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CASE REPORT
Year : 2016  |  Volume : 35  |  Issue : 2  |  Page : 150-153

Diverticulitis of the appendix: is it clinically significant?


Department of General Surgery, Kafr El-Sheikh General Hospital, Kafr El-Shiekh, Egypt

Date of Submission22-Aug-2015
Date of Acceptance12-Oct-2015
Date of Web Publication20-May-2016

Correspondence Address:
Ahmed M El-Saady
MD, 40 El-Ommal Street, Takseem 2, Kafr El-Shiekh
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-1121.182792

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  Abstract 

We represent here, a case of male patient aged 32 years coming complaining of diffuse periumbilical pain since 2 days that shifted to the right iliac fossa and suprapubic areas within 6 h from onset. The condition was accompanied by vomiting (once), constipation, and fever. Abdominal examination revealed tender Mc-Burney point with rebound tenderness in the right iliac fossa; he had a pulse of 97 beats/min, temperature of 38.1΀C, and total leukocytic count of 9000 c/m. Ultrasonography revealed minimal free fluid with noncompressible tubular blind structures, indicating acute appendicitis [Figure 1]. The patient was prepared for appendectomy in the usual manner through Lan's incision. On operation, two bulges were found arising from the antimesenteric border of the distal half of the appendix [Figure 2] as diverticulae with impending rupture of one of them [Figure 3]. Both the appendix and diverticulae are seats of inflammation [Figure 4]. Appendectomy was performed and the specimen was sent for histopathologic examination, revealing diverticulitis of an inflamed appendix (type 2 diverticulosis of the appendix). We reviewed the literature to study cases on such a clinical entity and determine whether appendectomy was sufficient in all cases and whether there was actual increased risk for another diverticulae elsewhere.

Keywords: Appendiceal diverticulitis, colonic diverticulae, rare diverticular disease


How to cite this article:
El-Saady AM. Diverticulitis of the appendix: is it clinically significant?. Egypt J Surg 2016;35:150-3

How to cite this URL:
El-Saady AM. Diverticulitis of the appendix: is it clinically significant?. Egypt J Surg [serial online] 2016 [cited 2018 Oct 20];35:150-3. Available from: http://www.ejs.eg.net/text.asp?2016/35/2/150/182792


  Discussion Top


Although acute appendicitis is one of the most common acute abdominal conditions [1], diverticulosis of the appendix is an uncommon entity [2] [Figure 1],[Figure 2],[Figure 3] and [Figure 4]. It was first described by Kelynack [3] in 1893 as a greatly distended appendix, totally shut off from the cecum, having two distinct diverticular processes directed between the folds of the mesentery [4]. Over the years several cases have been reported [5]. The incidence of diverticulae found in appendectomy specimens ranges from 0.004 to 2.1% and that from routine autopsies from 0.20 to 0.6% [6]. Some believe that the incidence may be greater than that generally appreciated and may be dismissed by surgeons and pathologists as a variant of true appendicitis [7]. However, appendiceal diverticulitis is a discrete clinical process that must be considered in the appropriate setting [6].
Figure 1: Ultrasound demonstrated a noncompressible blind tube with minimal free fluid. There is difference in the usual presentation of appendicular diverticulitis and appendicitis.

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Figrue 2: Two bulges on the antimesenteric border of the appendix.

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Figure 3: Impending rupture of the diverticulum.

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Figrue 4: Type 2 diverticulosis of the appendix - that s, diverticulitis with appendicitis.

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Two types of appendiceal diverticulae have been identified: congenital and acquired [8]. The acquired type, which is the most prevalent, is a false diverticulum. It represents a herniation of the mucosa through a muscular defect of the appendix (mainly on the mesenteric border) [2]. Some believe that nearly all appendiceal diverticulae are acquired [8]. The exact pathogenesis is still unknown, but several explanations have been postulated [4]. The inflammatory theory is one of these explanations: it postulates that an attack of appendicitis occurs with a postappendicitis weakness of the wall, followed by ulceration and regenerated epithelium over the injured area [9]. Alternatively, Stout [10] suggested a combination of luminal obstruction (coupled with the 1-2 ml of appendiceal secretions that are produced daily) in the presence of active muscular contraction, which leads to development of high intraluminal pressure with subsequent formation of a diverticulum on the mesenteric border of the appendix, often at the site of entry of the artery. Others suggested a multifactorial origin [9].

Incidental reports of congenital diverticulae have been reported [5]. The congenital type is a true diverticulum characterized by the presence of all layers of the bowel wall. This type is extremely rare, with ∼50 cases reported in the literature [7]. There may be a chromosomal basis for this lesion with possible linkage to a group D chromosomal trisomy 13-15 (trisomy D13-D15 syndrome) [7]. Some have suggested embryonic deformities such as appendiceal duplication with local sacculations formed during appendiceal recanalization, or epithelial inclusion in the appendiceal wall or traction [10].

Progression from diverticulosis to diverticulitis follows a partial or complete obstruction of the lumen [11]. This may be due to swelling of the mucosa, inflammation, fecaliths, fibrous strictures, or torsion [5].

Classically, there is a diverticulum with a cylindrical appearance in the distal third of the appendix in nearly 60% of cases [12]. The acquired lesions occur on the mesenteric border of the appendix, often in association with an arteriolar blood vessel and thinning of the muscularis propria, and macroscopically it may be associated with periappendicitis [12]. Microscopic examination of the appendiceal specimen often reveals a small lumen with increased thickness of the submucosa and muscular wall, as well as atrophy of the mucosal lymphoid tissue [12] [Figure 5].
Figure 5: Microscopic picture of a false diverticulum.

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These findings are likely physiological responses to a chronically elevated luminal pressure [9]. Appendiceal diverticula occurs in the absence of colonic diverticulosis [7].

Four subtypes of appendiceal diverticulitis have been reported. Type 1 is defined as a normal-appearing appendix with an acutely inflamed diverticulum. Type 2 involves an acutely inflamed diverticulum with surrounding appendicitis, as seen in this case. Type 3 is conventional appendicitis with an incidental uninvolved diverticulum. Type 4 is an incidental appendiceal diverticulum with no evidence of appendicitis or diverticulitis [6].

The clinical presentation varies greatly from the asymptomatic group to the seriously complicated group with 30-fold increased mortality compared with simple appendicitis [4].

Patients with diverticulosis may be asymptomatic or may just complain of persistent lower abdominal pain [13]. When acute diverticulitis develops, the patient presents with acute appendicitis. Some cases of acute appendicitis may present difficulties in diagnosis [14]. The confusion is greater in cases of diverticulitis of the appendix [13]. On comparison with appendicitis, pain is often described as insidious in nature, intermittent, and extended over a long period. Anorexia, nausea, and vomiting, which are cardinal features in classic appendicitis [15], are usually absent [13]. Signs may be few [16]. Most of the patients would have had one or more admissions before the operative admission [16]. Appendiceal diverticulitis occurs more often in the male population [11] and in patients with cystic fibrosis [7]. Appendicitis classically manifests in patients before the third decade of life, whereas appendiceal diverticulitis usually appears after the third decade of life [17] [Table 1]. Occasionally, these two conditions can be distinguished with a thorough history and physical examination. With detailed questioning, some patients will report prior episodes of right lower-quadrant pain (i.e. chronic appendicitis). Patients seek medical treatment much later than those with classic appendicitis, and if there is a delay in establishing the correct diagnosis perforation within the mesentery is found at the time of operation [17].
Table 1: Comparison of usual presentation of appendiceal diverticulitis[4]

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Perforation of the appendiceal diverticulitis is four-fold that of simple appendicitis, and there is a 30-fold increase in mortality rate. However, generalized peritonitis is unusual as the inflammatory process is contained within the mesoappendix by surrounding adhesions [18]. This 'mass-like' effect is often mistakenly identified as carcinoma [18]. Hemorrhage from the appendiceal diverticulae may also occur that sometimes requires several units of blood transfusion [12]. In addition, several cases of pseudomyxoma peritonei have been reported from appendiceal diverticuli [19]. Pseudomyxoma peritonei is a potential risk [15]. This may make removal of an appendix with diverticuli appropriate when found incidentally during surgery or upon barium enema [6]. Some suggested possible associations with locoregional neoplasms. However, most of the studies in the literature have not shown any association of it with appendiceal neoplasm or locoregional neoplasm and advised the pathologists to ensure they do not overdiagnose any reactive atypia or ruptured diverticulum as low-grade mucinous neoplasm [2]. Chronic diverticulitis sometimes presents with chronic intermittent lower abdominal pain and a mass-like effect on imaging study [18].

No current diagnostic radiographic evaluations are available for appendiceal diverticulosis [6]. Because of the likelihood of complications, diverticulosis of the appendix is a finding that radiologists stress upon. Ultrasonography has been used to identify peridiverticulitis, but its role in detecting appendiceal diverticulitis remains to be established [20].

Computed tomography is a very useful diagnostic tool [Figure 6] especially in cases of persistent nonspecific right lower-quadrant abdominal pain. CT can identify the appendicecal diverticulum with the pericecal fat usually shows increased density. Also, a large pericecal phlegmon with or without evidence of abscess formation may be present [11]. The literature shows that computed tomography is the best imaging modality for diagnosis of appendiceal diverticular diseases [11].
Figure 6: Computed tomography (CT) of diverticulitis of the appendix.

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Treatment options vary from appendectomy, cecectomy, to right hemicolectomy, depending on the extent of indurations and intraoperative findings [21].

Once the diagnosis of appendiceal diverticular disease has been established, resection is recommended. Laparoscopic or conventional resection of the incidentally discovered appendix with diverticulosis is indicated because two-third of patients will experience an episode of acute inflammation [21]. However, some investigators doubt the potential benefit of a prophylactic appendectomy [7].


  Conclusion Top


Although diverticulitis of the appendix is an uncommon clinical entity, it should be considered because of its possible clinical significances. Its insidious onset and initial minimal signs make late presentation common. Risk for perforation is four times more than that in simple appendicitis with 30-fold increase in mortality rate. Pseudomyxoma peritonei and significant hemorrhage may also occur. Sometimes the presentation of a mass-like effect is often mistakenly identified as carcinoma. It may also be the cause of chronic lower abdominal pain. No current diagnostic radiographic evaluations are available for appendiceal diverticulosis. However, computed tomography is very useful in patients with complications.[22] Appendectomy is usually sufficient, but sometimes extended resection until right hemicolectomy may be needed. Prophylactic appendectomy is recommended because of the serious sequelae that may occur.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Brunicardi FC, et al. The Appendix. Schwartz′s principles of surgery. Liang MK, Andersson RE, Jaffe BM, BergerMcGraw-Hill DH Education. 10th ed. 2015; 30:1241-1245  Back to cited text no. 1
    
2.
Al-Brahim N, Al-Kandari I, Munahai M, Sharma P. Clinicopathological study of 25 cases of diverticular disease of the appendix: experience from Farwaniya Hospital. Pathol Res Int 2013; 2013:404308.  Back to cited text no. 2
    
3.
Kelynack TN. A contribution to the pathology of the vermiform appendix. London, England: HK Lewis; 1893.   Back to cited text no. 3
    
4.
Halder SK, Khan I. An Indian female presenting with appendicular diverticulitis: a case report and review of the literature. Case J 2009; 2:8074.  Back to cited text no. 4
    
5.
Phillips BJ, Perry CW. Appendiceal diverticulitis. Mayo Clin Proc 1999; 74:890-892.  Back to cited text no. 5
    
6.
Friedlich M, Malik N, Lecompte M, Ayroud Y. Diverticulitis of the appendix. Can J Surg 2004; 47:146-147.  Back to cited text no. 6
    
7.
Kabiri H. Appendiceal diverticulitis. Internet J Surg 2004; 7:7023-7025.  Back to cited text no. 7
    
8.
Place RJ, Simmang CL, Huber PJ. Appendiceal diverticulitis. South Med J 2000; 93:76-79.  Back to cited text no. 8
    
9.
Lock JH, Wheeler WE. Diverticular disease of the appendix. South Med J 1990; 83:350.  Back to cited text no. 9
    
10.
Stout AP. A study of diverticular formation in the appendix. Arch Surg 1923; 6:793-829.  Back to cited text no. 10
    
11.
Mahmood RD. Appendiceal diverticulosis. BMJ Case Rep 2010; 07:2085-2089. doi:10.1136/bcr.07.2009.2090.  Back to cited text no. 11
    
12.
Majeski J. Diverticulum of the vermiform appendix is associated with chronic abdominal pain. Am J Surg 2003; 186:129-131.  Back to cited text no. 12
    
13.
Satoshi H, Ryutaro M, Koichiro M, Seiji H, Kajuya E, Akira N. Clinical study of diverticulum of appendix. J Japan Surg Assoc 2004; 65:1592-1595.  Back to cited text no. 13
    
14.
Sandell E, Berg M, Sanblom G, Sundman J, Franneby U. Surgical decision-making in acute appendicitis. BMC Surg 2015; 15:69.  Back to cited text no. 14
    
15.
Stefan R, Brendan M. Pseudomyxoma peritonei. Recent advances insurgery, Irving Taylor & Colin D Johnson, The Royal Society of Medicine Press Limited. 36; 2014;8:109-19.  Back to cited text no. 15
    
16.
Friedlich M, Malik N, Lecompte M, Ayroud Y. Diverticulitis of appendix. J Can Chir 2004; 47:146-147.  Back to cited text no. 16
    
17.
Chang Gung Med J 2000, 23:711-714. Journal of Japan Surgical Association 2004, 65:1592-1595  Back to cited text no. 17
    
18.
Lin CH, Chen TC. Diverticulosis of the appendix with diverticulitis - case report. Chang Gung Med J 2000; 23:711-714.  Back to cited text no. 18
    
19.
Konen O, Edelstein E, Osadchi A, et al. Sonographic appearance of an appendiceal diverticulum. J Clin Ultrasound 2002; 30:45-47.  Back to cited text no. 19
    
20.
Delikaris P, Stubbe Teglebjaerj P, Fisker-Sorensen P, Balslev I. Diverticula of the vermiform appendix: alternatives of clinical presentation and significance. Dis Colon Rectum 1983; 26:374-376.  Back to cited text no. 20
    
21.
Bradley JP, Charles WP. Appendiceal diverticulitis. Mayo Clin Proc 1999; 74:890-894.  Back to cited text no. 21
    
22.
Subramanian M, Chawla A, Chokkappan K, Liu H. Diverticulitis of the appendix, a distinctive entity: preoperative diagnosis by computed tomography. Emerg Radiol 2015; 22(5):609-12.  Back to cited text no. 22
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1]


This article has been cited by
1 Unexpected histopathology of Acute Appendicitis
Mutee Ur Rehman
International Journal of Surgery Case Reports. 2017;
[Pubmed] | [DOI]



 

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