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Case Report |
1 Department of Radiology, Winthrop-University Hospital, 259 First Street,
Mineola, NY 11501.
2 Department of Surgery, Winthrop-University Hospital, Mineola, NY 11501.
3 Division of Gastroenterology, Hepatology, and Nutrition, Department of
Internal Medicine, Winthrop-University Hospital, Mineola, NY 11501.
4 Department of Emergency Medicine, North Shore University Hospital, Manhasset,
NY, 11030.
Received February 20, 2004;
accepted after revision April 30, 2004.
Address correspondence to D.S. Katz
(dsk2928{at}pol.net).
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On admission, the patient was afebrile and his vital signs were otherwise normal. Physical examination revealed moderate to severe tenderness in the right abdomen and right flank without evidence of rebound, guarding, or other peritoneal signs. Routine laboratory studies were remarkable for a WBC count of 13,400/mm3 with 88% neutrophils. Urinalysis was negative.
A CT scan of the abdomen and pelvis was performed with oral and IV contrast, which showed a tubular structure extending from the base of the cecum, with an enhancing wall and stranding of the adjacent fat, consistent with an inflamed appendiceal stump (Fig. 1A). There were also findings representing the surgical staple line from the recent appendectomy (Fig. 1B). A preoperative diagnosis of stump appendicitis was made on the basis of the CT study.
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Laparoscopic exploration performed 4 hr after completion of the CT scan showed a 6.5-cm-long inflamed appendiceal stump, with associated retrocecal inflammatory changes but no abscess. A laparoscopic stump appendectomy was performed uneventfully, along with partial resection of the mesoappendix (Fig. 1C). Stump appendicitis was also confirmed on gross pathologic and histologic examination of the resected specimen. No evidence of gross perforation was present. The patient developed a transient adynamic ileus on postoperative day 5 and was discharged 72 hr later.
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The clinical presentation of stump appendicitis may be acute or subacute [3] and can occur as early as 2 months to 50 years after initial appendectomy [3, 4]. Patients range in age from 11 to 72 years [5, 6]. Its true incidence and prevalence are unknown, but stump appendicitis is thought to be underestimated in the literature [1, 2].
Failure to resect the appendix at its base appears to be necessary for stump appendicitis to occur [4, 6, 7]. Stump appendicitis can be found in patients who have undergone open or laparoscopic appendectomies. Eleven of 17 cases of stump appendicitis have occurred after open procedures, with the earliest report from 1945 [4]. No uniform consensus is available in the surgical literature as to which surgical technique is preferable to reduce the risk of stump appendicitis: simple ligation of the appendix or stump inversion into the cecum [3]. Thomas et al. [2] found seven cases of stump appendicitis in which the stump was ligated but not inverted. More recently, two cases of stump appendicitis identified by Mangi and Berger [3] had undergone stump inversion at the initial appendectomy.
Laparoscopic appendectomy is now a widely accepted surgical technique to treat appendicitis instead of an open approach for a variety of reasons, including decreased length of hospital stay, decreased postoperative pain, and smaller surgical scars. However, the potential limitations of laparoscopy include a smaller field of view, more difficult depth perception, and the absence of tactile feedback, necessitating a more careful dissection technique near the cecal wall, all of which increase the risk for incomplete appendectomy [6]. The failure to identify the base of the appendix is believed to be an indication for conversion from a laparoscopic to an open procedure [3]. Although no formal studies have been performed to determine whether the incidence of stump appendicitis has increased with the more widespread use of laparoscopic appendectomy, several authors believe this is the case [6, 7]. Although anecdotal and coincidental, a few days after our patient presented with stump appendicitis, a CT scan performed on a different patient clearly depicted an otherwise normal residual appendiceal stump (Fig. 2).
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A history of previous appendectomy may delay the correct diagnosis of stump appendicitis in a patient presenting with signs and symptoms of a right lower quadrant inflammatory process, and the correct diagnosis may only be determined after perforation of the appendiceal stump has occurred [5]. CT findings may not be as specific as those seen in our patient, and awareness that stump appendicitis can occur, combined with a high index of suspicion, may be needed to suggest the diagnosis. CT findings in the handful of cases described in the literature include pericecal inflammatory changes, abscess formation, fluid in the right paracolic gutter, cecal wall thickening, and an ileocecal mass [1, 4-6, 8]. A specific diagnosis can be made preoperatively when inflammatory changes surround a distended appendiceal stump [2].
A stump that is long enough to be identified as such prospectively on CT may not be present, and the stump may be obscured by local inflammation. Possibly, thin-section axial reconstructions performed using an MDCT data set can be helpful if this diagnosis is considered or if the CT findings are equivocal on initial image review.
To our knowledge, only two cases have been reported in which CT was used to correctly diagnose stump appendicitis prospectively [1, 2]. Rao et al. [1] describe a 39-year-old woman with a history of appendectomy 34 years earlier, in whom both a cecal "arrowhead sign," indicating inflammation at the base of the appendix, and an appendicolith in the stump were present on CT. At surgery, a periappendiceal stump abscess with cecal perforation was found, and distal ileal and right colonic resection was performed with primary anastomosis of the ileum to mid transverse colon [1]. In a case reported by Thomas et al. [2], CT in a 53-year-old woman with a history of appendectomy 21 years earlier showed pericecal fat inflammation and a tubular, retrocecal structure adjacent to the right psoas muscle, which was contiguous with a small abscess. Stump appendectomy and abscess drainage were performed at the exploratory laparotomy [2]. Presumably, open procedures were performed in both patients to address the stump appendicitis as opposed to laparoscopy, which was used in our patient.
A single case of stump appendicitis has been diagnosed preoperatively using sonography [8]. A thickened appendiceal stump was identified in a 13-year-old girl in whom an appendectomy was performed 2 months earlier; the appendiceal stump, measuring 8 mm in diameter, was identified, along with enlarged right lower quadrant lymph nodes and fluid in the right iliac fossa [8].
Although rare, a diagnosis of stump appendicitis should be considered when a patient with a history of appendectomy presents with signs and symptoms similar to appendicitis. All patients who have undergone appendectomy are potentially at risk. Although not proven, we and other authors believe that with the increasing use of laparoscopic appendectomy, stump appendicitis may become a more frequently encountered problem in clinical practice. Increased awareness of stump appendicitis and its CT findings will raise the awareness of this diagnosis and hopefully expedite and improve proper patient management.
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