Endometriosis of the appendix

Appendiceal Endometriosis: A Comprehensive Review of the Literature

Objective: the purpose of this review was to evaluate the prevalence of appendiceal endometriosis and the safety of concomitant appendectomy in women with endometriosis or pelvic pain. Materials and Methods: We searched the electronic databases Medline (PubMed), Scopus, Embase, and Web of Science (WOS). The search was not subject to any limitation in terms of time or method. The primary research question was: what is the prevalence of appendiceal endometriosis? The secondary research question was: is it safe to perform appendectomy during surgery for endometriosis? Publications that reported data about appendiceal endometriosis or appendectomy in women with endometriosis were reviewed regarding the inclusion criteria. Results: We found 1418 records. After review and screening, we included 75 studies published between 1975 and 2021. With regard to the first question of the review, we found 65 eligible studies and divided these into the following two categories: (a) endometriosis of the appendix presenting as acute appendicitis, and (b) endometriosis of the appendix as an incidental finding in gynecological surgery. Forty-four case reports described appendiceal endometriosis in women who were admitted for the treatment of pain in the right-sided lower abdomen. Endometriosis of the appendix was observed in 2.67% (range, 0.36-23%) of women who were admitted due to acute appendicitis. In addition, appendiceal endometriosis was an incidental finding during gynecological surgery in 7.23% of cases (range, 1-44.3%). With regard to the second question of the review, which was the safety of appendectomy in women with endometriosis or pelvic pain, we found 11 eligible studies. Reviewed cases had no significant intraoperative or follow-up complications during the 12 weeks. Conclusion: Based on the reviewed studies, coincidental appendectomy appears reasonably safe and was associated with no complications in the cases reviewed for the present report.

Appendiceal endometriosis: Case report of a rare differential diagnosis of acute appendicitis

INTRODUCTION AND IMPORTANCE

Appendiceal endometriosis is an entity of extragonadal endometriosis. It commonly affects women of childbearing age with a wide spectrum of clinical manifestations. Women can present with symptoms mimicking acute appendicitis. Ultrasound, computed tomography scan (CT-Scan) and laparoscopy can be used for evaluation although the definitive diagnosis is obtained only with the histopathological study.

CASE PRESENTATION

We report a case of appendiceal endometriosis presenting as acute right lower quadrant abdominal pain in a woman of childbearing age.

CLINICAL DISCUSSION

We discuss appendiceal endometriosis as a rare differential diagnosis of acute appendicitis in young women and the diagnostic challenges this condition may pose to general surgeons.

CONCLUSION

Appendiceal endometriosis is a rare condition with a challenging diagnosis. Although appendectomy relieves the acute symptoms, gynecological follow up is strongly recommended.

Ectopic endometriosis, menstruation, and acute appendicitis: A thought-provoking case

INTRODUCTION AND IMPORTANCE

Ectopic endometrium in the appendix is rare. The relationships between ectopic endometrium in the alimentary tract and digestive symptoms and between digestive symptoms due to ectopic endometriosis and periodic menstruation are controversial. We herein describe the successful treatment of acute appendicitis that we suspect was caused by ectopic endometriosis and periodic menstruation.

PRESENTATION OF CASE

A 38.9-year-old multipara with uterine didelphys developed lower abdominal pain during menstruation, and she was clinically diagnosed with acute appendicitis. She received conservative management with cephem antibiotics, and her pain disappeared uneventfully. However, the lower abdominal pain during menstruation later recurred, and she again received conservative treatment. Laparoscopic appendectomy was subsequently performed because for 4 months, her appendicitis-induced digestive symptoms had recurred in association with periodic menstruation. Ectopic endometrial gland proliferations were histopathologically observed in the proper muscular layer of the appendiceal tip. She developed no further episodes of digestive symptoms postoperatively.

CLINICAL DISCUSSION

Ectopic endometriosis of the alimentary tract may be accompanied by digestive symptoms; moreover, these symptoms may be related to periodic menstruation. However, the sensitivity of ectopic endometrium to hormones shows considerable variation among patients. We speculate that the acute appendicitis might have been triggered by ectopic endometriosis in our case because the patient developed repeated digestive symptoms in association with periodic menstruation. Ectopic endometrium may be incidentally observed in histopathological assessments of resected specimens. The therapeutic strategy should be carefully decided on a case-by-case basis.

CONCLUSION

We hope this thought-provoking case provides a timely reminder for gastrointestinal clinicians and general surgeons.

Clinicopathologic findings in gynecologic proliferations of the appendix

Appendiceal endometriosis, endosalpingiosis, and decidual lesions have received little attention in the pathology literature, meaning their clinicopathologic features remain unclear. We identified 72 cases of appendiceal gynecologic proliferations with available slides. Clinical presentation was recorded when available, and histologic findings were correlated with clinical data. Cases included conventional endometriosis (51), endosalpingiosis (14), and decidual lesions (7). The patients with endosalpingiosis were significantly older (median 45 years) than those with endometriosis (median 34 years, P = .0085) or decidual lesions (median 31 years, P = .0088). Most endometriosis patients presented with known/suspected endometriosis (20/51, 39%), while acute appendicitis was the most common presentation for patients with endosalpingiosis (5/14, 36%) or a decidual lesion (5/7, 71%). Few patients presenting with appendicitis were ever diagnosed with extra-appendiceal disease. All 51 endometriosis cases showed both glands and stroma, and 18 (35%) had hemosiderin. One case progressed to endometrioid adenocarcinoma. Endosalpingiosis was an incidental finding in all cases, confined to the serosa in 4 and extending intramurally in 10. Four of the 7 patients with a decidual lesion were pregnant, and 2 others were taking oral contraceptives. The cases included florid decidualized endometriosis (5) and deciduosis (2). Two cases spread transmurally and effectively obliterated the appendix. Conventional appendiceal endometriosis can have several clinical presentations. Patients with it who present with acute appendicitis rarely develop it elsewhere. Appendiceal endosalpingiosis is rare and effectively incidental. Decidualized endometriosis may overtake the entire appendix.

Endometriosis of the Appendix: When to Predict and How to Manage-A Multivariate Analysis of 1935 Endometriosis Cases

STUDY OBJECTIVE

To evaluate appendiceal endometriosis (AE) prevalence and risk factors in endometriotic patients submitted to surgery.

DESIGN

A retrospective cohort study.

SETTING

A tertiary level referral center, university hospital.

PATIENTS

One thousand nine hundred thirty-five consecutive patients who underwent surgical removal for symptomatic endometriosis.

INTERVENTIONS

Electronic medical records of patients submitted to surgery over a 12-year period were reviewed. We assessed any correlation between demographic, clinical, and surgical variables and AE. In our center, appendectomy was performed using a selective approach. Appendix removal was performed in case of gross abnormalities of the organ, such as enlargement, dilation, tortuosity, or discoloration of the organ or the presence of suspected endometriotic implants.

MEASUREMENTS AND MAIN RESULTS

AE prevalence was 2.6% (50/1935), with only 1 false-positive case at gross intraoperative evaluation. In multivariate analysis using a stepwise logistic regression model, independent risk factors for AE were adenomyosis (adjusted odds ratio [aOR] = 2.48; 95% confidence interval [CI], 1.32-4.68), right endometrioma (aOR = 8.03; 95% CI, 4.08-15.80), right endometrioma ≥5 cm (aOR = 13.90; 95% CI, 6.63-29.15), bladder endometriosis (aOR = 2.05; 95% CI, 1.05-3.99), deep posterior pelvic endometriosis (aOR = 5.79; 95% CI, 2.82-11.90), left deep lateral pelvic endometriosis (aOR = 2.11; 95% CI, 1.10-4.02), and ileocecal involvement (aOR = 12.51; 95% CI, 2.07-75.75).

CONCLUSION

Among patients with endometriosis submitted to surgery, AE was observed in 2.6%, and it was associated with adenomyosis, large right endometrioma, bladder endometriosis, deep posterior pelvic endometriosis, left deep lateral pelvic endometriosis, and ileocecal involvement.

Isolated appendiceal endometriosis resulting in intussusception

An inverted (intussuscepted) appendix is a rare finding, often mistaken for a polyp as it presents with vague symptoms. This can result in misdiagnosis and inappropriate management. Diagnosis is usually made through surgery. Rarely, endometriosis has been found as the cause of the intussusception. A 42-year-old woman presented with frequent loose stools over 2 years, an elevated calprotectin over 400 μg/g faeces (normal <110) and a serum C-reactive protein of 40 mg/l (normal <5 mg/l). Endoscopy showed an inverted appendix. Histopathology results showed inflammation and ulceration. Laparoscopic appendicectomy was performed successfully, and endometriosis was found on the inverted appendix. This is the first case reported of an inverted appendix containing endometriosis, in which the intussusception of the appendix has been diagnosed on endoscopy. This case highlights how endometriosis can involve just the appendix, without any involvement of reproductive organs. We suggest considering inverted appendix as a differential diagnosis when investigating caecal lesions.

Professor Barrie Vernon-Roberts, AO, MD, BSc, PhD, FRCPath, FRCPA, FAOrthA (Hon), FRS.SA

This issue of Inflammopharmacology contains papers that have been submitted to commemorate the life and work of Professor Barrie Vernon-Roberts, an outstanding clinical scientist in the field of bone pathology and its pharmacological regulation. This review briefly summarizes his major works and achievements as well as a list of his publications.

Acute appendicitis caused by endometriosis: a case report

Introduction

Endometriosis is a well-recognized gynecological condition in the reproductive age group. Surgical texts present the gynecological aspects of the disease in detail, but the published literature on unexpected manifestations, such as appendiceal disease, is inadequate. The presentation to general surgeons may be atypical and pose diagnostic difficulty. Thus, a definitive diagnosis is likely to be established only by the histological examination of a specimen.

Case presentation

We report a case of endometriosis of the appendix in a 25-year-old Caucasian woman who presented with symptoms of acute appendicitis and was treated by appendectomy, which resulted in a good outcome.

Conclusions

We discuss special aspects of acute appendicitis caused by endometriosis to elucidate the pathologic entity of this variant of acute appendicitis.

A case of endometriosis of the appendix with adhesion to right ovarian cyst presenting as intussusception of a mucocele of the appendix

Endometriosis of the appendix is rare, and we present a case of endometriosis of the appendix with adhesion to right ovarian cyst presenting as intussusception of a mucocele of the appendix in a 35-year-old woman with no associated sign of endometriosis. Colonoscopy revealed intussusception-like change and mucosal defect in the mucosa at the orifice of the appendix. Abdominal computed tomography showed a low-density lesion, which seemed to be right ovarian cyst. However, as the appendix was located near this site, differentiation between ovarian cyst and mucocele of the appendix was difficult. Laparoscopic examination disclosed blue berry spots on the Douglas cul-de-sac and right ovarian cyst, and the appendix was atrophied and hardened and tightly adhered to the right ovary. Laparoscopic appendectomy and partial cecectomy was performed, and on pathologic examination, thickening and fibrosis of the muscle layer owing to endometriosis were judged to have caused intussusception-like changes.

Appendiceal endometriosis: two case reports

The incidence of appendiceal endometriosis is lower than 1% among pathologies of pelvic endometriosis. They may occur with findings such as acute appendicitis, invagination, colic or melena, though they are mostly seen with an asymptomatic character. Diagnosis can be made only after a histopathological examination following the operation. We present here two appendiceal endometriosis cases, which were operated on for a prediagnosis of acute appendicitis, but postoperatively diagnosed as appendiceal endometriosis.

Endometriosis of the appendix resulting in perforated appendicitis

Endometriosis is a relatively common disease among women of reproductive age. However, gastrointestinal endometriosis is rare and endometriosis of the appendix resulting in perforated appendicitis is even rarer. We experienced a case of endometriosis of the appendix manifesting as panperitonitis caused by perforation of the appendix. The patient was a 35-year-old woman who was hospitalized with an acute abdomen. She was diagnosed with panperitonitis and underwent urgent laparotomy. When perforation of the appendix was detected, appendectomy and intraperitoneal drainage were performed. Pathological examination revealed endometriosis extending from the muscularis propria to the subserosa, and a diagnosis of endometriosis of the appendix was made. We consider the relevant literature describing the mechanism by which endometriosis of the appendix occurs, and the association between endometriosis of the appendix and acute appendicitis.

Laparoscopic appendectomy for appendiceal endometriosis presenting as acute appendicitis: report of a case

Endometriosis is a relatively common disorder in women of reproductive age; however, appendiceal endometriosis is rare. Thus, a definitive diagnosis is likely to be established only by histology of the appendix. We report a case of endometriosis of the appendix in a 42-year-old woman who presented with symptoms of acute appendicitis. We treated the patient by performing laparoscopic appendectomy, which resulted in a good outcome.

Endometriosis and the appendix: a case series and comprehensive review of the literature

OBJECTIVE

To report the prevalence of appendiceal disease in women with chronic pelvic pain undergoing laparoscopy for possible endometriosis, summarize the literature, and more accurately estimate the prevalence of endometriosis of the appendix.

DESIGN

Prospective case series and literature review.

SETTING

Academic research institute.

PATIENT(S)

One hundred thirty-three patients with chronic pelvic pain and possible endometriosis undergoing laparoscopy.

INTERVENTION(S)

History, physical exam, and abdominopelvic laparoscopy. Endometriosis and adhesions were excised using selective Nd:YAG contact laser trabeculoplasty and pathologically evaluated. Only patients with visible abnormalities involving the appendix were treated via concurrent laparoscopic appendectomy.

MAIN OUTCOME MEASURE(S)

Appendiceal abnormalities at laparoscopy.

RESULT(S)

Of 133 patients, 13 had a previous appendectomy with unknown pathology. Of the remaining 120 patients, 109 reported right lower quadrant pain. Of this subgroup, six patients had appendiceal pathology: four with pathology-confirmed endometriosis, one with Crohn's disease suspected at laparoscopy, and one with chronic appendicitis. The prevalence of appendiceal endometriosis in patients with biopsy-proven endometriosis (n = 97) or with right lower quadrant pain (n = 109) was 4.1% and 3.7%, respectively. This rate was similar to the 2.8% prevalence confirmed by literature review in patients with endometriosis but was much higher than that reported in all patients (0.4%).

CONCLUSION(S)

Appendiceal endometriosis, while relatively uncommon in patients with endometriosis, is rare in the general population. In patients with right lower quadrant or pelvic pain, the appendix should be inspected for endometriosis and evidence of nongynecologic disease.

Colonoscopic diagnosis of appendiceal intussusception: a case report

Intussusception of the appendix is an uncommon condition and the diagnosis is rarely made preoperatively. Intussusception of the appendix may mimic a neoplastic lesion. Colonoscopy is a valuable tool for diagnosis of the appendiceal intussusception. A 17-yr-old female admitted with repeated abdominal pain, nausea, vomiting and febrile sensation. We diagnosed as appendiceal intussusception by colonoscopy, which showed a polypoid tumor (about 1.5 cm) in the cecum. This sessile polypoid mass looks like foreskin or glans. We present colonoscopic finding of appendiceal intussusception and review the literature.

Miscellaneous conditions of the appendix

A variety of miscellaneous conditions affect the appendix, both as incidental findings and as causes of clinical signs and symptoms that often mimic appendicitis. Congenital abnormalities of the appendix are rare; the two most commonly reported are congenital absence and appendiceal duplication. Diverticular disease may be an incidental finding, but when inflamed, can be clinically confused with appendicitis. Endometriosis of the appendix, which usually occurs in the setting of generalized gastrointestinal endometriosis, often presents as acute appendicitis, but may present as intussusception, lower intestinal bleeding, and, particularly during pregnancy, perforation. Peritoneal endosalpingiosis often involves the appendiceal serosa and occasionally the wall but has no clinical manifestations in contrast to endometriosis. Vasculitis may be either isolated to the appendix or part of a systemic vasculitis, most often polyarteritis nodosa. Neural proliferations of the appendix include lesions associated with von Recklinghausen's disease, as well as mucosal and axial neuromas that are theorized to progress to fibrous obliteration of the appendix. Mesenchymal tumors of the appendix are most often of smooth muscle type, usually leiomyoma but rarely leiomyosarcoma; nonmyogenic neoplasms such as gastrointestinal stromal tumor, granular cell tumor, Kaposi's sarcoma, and miscellaneous other curiosities occur rarely. Lymphoma affects the appendix exceptionally; in children, Burkitt lymphoma is most common whereas in adults, large cell lymphomas and low grade B-cell lymphomas predominate. Secondary involvement of the appendix by leukemia has been reported. Secondary involvement of the appendix by carcinomas of the female genital tract, particularly ovary, and diverse other sites are in aggregate common but only rarely a clinical or pathological difficulty. Occasionally, however, appendiceal neoplasia that is secondary from another site may dominate the clinical picture and lead to potential pathologic misdiagnosis as primary appendiceal disease.

Intestinal endometriosis: presentation, investigation, and surgical management

The study was undertaken to identify the presenting features of intestinal endometriosis and to evaluate its investigation and surgical management. Twenty-six cases of intestinal endometriosis were identified during a fourteen year period. The commonest site of occurrence was the rectosigmoid region (11 cases) followed by the appendix (9 cases), and ileocaecal region (6 cases). Abdominal pain was the main presenting feature in 20 cases, with associated nausea and vomiting in 12 cases and altered bowel habit in ten. Other presenting features included rectal bleeding, abdominal bloating and tenesmus. Endometriosis was not suspected preoperatively in any of the patients without a past history of this condition. Accurate preoperative diagnosis proved very difficult, with only laparoscopy providing definite evidence of intestinal endometriosis prior to formal surgery. Colonic resections were performed in 12 cases, small bowel resection in six cases and appendicectomy in nine cases, together with resection of adjacent adherent structures. This series illustrates the difficulty of establishing an accurate preoperative diagnosis, and the propensity of intestinal endometriosis to mimic other gastrointestinal diseases, particularly carcinoma and inflammatory bowel disease.

Endometriosis. An important condition in clinical gastroenterology

Endometriosis, a condition defined by the presence of ectopic endometrium, is a disorder of increasing incidence and a significant cause of gastroenterologic distress in young women. Although clinical manifestations vary considerably depending upon the anatomic extent of disease, characteristic abdominal complaints and typical physical findings continue to be associated with misdiagnosis and delayed recognition of gastrointestinal involvement. The authors of this paper review the medical literature concerning endometriosis of the digestive tract--emphasizing modes of presentation, risk factors, diagnostic testing, complications, and therapy. Greater familiarity with the disease and heightened awareness of its sequellae are needed and prerequisite to improved medical management.

Endometriosis of the large bowel: a report of 11 cases

The clinical and pathological features of 11 cases of large bowel endometriosis are reported, one of which also had lesions in the small intestine. All of the cases had rectal or rectosigmoid involvement. Altered bowel habit and pain were common symptoms but were rarely associated with the menstrual cycle. Sigmoidoscopy was generally unhelpful. Rectal or vaginal examination and barium enema often revealed a mass which was usually diagnosed preoperatively as a malignancy. A correct diagnosis was made preoperatively in only two cases; carcinoma was suspected in four and carcinoid in one case. Histological evidence of recent hemorrhage was confined to those cases where endometriosis seemed to be the major cause of intestinal symptoms. The colonic mucosa overlying the endometriotic deposits was commonly histologically abnormal. It showed a range of changes resembling colitis, solitary ulcer, prolapse or even neoplasm. An appreciation of these mucosal alterations is important to those reporting colonic and rectal biopsies; when observed to be focal in a female patient they should arouse a suspicion of endometriosis.

Intestinal endometriosis

Endometriosis involving the intestine usually takes the form of asymptomatic, small, superficial serosal implants on segments of bowel lying in the pelvis in proximity to the genital organs. Deeper and more extensive intestinal wall involvement may result in obstruction and occasionally bleeding and requires distinction from a neoplasm or other inflammatory bowel process. Intestinal endometriosis should be considered in the differential diagnosis of recurring lower abdominal pain and other episodic bowel symptoms in women of child-bearing age. The diagnosis may be suspected based on the patient's history and frequently associated gynecologic symptoms. Due to the extramucosal location of the endometrioma, preoperative evaluation is unlikely to establish the diagnosis with certainty. Intestinal involvement by endometriosis, to the degree that it produces symptoms, almost always requires excision. Asymptomatic serosal lesions found incidentally at celiotomy for other disease should be biopsied and the diagnosis confirmed by frozen section. Symptomatic disease should be treated by resection of the involved intestine or by local excision, if the latter is feasible, and primary colon carcinoma can be excluded with confidence. Decisions regarding concurrent treatment for the underlying endometriosis should be made after consultation with an experienced gynecologist and must be based on the patient's menstrual status, age, and desire for future pregnancy.

Endometriosis of the vermiform appendix

The pathological findings and clinical aspects of 22 patients with endometriosis of the vermiform appendix are presented. The cases were found among 10,000 appendices examined from 1950 to 1981. During this period of 32 years, 800 cases of pelvic endometriosis were seen. In 10 patients no other locations of pelvic endometriosis were found.

Ileocecal endometriosis presenting with abdominal pain and gastrointestinal bleeding

A 26-year-old woman with enteric endometriosis presenting with cecocolic intussusception, a cecal mass on barium enema, and gastrointestinal hemorrhage is described. Laparotomy revealed cecocolic intussusception, ileocecal endometrial implants, and cecal mucosal ulceration presumed secondary to ischemia of the intussuscepted bowel. Histopathology showed serosal and subserosal endometrial implants without mucosal invasion. A review of the literature of endometrial bowel disease is presented.