AJR 2000; 175:503-504
© American Roentgen Ray Society
Acute Edematous Stump Appendicitis Diagnosed Preoperatively on Sonography
Matteo Baldisserotto1,
Silvio Cavazzola1,
Leandro Totti Cavazzola1,2,
Maria Helena Itaqui Lopes3 and
Cláudio
Corá Mottin4
1
Department of Ultrasound in Medicine, Hospital
São Lucas da
Pontifícia, Universidade
Católica do Rio Grande do Sul, Av. Ipiranga,
6680/209, Porto Alegre, RS, 90.8610-000, Brazil.
2
Present address: Department of Surgery, Hospital de
Clínicas de Porto Alegre, Rua Ramiro Barcelos,
2350/201, Porto Alegre, RS, 90.035-003, Brazil.
3
Department of Internal Medicine, Hospital São
Lucas da Pontifícia, Universidade
Católica do Rio Grande do Sul, Porto Alegre,
RS, 90.610-000, Brazil.
4
Department of Surgery, Hospital São Lucas da
Pontifícia, Universidade
Católica do Rio Grande do Sul, Porto Alegre,
RS, 90.610-000, Brazil.
Received August 31, 1999;
accepted after revision December 20, 1999.
Address correspondence to M. Baldisserotto, Rua
Eça de
Queiróz, 384, Apto. 502, Porto Alegre, CEP
90.670-020, Brazil.
Introduction
The inflammation of the appendiceal stump after appendectomy is a rare
disease, and its diagnosis is not routinely suspected in patients who have
previously undergone appendectomy. Few cases are reported in the medical
literature, and only two of these reported cases were diagnosed through CT
before surgery [1].
The role of sonography in the diagnosis of acute appendicitis is well
established, but its usefulness in the diagnosis of acute edematous stump
appendicitis has not yet been assessed. This paper reports a patient with an
early inflammation of the appendiceal stump that was preoperatively diagnosed
using sonography. It also describes the corresponding sonographic
findings.
Case Report
A 13-year-old girl presented with a history of abdominal pain associated
with nausea, vomiting, and hyperthermia (38-39°C). She reported that the
pain had started 15 days before the consultation and that it was increasing in
intensity. At the time of the consultation, it was localized in the right
lower quadrant and radiated to the right leg. She mentioned having undergone
appendectomy in another hospital 2 months before the current consultation.
Physical examination revealed guarding over the right lower quadrant during
abdominal palpation. Signs of peritoneal irritation in the vicinity of the
surgical scar were present. Laboratory analysis showed leukocytosis with a
left shift of the WBC (14,000/µL) with predominance of immature forms).
Sonography showed increased thickness (8 mm) of the residual cecal appendix
(Figs. 1A and
1B), two enlarged lymph nodes,
and a small amount of fluid in the right iliac fossa.
At video laparoscopy, a residual appendiceal stump was found and removed
(Fig. 1C).
Discussion
The inflammation of the appendiceal stump is a rare late complication after
appendectomy. Its exact rate of incidence and its prevalence in the population
are not accurately defined. A review of medical literature to this date has
produced reports of only 15 cases of edematous stump appendicitis. Four of
these are recent and occurred after laparoscopic appendectomy
[2,
3]. In the 15 cases reported,
the time of onset ranged from 3 months to 34 years after appendectomy
[1,
4]. In eight cases, the
technique used was laparoscopic appendectomy and simple ligation of cecal
appendix without stump invagination
[4,
5]. A long residual amputation
stump, which might be left behind in laparoscopic surgery, is considered a
prerequisite for the development of this disease
[6].
Results of CT have been reported for only five cases so far
[1,
3,4,5,
7]. In only two was the
diagnosis of edematous stump appendicitis suggested before surgery by CT
findings. For one of these cases, CT showed a distended appendiceal stump
[4], whereas for the other it
revealed the presence of an abscess in the form of an appendiceal stump
[1]. In the other three cases,
CT findings were not specific and revealed an ileocecal mass or pelvic
abscess, and diagnosis was confirmed only during surgery.
In the patient reported here, sonography before surgery revealed the
appendiceal stump with initial signs of edema of the mucosa. The changes
observed were similar to those in acute edematous appendicitis but were found
in a short segment of the cecal appendix. Sonography has become the method of
choice for the diagnosis of acute appendicitis since Puylaert's technique was
adopted [8]. However, its
usefulness in the identification of changes in the appendiceal stump has not
been assessed before. In the patient discussed here, sonography proved capable
of identifying initial inflammatory changes present in acute edematous stump
appendicitis. We suggest, therefore, that early diagnosis of stump
appendicitis may be made by sonography alone, as long as the examiner suspects
this disease and is familiar with its sonographic findings. It is thus
possible to avoid a delayed diagnosis or the use of more sophisticated
examinations such as CT.
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Introduction
Case Report
