Stump appendicitis: A diagnostic dilemma

Case Report

Stump appendicitis: A diagnostic dilemma

Majid R. Wani *, Juneed M. Lanker, Prasanna Kumar Reddy

Department of Surgical Gastroenterology and Minimal Access Surgery, Apollo Hospitals, Greams Road, Chennai, India

1. Case presentation

1.1. Case 1

A 53-year-old female presented with complaints of pain in theright iliac fossa for the past 2 days, and was associated withfever and loss of appetite. There was no history of vomiting,loose motions, malena, dysuria or frequency of micturition.Positive clinical and laboratory findings included right lowerquadrant tenderness and leukocytosis of 13,500 cells/mm3.The patient had undergone laparoscopic appendectomy,elsewhere, 7 months back. Postoperative period was unevent-ful. Two and a half months after appendectomy, the patientdeveloped fever, vomiting and pain abdomen. The patient wasagain hospitalised, and ultrasonography of the abdomen wasdone, which revealed gallstone disease, withmild thickness ofgallbladder wall. She was posted for surgery, and laparoscopiccholecystectomywas performed. Shewas put on IV antibioticsfor 3 days. After that the patient recuperated well. A monthafter laparoscopic cholecystectomy, she again started havingpain in the abdomen, which was managed by oral antibioticsand analgesics, on and off.

A computed tomogram of the abdomen was done (Fig. 1),which revealed dilated and thickened appendiceal stump,with stranding of the surrounding tissues. The patient wassubsequently posted for a diagnostic laparoscopy afterinformed consent.

Intra-operative findings included dense adhesions aroundthe ileocecal region. There was a 2–3 cm long inflamedappendicular stump (Fig. 2), with periappendiceal abscessformation (Fig. 3). The appendicular stump was doubly ligatedat the base with the help of an endoloop (Fig. 4), divided andextracted out. The specimen was sent for histopathology.Postoperative periodwas uneventful. Oralswere started on the2nd postoperative day, and the patient was discharged on the3rd postoperative day. Histopathology revealed features ofacute appendicitis.

1.2. Case 2

A 21-year-old male presented to our unit with complaints ofpain in the abdomen for the past 2 days duration, whichstarted in the periumblical region, and migrated to right iliacfossa. It was associated with fever, loss of appetite and two

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a r t i c l e i n f o

Article history:

Received 25 April 2015

Accepted 5 May 2015

Available online 12 June 2015

Keywords:

Appendicitis

Post-appendectomy appendicitis

Stump appendicitis

a b s t r a c t

Stump appendicitis is the inflammation of the appendiceal stump left after an appendecto-

my. It can represent a diagnostic dilemma if the attending physician or surgeon is not aware

of this uncommon entity. Prompt recognition of this disease is important, as delay in the

treatment may result in complications such as perforation, abscess formation and sepsis.

We report a series of cases of stump appendicitis that presented to our unit over the last

5 years.

# 2015 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights

reserved.

* Corresponding author. Tel.: +91 9940635386.E-mail address: drmajidwani@yahoo.in (M.R. Wani).

Available online at www.sciencedirect.com

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journal homepage: www.elsevier.com/locate/apme

http://dx.doi.org/10.1016/j.apme.2015.05.0050976-0016/# 2015 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights reserved.

episodes of vomiting. He gave history of laparoscopicappendectomy. One month after appendectomy, he gothigh-grade fever and severe pain in right lower abdomen.He was subjected to diagnostic laparoscopy, and drainage ofintra-abdominal abscess, localised to right iliac fossa, wasdone. He was put on IV antibiotics, and was discharged on 5thpostoperative day.

The present clinical and laboratory findings includedtemperature of 101 8F, tenderness in right iliac fossa, leuco-cytosis of 16,100 cells/mm3 and polymorphs of 85%. CECTabdomen revealed collection in right iliac fossa and dilated,inflamed appendicular stump. Diagnostic laparoscopy corre-lated with imaging studies, and aspiration of pus was done,followed by completion appendectomy. The patient's condi-tion dramatically improved on first postoperative day and hewas discharged on second postoperative day. Histopathologyreports confirmed the diagnosis.

1.3. Case 3

A 60-year-old female, a known diabetic, presented to our unit,with complaints of pain for the past 3 days in the right lowerabdomen. It was associatedwith fever and loss of appetite. Shegave no history of vomiting, loose motions, malena or urinarytract symptoms. She had undergone open appendectomy2 years back and hysterectomy 12 years back. On examination,she was febrile, mildly dehydrated and had severe tendernessin right iliac fossa. Laboratory findings included leucocytosis of14,800 cells/mm3, with polymorphs of 91%. CECT abdomenwas done, which revealed large intra-abdominal collectionand dilated, thick walled appendicular stump, with strandingof surrounding tissues. Diagnostic laparoscopy was done,which revealed pus in right iliac fossa and severe adhesionsof small bowel and omentum to anterior abdominal wall. Puswas aspirated and tube drain was inserted with difficulty.Stump appendectomywas deferred due to the above technicaldifficulties and was done electively after 6 weeks.

2. Discussion

The first person who gave description of the stumpappendicitis, for patients who had previously undergonean appendectomy for appendicitis, was Rose in 1945.1 Stumpappendicitis is a rare, delayed complication of appendecto-my. Its incidence is one in about 50,000 cases,2 although theincidence might be higher due to underestimation of theentity. Surgeons or physicians need to be more aware thatstump appendicitis exists, and must consider it in the

[(Fig._1)TD$FIG]

Fig. 1 – CECT abdomen showing dilated and thickenedappendiceal stump, with stranding of surrounding tissues.[(Fig._2)TD$FIG]

Fig. 2 – Large inflamed appendiceal stump (arrow).

[(Fig._3)TD$FIG]

Fig. 3 – Suppuration (vertical arrow) around inflamedappendiceal stump.

[(Fig._4)TD$FIG]

Fig. 4 – Ligation of residual appendix stump with anendoloop.

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differential diagnosis of patients with right iliac fossa paindespite history of appendectomy. The presenting symptomsare often indistinguishable from those of primary appendi-citis. There is the notion that laparoscopic appendectomy isa risk factor for stump appendicitis. This assumption iscontradicted by a study of Liang et al. that shows that about66% of stump appendicitis cases follow open appendecto-my.3 There are three basic methods for treating the stump ofthe appendix: simple ligation, ligation and inversion andinversion without ligation.4 No agreement exists on which isthe best method. Several authorities recommend a stumpshorter than 3–5 mm at appendectomy, in order to avoid thiscomplication. Identification of the appendiceal-cecal junc-tion is mandatory for this, as many appendectomies arebeing carried out without proper dissection of the retrocecalsubserous appendix. For the proper identification, it isimportant to dissect and ligate the recurrent branch of theappendiceal artery, and to follow the taenia coli to the base ofthe appendix.5,6 Treatment of stump appendicitis can beperformed laparoscopically, as laparoscopy often helps inthe differential diagnosis.7 Surgeons need to have a height-ened awareness of the possibility of stump appendicitis,identify the appendiceal base correctly and remove theappendix in toto, leaving a stump of <3 mm.

Conflicts of interest

The authors have none to declare.

Acknowledgements

Wearehighly obliged to our patientswho consented to publishthis manuscript.

r e f e r e n c e s

1. Rose T. Recurrent appendiceal abscess. Med J Aust.1945;32:659–662.

2. Mangi AA, Berger DL. Stump appendicitis. Am Surg. 2000;66(8):739–741.

3. Liang MK, Lo HG, Marks JL. Stump appendicitis: acomprehensive review of literature. Am Surg. 2006;72(2):162–166.

4. Nicolau AE. Laparoscopic appendectomy. Chirurgia (Bucur).2011;106(4):495–503.

5. Ismail I, Iusco D, Jannaci M, et al. Prompt recognition ofstump appendicitis is important to avoid seriouscomplications: a case report. Cases J. 2009;2:7415.

6. Munteanu R, Copãescu C, Liåescu M, et al. Laparoscopicappendectomy – considerations in about 1000 cases. Chirurgia(Bucur). 2005;100(6):541–549.

7. Dragomirescu C, Copãescu C, Munteanu R, et al. Laparoscopicreoperations. Chirurgia (Bucur). 2001;96(5):469–477.

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