disease or malignancy. The appendicular stumpsize range was (0.5 cme6.5 cm).

4. Discussion

The length of the human appendix has a very wide range inliterature. Samaha et al., 2011 reported a unique case of

d. All rights reserved.

Table 1Summary of the reviewed literature.

Author, year, country Age Gender Initialoperation

Main symptoms Imaging diagnostic(Dx) Non specific (ns)

Interval timemonth/year(m/y)

Histopathologyreport available

Stumplength

Roberts et al 20117

(USA) e 2 cases33 F Open Abdominal pain CT (Dx) 20y Yes 5 cm48 M Laparoscopic Right lower quadrant

(RLQ) painCT (Dx) 3m Yes 2 cm

Tang et al 20108

(China) - 3 cases14 M Open Abdominal pain CT (ns) 5y Yes 3 cm11 M Open No abdominal pain, febrile CT (ns)

Fistulography (Dx)2m Yes ?

13 F Open Abdominal pain CT (ns)Barium enema(Dx)

10m Yes 4 cm

Parameshwarappa et al20109 (India)

18 M Laparoscopic Lower abdominal pain CT (Dx) 1y No ?

O’Leary et al 201010 (Ireland) 43 M Open Right upper quadrant(RUQ) pain

USS (Dx) 10y Yes 2.5 cm

Gasmi et al 200911 (Tunisia) 9 M Open RLQ pain, pyrexia USS (Dx) 3y No 3.5 cmIsmail et al 200912 (Italy) 25 M Open Central abdominal pain

radiating to RLQUSS (ns)CT (ns)

1y Yes 6 cm

Al-Dabbagh et al 200913 (UK) 41 M Open Abdominal pain, nausea USS (Dx) 14 m Yes 4.5 cmPatel et al 200914 (USA) 8 M Laparoscopic RLQ pain CT (ns) 2m Yes ?Mentes et al 200815 (Turkey) 32 M Open RLQ pain USS (ns) 12y Yes 1.5 cmJacombs et al 200816 (Australia) 25 M Open RLQ pain CT (ns) 10y Yes 5 cmTruty et al 200817 (USA) 32 M Open RLQ pain, nausea CT(Dx) 1y Yes 3.5 cmOsime et al 200818 (Nigeria) 37 F Open RLQ pain, nausea none 7y No 4 cmWaseem et al 200719 (USA) 15 M Laparoscopic Central abdominal pain

radiating to RLQCT (ns) 2y No 0.6 cm

Gifford et al 200620

(USA) e 4 cases28 M Laparoscopic RLQ pain CT (ns) 2y No 3.5 cm26 F Open Central abdominal pain

radiating to RLQBarium followthrough (Dx)

1y No 2.5 cm

31 M Laparoscopic RLQ pain CT (ns) 4m Yes 3.5 cm62 F Laparoscopic RLQ pain CT (ns) 1y Yes 5.5 cm

Uludag et al 200621 (Turkey) 47 M Open Central abdominal painradiating to RLQ, pyrexia

CT (Dx) 20y Yes 2 cm

Liang et al 20065 (USA) 32 F Laparoscopic RLQ pain, nausea CT(Dx) 5m Yes 4 cmAschkenasy et al 200522 (USA) 27 M Open RLQ pain CT (Dx) n/a No ?Roche-Nagle et al 200523 (UK) 35 M Open RLQ pain, pyrexia CT (ns) 14y Yes 4 cmShin et al 200424 (USA) 41 M Laparoscopic RLQ pain CT (Dx) 2m Yes 6.5 cmWatkins et al 200425 (USA) 62 F Laparoscopic Abdominal pain, nausea,

vomiting, diarrhoeaCT (Dx) 9m Yes 5.5 cm

Clark et al 200426 (UK) 34 F Open RLQ pain, pyrexia CT (ns) 2m Yes 3 cmDurghun et al 200327 (Turkey) 68 F Open Abdominal pain, pyrexia Nil 8m No 3 cmMarcoen et al 200328

(Belgium) e 2 cases49 M Laparoscopic RLQ pain CT (ns) 6m No 4 cm16 F Laparoscopic RLQ pain, febrile Nil 15m No 5 cm

Nahon et al 200229 (France) 33 M Open RLQ pain, pyrexia, diarrhoea Colonoscopy (ns)CT (ns)

18y Yes ?

Gupta et al 200030 (USA) 11 M Open RLQ pain, pyrexia, vomiting CT (ns) 1y No 4.5 cmMangi et al 200031

(USA) e 3 cases43 F Open RLQ pain Barium study (ns)

Colonoscopy (Dx)40y Yes 0.5 cm

64 M Open RLQ pain Barium study (ns)Colonoscopy (Dx)

? Yes 0.6 cm

63 F Open ? ? 50y Yes ?Baldisserotto et al 199932 (Brazil) 14 F Open RLQ pain, pyrexia USS (Dx) 2m No 0.8 cm

(scan)Erzurum et al 199733 (USA) 11 F Open RLQ pain, radiating to the back CT (Dx) 12m No 3.5 cmRao et al 199734 (USA) 39 F Open Lower abdominal pain CT (Dx) 34y Yes ?Walsh et al 199735 (Australia) 72 F Laparoscopic Central abdominal pain

radiating to RLQ, vomitingnone 5m Yes 2.5 cm

Greenberg et al 199636 (USA) 31 M Laparoscopic RLQ pain CT (?) ? No ?Milne et al 199637 (UK) 25 M Laparoscopic Central abdominal pain

radiating to RLQ, nausea,anorexia, pyrexia

none 18 m Yes 3.2 cm

Fillippi et al 199438 (France) 25 M Laparoscopic Abdominal pain, pyrexia USS (ns),CT (ns)

2y Yes ?

Devereaux et al 199439 (USA) 49 M Laparoscopic RLQ pain Nil 9w Yes 2 cmThomas et al 199440 (USA) 53 F Open RLQ and flank pain,

diarrhoea, nausea,USS (ns)CT (Dx)

21 y No ?

Wright et al 199441

(USA) e 2 cases35 M Laparoscopy Recurrent symptoms Colonoscopy (Dx) 2 months No 4.5 cm48 M Laparoscopy RLQ pain, pyrexia CT and

Colonoscopy (Dx)15 m No 4 cm

Feigin et al 19936 (USA) 26 M Open RLQ pain, pyrexia none 1y Yes ?Harris et al 198942 (USA) 26 M Open Central abdominal pain

radiating to RLQCT (ns) 10y No ?

Siegal et al 195943

(USA) e 3 cases68 M Open Lower abdominal pain none 8y Yes 2 cm65 M Open RLQ pain, febrile none 33y ? 2 cm63 M Open Abdominal pain none 3y ? 0.5 cm

H. Kanona et al. / International Journal of Surgery 10 (2012) 425e428426

REVIEW

Fig. 1. Computed tomography (CT) performed following oral and intravenous contrastadminstration showing features of stump appendicitis; inflammatory changes in thefat surrounding a thickened appendix stump (arrow).

H. Kanona et al. / International Journal of Surgery 10 (2012) 425e428 427

REVIEW

a “Megaloappendix” with an exceptional length of 55 cm.44 Thebase of the appendix lies at the junction of the taenia coli on theposteromedial surface of the caecum, while the appendicular tiplies in various positions.

SA happens due inflammation and perforation of the stumppossibly due topoor blood supply or lodgingof a fecolith, though theexactmechanism isnotveryclear. It hasbeen recommended that thelength of an appendicular stump should be less than (0.5 cm) todecrease the chances of developing SA.31,8 Table 1 shows that SA canoccur in stumps that are as short as (0.5 cm). Therefore, it is essentialfor the operating surgeon to identify the appendicular base clearlybefore performing appendicectomy. This can be done by tracing thetaenia coli till the base of the appendix, or locating and ligating therecurrent branch of the appendicular artery that marks the appen-dicular base.25,41,45 However, this is not always an easy task, as it canbe really challenging to accurately locate the true appendicular base,especially in the presence of severe local inflammation or in caseswhere the appendix lies in retro-caecal or sub-serosal positions.11

The narrow fields of vision and absence of tactile feedback inlaparoscopic surgery was suggested by some studies to be a signif-icant factor that may play a role in the misidentification of the baseof the appendix, which can increase the risk of developingSA.13,21,32,34 We do not totally agree with this assumption especiallythat our review has shown that SA can happen even after openappendicectomy. It is a well known fact that laparoscopy providesa wider view of the surgical field; in addition, it helps in excludingother pathologies.

It seems that SA could happen after open or laparoscopicappendicectomy; surgical technique and the operative experience,in addition to the anatomical variations and the complexity of casesat the inital appendicectomy, may all play a role in the developmentof SA at later stages.

It is not clear from our review whether invagination or simpleligation of the appendicular stump at the initial appendicectomy canincrease the riskofdevelopingSA, since this information ismissing inthe vastmajority of the reviewed cases. Some prospective trials haveshown that there is no clear benefit in invaginating the stump.27

Therefore, the decision to perform either remains controversial.31

The use of stapling devices at open or laparoscopic appenide-cectomy; where the appendix can be stapled-off at its base leavingvirtually no appendicular tissue at all, could be considered as anoption to prevent the possibility of developing SA . Whether thisoption is practically and economically viable, the answer could onlybe obtained through prospective trials, which is rather difficult inthe emergency settings like acute appendicitis.

� Clinical Presentation

It is not surprising that the clinical suspicion of having recur-rence of appendicitis (i.e. SA) would be very low in daily clinicalpractice. SA may be presented in much similar way to the classicclinical picture of acute appendicitis like right lower or centralabdominal pain, nausea and vomiting, anorexia, pyrexia, localperitonism, and leucocytosis.25 Also, it can be presented as nonspecific abdominal pains or chronic non-healing appendicectomyincision or formation of an infected fistula.8

Delay in the diagnosis of SA can lead to serious complicationslike stump gangrene, perforation and peritonitis. In addition, SAmight be associated with adenocarcinoma of the appendicularstump, which is extremely rare.40

� Diagnosis

Diagnosis is guided by a high index of clinical suspicion sup-ported by investigations such as abdominal USS or CT scan.

Colonoscopy and barium follow through have also been used inestablishing the diagnosis.5 Ultrasound may identify a tubularremnant arising from the caecum in the right iliac fossa orextending retrocaecally or subhepatically.10,32 Reported CTfeatures are inflammatory changes or abscess centred on theappendix stump (Fig. 1). Also, peri-caecal or right para-colic fluid,thickening of the caecum or an inflammatory mass involving theterminal ileum and caecum.24,33,34 Stump phlebolith has also beendescribed as a CT finding.34 However, the diagnosis may be verychallenging, and can only be established at laparotomy or duringdiagnostic laparoscopy. Our review has surprisingly indicated thatabdominal USS may well have a high accuracy in establishing thediagnosis of SA. This conflicts with most clinicians’ experience inthe setting of diagnosis of appendicitis, where CT scan is thepreferred imaging modality. However; this could represent theimaging technique used in the reported cases only, and might notreflect the true abdominal USS sensitivity in this prospect. Inaddition, the use of abdominal USS as the diagnostic imagingmodality in a significant number of patients may reflect theavailability of local resources.

� Treatment

Surgical resection seems to be the treatment of choice in thereported cases. However, the decision of using laparoscopic and/oropen approach in this prospect has not been emphasized in thereviewed literature. In practice, the choice of surgical approachdepends on various factors like the patient’s clinical condition andthe local expertise/resources.

When the stump could be identified, then surgical resection ofthe inflamed appendicular stump with or without invagination isrecommended (i.e. completion appendicectomy). In cases withperforated stump, inflammatory involvement of the caecum, orsuspicion of malignancy or diverticulitis, then Ileocaecal resectionor right hemicolectomy with or without ileostomy should beconsidered accordingly.7,25,31

H. Kanona et al. / International Journal of Surgery 10 (2012) 425e428428

REVIEW

5. Conclusion

Stump appendicitis is a late complication of open or laparo-scopic appendicectomy; where inflammation occurs in theremaining appendicular stump. Delay in the diagnosis of SA mayresult in and serious complications like stump gangrene, perfora-tion and peritonitis. A high index of clinical suspicion combinedwith the appropriate imaging can help in establishing an earlydiagnosis of SA and reduce the risk of complications. Although it isnot that common, SA may well be considered as one of the differ-ential diagnoses of acute right lower abdominal pain in patientswith history of appendicectomy. Obviously, other more commoncauses should be excluded first.

Key points

� Stump appendicitis is a late and potentially seriouscomplication of open or laparoscopic appendicectomy.

� Diagnosis of stump appendicitis is very challenging. Highindex of clinical suspicion combined with the appropriateimaging may help in establishing the diagnosis.

� Regardless of the approach or technique used, operatingsurgeons should make sure that the appendicular base isidentified cleary before performing appendicectomy. It isadvisable that the remaining appendicular stump lengthshould be < 0.5 cm.

� Stump appendicitis may well be considered as one of thedifferential diagnoses of acute right lower abdominal painin patients with history of appendicectomy. Obviously,other more common causes should be excluded first.

Ethical approvalNone.

FundingNone.

Author contributionMs Hala Kanona: Literature search, writing, data analysis.Mr Ahmad Al Samaraee: Literature search, writing, design.Dr Colin Nice: Writing, image providing.Mr Vish Bhattacharya (Consultant Surgeon): comments/

corrections and final approval before submission for publications.

Conflicts of interestNone.

References

1. Humes DJ, Simpson J. Acute appendicitis. BMJ 2006;333:530e4.2. Sim KT, Picone S, Crade M, Sweeney JP. Ultrasound with graded compression in

the evaluation of acute appendicitis. J Natl Med Assoc 1989;81:954e7.3. Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis

and appendectomy in the United States. Am J Epidemiol 1990;132:910e25.4. Rose T. Recurrent appendiceal abscess. Med J Aust 1945;32:659e62.5. Liang MK, Lo HG, Marks JL. Stump appendicitis: a Comprehensive review of

literature. Am Surgeon 2006;72:162e6.6. Fegin E, Carmon M, Szold A, Seror D. Acute stump appendicitis. The Lancet

1993;341:757.7. Roberts KE, Starker LF, Duffy AJ, Bell RL, Bokhari J. Stump appendicitis:

a surgeons dilemma. JSLS 2011;15:373e8.

8. Tang XB, Qu RB, Bai YZ, Wang WL. Stump appendicitis in children. J PaediatricSurg 2011;46:233e6.

9. Parameshwarappa S, Rodrigues G, Prabhu R, Sambhaji C. Stump appendicitisfollowing laparoscopic Appendecetomy. SQUMJ 2010;11:112e4.

10. O’Leary DP, Myers E, Coyle J, Wilson I. Case report of recurrent acute appen-dicitis in a residual tip. Cases J 2010;3:14.

11. Gasmi M, Fitouri F, Sahli S, Hamzaoui JR. A stump appendicitis in a child: a casereport. Italian J Pediatrics 2009;35:35.

12. Ismail I, Iusco D, Jannaci M, Navarra GG, Grassi A, Bonomi S. Prompt recognitionof stump appendicitis is important to avoid serious complications: a casereport. Cases J 2009;2:7415.

13. Al-Dabbagh AK, Thomas NB, Haboubi N. Stump appendicitis:A diagnosticdilemma. Tech Coloproctol 2009;13:73e4.

14. Patel RP, Kan JH. Stump appendicitis. Pediatr Radiol 2009;39:306.15. Mentes O, Zeybek N, Oysul A, Onder SC, Tufan T. Stump appendicitis, rare

complication after appendicectomy: report of a case. Turkish J Trauma EmergSurg 2008;14:330e2.

16. Jacombs A, Webb G, Leibman S. Right iliac fossa pain 10 years after appendi-cectomy and the diagnosis of stump appendicitis. ANZ J Surg 2008;78:711e2.

17. Truty MJ, Stulak JM, Utter A, Solberg JJ, Degnim AC. Appendicitis after appen-dicectomy. Arch Surg 2008;143:413e5.

18. Osime CO, Moses MI. Stump appendicitis- a rarely considered diagnosis. Am JCase Rep 2008;10:52e4.

19. Waseem M, Devas G. A child with appendicitis after appendicectomy. J EmergMed 2008;34:59e61.

20. Shaun M, Gifford MC, Bowman J, Perry B, Richards M. Right lower quadrantpain in a Young Adult male. Curr Surg 2006;63:318e21.

21. Uludag M, Isgor A, Basak M. Stump appendicitis is a rare delayed complicationof appendicectomy: a case report. World J Gastroenterol 2006;12:5401e3.

22. Aschkensay MT, Rybicki FJ. Acute appendicitis of the appendiceal stump.J Emerg Med 2003;28:41e3.

23. Roche-Nagle G, Kilgallen GC, Caldwell M. Stump appendicitis: a rare butimportant entity. Surgeon 2005;3:53e4.

24. Shin LK, Halpern D, Weston SR, Meiner EM, Katz DS. Prospective CT diagnosisof stump appendicitis. AJR 2005;184:62e4.

25. Watkins BP, Kothari SN, Landercasper J. Stump appendicitis: case report andreview. Surg Laparosc Endosc Percutan Tech 2004;14:167e71.

26. Clark J, Theodoru N. Appendicitis after appendicectomy. J R Soc Med2004;97:543e4.

27. Durgun AV, Baca B, Ersoy Y, Kapan M. Stump appendicitis and generalizedperitonitis due to incomplete appendicectomy. Tech Coloproctol 2003;7:102e4.

28. Marcoen S, onghena T, Van Loon C, Vereecken L. Residual appendicitisfollowing incomplete laparoscopic appendicectomy. Acta Chir Belg 2003;103:517e8.

29. Nahon P, Nahon S, Hoang JM, Traissac L, Delas N. Stump appendicitis diagnosedby colonoscopy. Am J Gastroenterol 2002;97:1564e5.

30. Gupta R, Gernshiemer J, Golden J. Abdominal pain secondary to stumpappendicitis in a child. J Emerg Med 2000;18:431e3.

31. Mangi AA, Berger DL. Stump appendicitis. Am Surg 2000;66:739e41.32. Baldisserotto M, Cavazzola S, Cavazzola LT, Lopes MHI, Mottin CC. Acute

Edematous stump appendicitis diagnosed preoperatively on Sonography. AJR2000;175:503e4.

33. Erzurum VZ, Kasirajan K, Hasmi M. Stump appendicitis: a case report. J Lap AdvSurg Tech 1997;7:389e91.

34. Rao PM, Sagarin MJ, McCabe CJ. Stump appendicitis diagnosed preoperativelyby computer tomography. Am J Emerg Med 1997;16:309e11.

35. Walsh DC, Roediger WE. Stump appendicitis - a potential problem after lapa-roscopic appendicectomy. Surg Laparosc Endosc 1997;7(4):357e8.

36. Greenberg JJ, Thomas TJ. Appendicitis after laparoscopic appendicectomy:a warning. J Laparoendo Surg 1996;6:185e7.

37. Milne AA, Bradbury AW. ’Residual’ appendicitis following incomplete laparo-scopic appendicectomy. Br J Surg 1996;83(2):217.

38. Filippi de la Palavesa MM, Vaxmann D, Campos M. Appendiceal stump abscess.Abdom Imaging 1996;21:65e6.

39. Devereaux DA, McDermott JP, Caushaj PF. Recurrent appendicitis followinglaparoscopic appendicectomy. Dis Colon Rectum 1994;37:719e20.

40. Thomas SE, Denning DA, Cummings MH. Delayed pathology of the appendicealstump: a case report of stump appendicitis and review. Am Surg1994;60:842e4.

41. Wright TE, Diaco JF. Recurrent appendicitis after laparoscopic appendectomy.Int Surg 1994;79(3):251e2.

42. Harris CR. Appendiceal stump abscess ten years afetr appendicectomy. Am JEmerg Med 1989;7:411e2.

43. Siegal B, Wolcott MW, Gables C. Appendicitis after appendicectomy. J.A.M.A1959;170:1152.

44. Samaha AA, Tawfik AS, Abbas TO, Abdelhamid A. Megaloappendix: a casereport. Case Rep Surg 2011. http://dx.doi.org/10.1155/2011/729304.

45. Green JM, Peckler D, Scuhmer W. Incomplete surgical removal of the appendix;its complications. J Int Coll Surg 1958;29:141e6.