Chronic appendicitis “syndrome” manifested by an appendicolith and thickened appendix presenting as chronic right lower abdominal pain in adults

Chronic appendicitis misdiagnosed as a periappendiceal orifice polyp: a case report

BACKGROUND

Unlike acute appendicitis, chronic appendicitis is characterized by nonspecific abdominal pain and intermittent course. This may lead to late diagnosis or misdiagnosis, with the possibility of serious complications.

CASE REPORT

A male patient of Arab origin aged 55 years had a 2-year history of recurrent episodes of mild pain in the right lower quadrant of the abdomen. The episodes were associated with nausea, chills, and abdominal bloating but no vomiting, rectal bleeding, or weight loss. On examination, the patient showed soft and lax abdomen with mild tenderness in the right lower quadrant, with no organomegaly or abdominal masses. Laboratory findings showed normal complete blood count and C-reactive protein. The patient underwent colonoscopy to rule out malignancy, which showed appendiceal orifice polyp that required resection. The computed tomography scan showed an enlarged appendix with multiple intraluminal dense appendicoliths. The largest stone at the appendiceal orifice measured 1.5 cm × 0.9 cm and was partially protruding within the cecal lumen. The diagnosis of chronic appendicitis was confirmed. The patient underwent appendectomy and was asymptomatic a few days after discharge.

CONCLUSIONS

We are reporting a patient with chronic appendicitis presented with multiple appendicoliths. The patient was initially misdiagnosed as periappendiceal orifice polyp. The current finding highlights the importance of imaging, especially computed tomography in confirming the diagnosis in patients with atypical appendicitis presentation.

A Rare Presentation of Chronic Appendicitis in the Right Upper Quadrant: A Case Report

Chronic appendicitis is a rare cause of chronic abdominal pain that can be difficult to diagnose. We present a patient with chronic right upper quadrant pain that was finally diagnosed as chronic appendicitis. This 71-year-old male had no systemic diseases and presented to our outpatient clinic with right upper quadrant pain for one month. The pain tended to worsen in the early morning but could be relieved by bowel movements, sitting up, or walking. The findings of a physical examination, laboratory data, and abdominal ultrasound were not significant. Upper endoscopy revealed a shallow gastric ulcer at the antrum. However, the abdominal pain was not relieved by esomeprazole. A computed tomography (CT) scan revealed a dilated appendix with some appendicoliths in the retrocecal region. Due to chronic appendicitis, the patient underwent laparoscopic appendectomy, and the histopathological examination of the removed appendix confirmed the diagnosis. The abdominal pain completely resolved after the surgery. Chronic appendicitis should be kept in mind in patients with chronic abdominal pain without a definite diagnosis. This case illustrates that in addition to right lower quadrant pain, chronic appendicitis can also present with right upper quadrant pain or vague abdominal pain. A CT scan is invaluable in the diagnosis of abdominal pain when medical treatment fails to yield improvement.

Clinical, ultrasonographic, and pathologic characteristics of patients with chronic right-lower-quadrant abdominal pain that may benefit from appendectomy

BACKGROUND

Chronic pains of the right lower quadrant of the abdomen (RLQA) remain a challenging problem worldwide, especially in areas with limited technical background; chronic appendicitis is still a subject of controversy. The aim of this study was to analyze the clinical and paraclinical data of patients with chronic pains of RLQA who had an appendectomy performed.

METHODS

During a period of 4 years, all patients presenting with a chronic pain of the RLQA were selected for our study and underwent clinical assessment and systematic ultrasonography of the abdomen; these served as a basis of selecting candidates for appendectomy. The intraoperative findings, histology results, and outcome after appendectomy were analyzed.

RESULTS

Three hundred nineteen patients presented with chronic pains of the RLQA of which 213 could be finally analyzed; their mean age was 15.3 years; 192 patients were females. They had pains for 2-8 years. Echography showed a heterogeneous lesion in the RLQA in 87% of the cases. The operative findings displayed adhesions and other signs of chronic inflammation in 182 cases. Pathological analysis frequently revealed fibrosis and lymphoplasmocytic infiltration indicative of chronic inflammation. Eighty-seven percent of the patients were cured by appendectomy.

CONCLUSIONS

There is a chronic process involving the appendix that occurs in the RLQA of patients with chronic pains, typically the adolescent female. Appendectomy usually solves the problem. The criteria for selection of candidates still need to be identified, but in the absence of laparoscopic facilities, we recommend appendectomy when no other cause for the pain has been identified.

Appendiceal faecaliths are associated with right iliac fossa pain

INTRODUCTION

There is debate over whether a normal-looking appendix should be removed at diagnostic laparoscopy performed for right iliac fossa (RIF) pain. Faecaliths are associated with appendicitis. This study assessed whether there was an association between the removal of normal appendices containing faecaliths and improvement of symptoms.

PATIENTS AND METHODS

Analysis of the histology database for all appendicectomies during 2003-2007 with normal histology, noting presence of a faecalith. Retrospective study using a telephone questionnaire for frequency/duration of pre-operative symptoms, postoperative symptom recurrence, re-admission rates and complications. The faecalith-positive (f(+)) group was compared to a similar control group of patients who had a normal appendix removed which did not contain a faecalith (f(-)). RESULTS Out of 203 appendicectomies performed with normal histology, 26 (13%) were f(+). Of these, 21 responded to the questionnaire. Thirty-one consecutive patients with normal histology and no faecalith were identified. A similar proportion in each group presented with three or more episodes of pain prior to appendicectomy (38% f(+); 39% control). Only one (5%) of the f(+) patients had recurring symptoms after the operation, compared with 14 (48%) of the control group (P = 0.0016). Only one (5%) of the f(+) patients underwent further investigations, compared with 11 (36%) of the control group (P < 0.02). None of the f(+) patients were re-admitted, compared to 19% of the control population. There were no significant postoperative complications in either group.

CONCLUSIONS

Appendiceal faecaliths may be a cause of right iliac fossa pain in the absence of obvious appendiceal inflammation. In this study, the policy of routine removal of a normal-looking appendix at laparoscopy in the absence of any other obvious pathology appeared to be an effective treatment for recurrent symptoms in those cases with a faecalith. Further studies are needed to assess this putative association.

Appendiceal fecalith is associated with early perforation in pediatric patients

PURPOSE

A fecalith is a fecal concretion that can obstruct the appendix leading to acute appendicitis. We hypothesized that the presence of a fecalith would lead to an earlier appendiceal perforation.

METHODS

Between January 2001 and December 2005, the charts of all patients younger than 18 years old who underwent appendectomy at our institution were reviewed. Duration of symptoms and timing between presentation and operation were noted along with radiologic, operative, and pathologic findings.

RESULTS

There were 388 patients who met the study criteria. A fecalith was present in 31% of patients (n = 121). The appendix was perforated in 57% of patients who had a fecalith vs 36% in patients without a fecalith (P < .001). The overall rate of interval appendectomies was 12%. A fecalith was present on the initial radiologic studies of 36% of the patients who had interval appendectomies, and the appendix was perforated significantly sooner in these patients when compared to those without a fecalith (91 vs 150 hours; P = .036).

CONCLUSION

The presence of fecalith is associated with earlier and higher rates of appendiceal perforation in pediatric patients with acute appendicitis. An expedient appendectomy should therefore be performed in the pediatric patient with a radiologic evidence of fecalith.

Outcomes in 74 patients with an appendicolith who did not undergo surgery: is follow-up imaging necessary?

The objective of this study was to report the clinical outcome of patients with an appendicolith on computed tomography (CT) who did not undergo appendectomy on initial presentation. Reports from 45,901 abdominal CT examinations performed between March 2000-March 2004 containing the words "appendicolith" or "fecalith" were identified. Patients with appendicoliths not initially undergoing appendectomy were followed to assess re-presentation with abdominal pain ultimately requiring appendectomy. Seventy-four patients had an appendicolith on CT report, were discharged without surgery, and had clinical follow-up. Fifty-two of 74 (70%) patients had no appendiceal symptoms, were given an alternate diagnosis, and did not return with appendicitis. Twenty-two of 74 (30%) patients were discharged without acute appendicitis but with possible appendiceal symptoms. Five of these 22 (23%) patients returned with pathologically proven acute appendicitis, and all had possible appendiceal symptoms at initial presentation. An appendicolith may be a marker of increased risk for appendicitis but is not an indication for appendectomy.