Endometriosis of the appendix: A diagnostic dilemma

Appendiceal Endometriosis Presenting As Chronic Appendicitis: A Case Report

The origin of endometriosis has multiple theories, with controversy over which may demonstrate the prominent pathophysiology. The most common extra-pelvic organ system affected by endometriosis is the gastrointestinal tract. Gastrointestinal endometriosis (GE) accounts for 3 to 37% of all endometriosis cases, and appendiceal endometriosis is present in around 3% of GE cases, therefore constituting less than 1% of all endometriosis cases. In this report, we present a 24-year-old female with a past medical history significant for endometriosis status post two excisional laparoscopies who presented with eight months' duration of right lower quadrant pain, constant and stabbing, with rebound tenderness. Appendectomy and histopathology demonstrated focal endometriosis, diffuse serosal fibrovascular adhesions involving the appendiceal serosa/subserosa, as well as a dilated lumen filled with hemorrhagic content. When the appendix is not considered in endometriosis pathology, patients are at increased risk for unresolved pain and further laparoscopic procedures. Prophylactic appendectomy appears to be a worthwhile consideration in patients with chronic pelvic pain, given the high frequency of appendiceal pathology.

Appendicular endometriosis: A case report and review of literature

INTRODUCTION

Patients with appendicular endometriosis (AE) constitute <1% cases of all pelvic endometriosis cases. AE presents with pain in right iliac fossa and symptomatically mimics appendicitis and definitive diagnosis is possible only after histopathological examination of excised appendix.

PRESENTATION OF CASE

In this case report, we present a rare case of appendicular endometriosis in a young woman suffering from pain in right iliac fossa and periumbilical region (on/off) for the past one year. She had a past history of infertility. Blood investigations were normal and CT scan of abdomen demonstrated findings suggestive of appendicitis. Laparoscopic appendicectomy was performed, which revealed 2 cm tumor-like mass (1.5 cm diameter) present at the tip of appendix involving the mesoappendix. There was no ascites, peritoneal or omental deposits or any signs of inflammation. Post-operative recovery was good. Dissected appendix specimen was sent for histopathological examination which confirmed endometriosis of appendix.

DISCUSSION

Gastrointestinal endometriosis (GE) accounts for 3-37% of all endometriosis cases, whereas AE is present in only ∼3% of all GE cases and constitutes <1% of all the endometriosis cases. AE frequently involves tip and body of the appendix. The layers of appendix most commonly affected are muscular and seromuscular (∼2/3rd cases), followed by the serosa (∼1/3rd cases).

CONCLUSION

Thus, appendicular endometriosis is a rare entity and should be included in differential diagnosis in young women presenting with pain in right iliac fossa and having history of infertility.

Leiomyomatosis peritonealis disseminata associated with appendiceal endometriosis: a case report

INTRODUCTION

Leiomyomatosis peritonealis disseminata is a very rare benign condition of the peritoneal cavity that may mimic peritoneal carcinomatosis or metastatic leiomyosarcomas. It mainly develops in association with pregnancy, but is also rarely associated with endometriosis.

CASE PRESENTATION

A 31-year-old Asian woman presented to our hospital with abdominal pain in the right lower quadrant. Her abdominopelvic computed tomography scan showed a 1.2cm-sized nodule at the appendiceal tip, but no other abnormal findings. We suspected acute appendicitis and performed an exploratory laparoscopy. Her appendix was enlarged at the tip portion. Also noted were blood-colored fluid collections in her pelvic cavity and bilateral ovarian cysts. Additionally, several small whitish firm solid nodules, ranging from 0.5 to 1.0cm in size, were present on her pelvic peritoneum. Her histological examination confirmed that the endometriosis of her appendix coexisted with leiomyomatosis peritonealis disseminata.

CONCLUSIONS

We report a case involving a 31-year-old woman with acute symptoms of endometriosis of the appendix associated with leiomyomatosis peritonealis disseminata. Appendiceal endometriosis with leiomyomatosis peritonealis disseminata presenting as acute appendicitis is extremely rare. To the best of our knowledge, this is the first such case reported in the literature.

An unusual cause of acute appendicitis: Appendiceal endometriosis

INTRODUCTION

While endometriosis is a common disorder in women of reproductive age, appendiceal endometriosis accounts for less than 1% of all pelvic endometriotic lesions. Appendiceal involvement may present as acute appendicitis and definitive diagnosis is made by only postoperative histological examination.

PRESENTATION OF CASE

In this study, we present two cases of female patients who underwent an appendectomy presumed diagnosis as acute appendicitis, and a histopathological examination of the retrieved specimen revealed appendiceal endometriosis.

DISCUSSION

Endometriosis is defined as the presence of ectopic endometrial tissue outside the lining of the uterine cavity. Gastrointestinal endometriosis is observed in 3-37% of all endometriosis cases, whereas appendiceal endometriosis accounts for only about 3% of gastrointestinal endometriosis. Appendiceal endometriosis is usually asymptomatic, although it sometimes causes abdominal cramps, nausea, chronic pelvic pain, lower gastrointestinal hemorrhage, intussusception, perforation, or acute appendicitis.

CONCLUSION

Appendiceal endometriosis is an unusual histopathological finding. A preoperative diagnosis is difficult, but this condition should be considered when women of childbearing age present with clinical symptoms of acute appendicitis.