Acute Perforated Appendicitis Associated with Appendiceal Diverticulitis in a Young Man: A Case Report with Literature Review

Acute Appendicitis or Appendiceal Diverticulitis? A Case Report and Systematic Literature Review

Background: Appendiceal diverticulitis is a rare and poorly understood condition of the appendix. The diagnosis of appendiceal diverticulitis is challenging due to its rarity and a clinical presentation that often mimics other ileocecal disorders. Unlike acute appendicitis, appendiceal diverticulitis may be associated with a higher risk of perforation, increased mortality, and a potential link to neoplasms. However, further research is necessary to enhance our understanding of its epidemiology, risk factors, clinical presentation, and outcomes. Case Report: A 53-year-old male presented to the emergency department with right lower abdominal pain. On physical examination, tenderness was noted in the right lower quadrant, without rebound tenderness or muscle guarding. Laboratory tests revealed leukocytosis and elevated C-reactive protein (CRP) levels. Ultrasonographic imaging of the ileocecal region suggested acute appendicitis, leading to a decision for surgical intervention. Laparoscopic exploration revealed multiple cylindrical, red, and edematous herniations, up to 4 mm in size, on the surface of the vermiform appendix. An appendectomy was performed. Histopathological examination confirmed appendiceal diverticulitis with surrounding peridiverticulitis. The surgery and early postoperative course were uneventful. Literature review: The study included 5 retrospective studies and 30 case reports, analyzing a total of 112 patients with appendiceal diverticulitis. Of these, 65.5% were male and 34.5% were female, with a median age of 49 years (IQR: 39-59). The most commonly reported clinical findings included pain in the right iliac fossa or right lower abdominal quadrant (56.5%), nausea (18.9%), vomiting (9.8%), rebound tenderness (24.6%), fever (15.6%), leukocytosis (25.4%), and elevated C-reactive protein levels (16.4%). Diagnosis was confirmed histopathologically in 86.9% of the cases via computed tomography imaging in 4.1% and ultrasonography in 1.6%. A histopathological analysis identified five neoplasms (4.1%), including two sessile serrated adenomas, two neuroendocrine carcinoids, and one mucinous tumor. Appendectomy was the treatment of choice, with no intraoperative or postoperative complications recorded and no mortality reported. The median hospital stay was 6.8 days (IQR: 3.0-6.8). Conclusions: Appendiceal diverticulitis should be considered as a differential diagnosis in patients presenting with symptoms resembling acute appendicitis. Early diagnosis and treatment are essential to reduce morbidity and mortality. Appendectomy is a safe and effective treatment approach for appendiceal diverticulitis.

Differentiating appendiceal neoplasm from perforated appendiceal diverticulum in chronic appendicitis: a case report

Low mucinous neoplasm of the appendix (LAMN) and appendiceal diverticulum are both uncommon pathologies that may pose a diagnostic challenge. Both may present as either appendicitis or asymptomatically and have a risk of perforation. LAMN, carries the additional risk of pseudomyxoma pertitonei and metastasis. Ensuring correct histopathology is crucial, as computed tomography (CT) abdomen/pelvis may only demonstrate a mildly dilated appendix, delaying diagnostic laparoscopy and appendicectomy. Here, we describe the case report of a 56-year-old woman who presented with chronic intermittent right iliac fossa pain initially determined to be chronic appendicitis. Following laparoscopic appendicectomy, histopathology demonstrated LAMN, however, on further re- assessment of histopathology, as well as the completion of a normal pan-CT and colonoscopy, a final diagnosis of ruptured appendiceal diverticulum was made. Our case demonstrates the utility of a multi-disciplinary approach in evaluating patients with possible appendiceal LAMN or appendiceal diverticulum.

Is Appendiceal Diverticulitis Mimicking Acute Appendicitis?

Appendicular diverticulitis (AD) is a rare entity characterized by the inflammation of the arising diverticulum of the appendix. It has been reported to carry a high risk of perioperative complications, such as bleeding and perforation. Furthermore, multiple articles have highlighted the importance of diagnosing AD early due to its strong association with malignancies. Limited published cases concerning AD in our country and globally are available in the literature. Hence, we present in this article a case series of five exciting cases of incidental findings of AD that were initially diagnosed as acute appendicitis based on clinical evaluation and imaging findings. In our series, we performed a retrograde evaluation of the computed tomography scans of all five cases that showed diverticula. In conclusion, histopathological evaluation remains the method of choice to reach the definitive diagnosis; however, it is essential to highlight the relevance of imaging in diagnosing AD preoperatively in the early stages to reduce morbidity and mortality.

Typical and Atypical Presentations of Appendicitis and Their Implications for Diagnosis and Treatment: A Literature Review

Appendicitis, an acute inflammation of the appendix, affects all demographic groups and exhibits various incidences and clinical manifestations. While acute appendicitis typically presents with colicky periumbilical abdominal pain that localizes to the right lower quadrant, atypical presentations are more common in children, geriatric, and pregnant patient populations, leading to delays in diagnosis. Clinical evaluation, clinical scoring systems, and inflammatory markers are commonly used, but their limitations have led to the increased use of diagnostic imaging in patients suspected of appendicitis. Acute appendicitis is managed by non-operative and operative management, depending on whether it is uncomplicated or complicated. Developing diagnostic pathways to improve outcomes and reduce complications is crucial. Although medical advancements have been made, diagnosing and managing appendicitis can be challenging, mainly when patients are present atypically. This literature review aims to comprehensively review typical and atypical presentations of appendicitis and their current implications for diagnosis and treatment modalities in pediatric, adult, pregnant, and geriatric patient populations.

Appendiceal Diverticulitis Presenting as Acute Appendicitis and Diagnosed After Appendectomy

Introduction

Diverticular disease of the appendix (DDA) is a rare appendiceal pathology. It is usually present similar to acute appendicitis. Because of its rarity, the DDA is poorly comprehended. This study evaluates the incidence, clinical and pathological characteristics of appendiceal diverticulitis diagnosed after appendectomy.

Methods

We performed a retrospective analysis of patients who underwent appendectomy between January 2016 and January 2022 at the Istanbul Sultanbeyli State Hospital General Surgery Clinic. The following parameters were analyzed: age and gender, preoperative diagnosis, laboratory results, radiological imaging findings, surgical technique, histopathological examination of specimens, and complications.

Results

A total of 1586 patients were analyzed. In the pathology, diverticular disease of the appendix was detected in 10 patients (0.63%). The DDA patients’ mean age was 34.4 years, and the male to female ratio was 4:1. We detected low-grade appendiceal mucinous neoplasia in one of our patients.

Conclusion

Appendiceal diverticulitis is rare and usually presents as acute appendicitis. Most DDAs are detected incidentally during the postoperative period and are associated with an increased risk of appendiceal neoplasm. Appendectomy specimens should be carefully examined histopathologically to detect diverticular disease of the appendix.