Stump appendicitis with appendicolith

Clinical History

A 39-yearold female patient who underwent appendicectomy two months before presented with severe stabbing pain in right iliac fossa near the scar site for one week. She reported two episodes of vomiting. She denied history of fever. Her menstrual periods were regular.

Imaging Findings

Ultrasound of the abdomen showed a well-defined hypoechoic structure (lumen diameter of approx. 6 mm) near the caecal base with an echogenic centre. The structure showed minimal vascularity and there were surrounding inflammatory changes. Correlated CT showed a well-defined hypodense structure located adjacent to the caecal base with a hyperdense centre. Minimal surrounding fat stranding was noted.

Discussion

Stump appendicitis is a rare complication of appendectomy. It occurs when the residual appendix becomes inflamed. Because of the low index of suspicion the diagnosis often is delayed. Complications routinely seen after appendectomy include wound infection, retrocaecal abscess, intestinal perforation, bleeding etc. However, stump appendicitis is very rare with an incidence of about 1 in 50, 000 cases. [1] A review of medical literature to this date has produced reports of only 15 cases of oedematous stump appendicitis. [2] Clinical presentation can be acute, subacute or even chronic with patients presenting as early as 2 months to 50 years post surgery. Patients usually present with periumblical pain radiating to the right lower quadrant with guarding and rebound tenderness along with nausea, vomiting and pyrexia. Diagnosis of stump appendicitis can be made by ultrasound and computed tomography. Ultrasound reveals a thick appendicular stump with oedema of the caecum with or without fluid in the right iliac fossa. CT findings are almost similar to appendicitis. If the stump left behind is long enough, it may present as a tubular contrast enhancing structure arising from the caecum with adjacent fat stranding. CT may also show pericaecal abscess or phlegmon and thickening of the wall. When oral contrast leaks into the expected location of the appendicial origin it is called the “arrowhead” sign. In rare cases like in ours, also find an appendicolith/faecolith can be found. Several causes have been attributed to stump appendicitis, and these include: insufficient inversion of the stump, incomplete removal of the distal remnant, long proximal remnant of the appendix, and partial laparoscopic or laparotomic appendectomy. Among all the possible causes, laparoscopic appendectomy is gaining a lot of the blame. And the reasons include: smaller field of vision during surgery, lack of three-dimensional view and absence of tactile feedback all leading to the increased risk of leaving behind a longer appendix stump which may result in chronic inflammation. The conclusion is that stump appendicitis should be considered as a possible differential in any patient presenting with abdominal pain in the right iliac fossa with a history of appendectomy. Ultrasound and CT are both useful for reaching a diagnosis. Complications that can occur include small bowel obstruction, haemorrhage, peritonitis, abscess formation and very rarely even malignant transformation. [3-5]

Differential Diagnosis List

Final Diagnosis

Stump appendicitis

URL:	https://www.eurorad.org/case/11676
DOI:	10.1594/EURORAD/CASE.11676
ISSN:	1563-4086