Acute appendicitis as a sign of a colorectal carcinoma

Elevated Colon Cancer Rates Linked to Prior Appendicitis: A Retrospective Cohort Study Based on Data from German General Practices

Background/Objective: The association between appendicitis and colon cancer is not yet fully understood. Previous studies have shown contradictory results. Currently, no population-based data from Germany are available with regard to the incidence of colon cancer following appendicitis. This study investigated the association between appendicitis and the incidence of colon cancer in Germany. Methods: In this retrospective cohort study, the incidence of colon cancer was compared for patients with appendicitis and patients without appendicitis, matched for age, sex, index year, average annual consultation frequency, and comorbidity. The aim of the study was to explore the relationship between appendicitis and the incidence of colon cancer. The evaluation was carried out using logistic regression analyses. Results: The study included 49,790 people with and without appendicitis, with a median age of 41 years. During a follow-up period of up to 15 years, 1.04% of cases with appendicitis and 0.60% of cases without appendicitis were newly diagnosed with colon cancer, with some 36.4% of colon cancer cases diagnosed within the first six months after appendicitis. Regression analyses revealed a significant association between appendicitis and colon cancer, particularly in men and in the age groups 41-50 (HR: 10.30; 95% CI: 1.03-43.82) and 18-30 years (HR: 8.17; 95% CI: 1.03-64.58). Conclusions: The present retrospective cohort study suggests an association between appendicitis and the incidence of colon cancer in Germany. Based on our results, we recommend offering a colonoscopy or at least a stool test within 12 months after appendicitis, especially for 18-50-year-olds and >60-year-olds in good general health.

Acute Appendicitis Review: Background, Epidemiology, Diagnosis, and Treatment

Appendicitis is a common occurrence in both the adult and pediatric populations. The condition most commonly occurs between the ages of 10 and 20 years with a lifetime risk of 8.6% and 6.7% for males and females respectively. Its diagnosis focuses on clinical presentation and imaging modalities classified according to scoring systems such as the Alvarado scoring system. A number of imaging modalities can be used, with CT being the most common one. For acute appendicitis, surgical intervention is considered to be the gold standard of treatment. However, recent research has focused on other modalities of treatment including antibiotics and endoscopic retrograde appendicitis therapy (ERAT) to avoid surgical complications.

Rates of colorectal cancer detection in screening colonoscopy post appendicectomy in patients 50 years and over

Introduction

Acute appendicitis in older adults is relatively uncommon and could be the first presentation of an underlying colorectal carcinoma. Colonoscopy in these individuals affords the opportunity for earlier diagnosis and treatment. The finding of increased rates of colorectal cancer (CRC) with older patients who have had appendicitis was supported by a number of small studies and case reports in the early 1980s.With the advent of CT scanning and laparoscopic appendicectomy, increased ability to visualize the caecum has been achieved.

Purpose

A retrospective 12-month study of all patients presenting with acute appendicitis aged 50 years and over from 1st May 2017 to 31st May 2018, and review of post operative screening colonoscopy findings.

Results

Forty-three patients met inclusion criteria. The patients' median age was 62 years (range 50-85 years). 47% of the patients were male. 86% of patients had abdominal CT scans prior to surgery with acute appendicitis visualized in 97% of these cases. Acute appendicitis was found in 100% of cases with no clinical suggestion of CRC operatively or pathologically. 46% of patients had pertinent findings on colonoscopy. This included a malignant obstructing tumour at the hepatic flexure and a tubular adenoma in the transverse colon in a second patient. The remaining findings in this cohort of patients included diverticular disease and benign polyps.

Conclusion

Despite the advancement in visualization of anatomy with CT scan and laparoscopic appendicectomy there is still a role for screening colonoscopy in patients greater than 50 years of age with appendicitis particularly if they have associated bowel symptoms or risk factors for CRC.

The evolving management of the appendix mass in the era of laparoscopy and interventional radiology

AIM

An appendix mass is the result of a walled-off perforation of the appendix which localises, resulting in a mass and it is encountered in up to 7% of patients presenting with acute appendicitis. However, its management is controversial due to the lack of high level evidence. This review article sets out a rationale diagnostic and therapeutic strategy for the appendix mass based upon up-to-date available evidence.

METHODS

A literature review of the investigation and management of appendix mass/complicated appendicitis was undertaken using PubMed, EMBASE and Google Scholar.

RESULTS/CONCLUSION

No prospective studies were identified. The great majority of recent evidence supports a conservative management approach avoiding urgent appendicectomy because of the high risk of major complications and bowel resection. Appendix abscesses over 5 cm in diameter and persistent abscesses should be drained percutaneously along with antibiotics. Appendix phlegmon should be treated with antibiotics alone. Surgery is reserved for patients who fail conservative treatment. Routine interval appendicectomy is not recommended, but should be considered in the context of persistent faecolith, ongoing right iliac fossa pain, recurrent appendicitis and appendix mass persistent beyond 2 weeks. Clinicians should be particularly wary of patients with appendix mass aged over 40 and those with features suggesting malignancy.

Beyond appendicitis; radiologic review of unusual and rare pathology of the appendix

Appendicitis is a very common cause of acute abdominal pathology, however, many other pathologic conditions of the appendix can be diagnosed utilizing CT. Examples of these conditions include primary appendiceal neoplasms, secondary inflammation of the appendix, stump appendicitis, endometriosis, appendicitis within a hernia, appendiceal diverticulosis and intussusception and intraluminal foreign bodies. The purpose of this article is to review appendiceal pathology outside of acute appendicitis, describe corresponding imaging findings on CT, and to illustrate various CT findings of appendiceal disease with representative cases.

The iatrogenic caecal polyp: can it be avoided?

A 60-year-old farmer was admitted with symptoms and signs suggestive of appendicitis. The diagnosis was confirmed at open appendicectomy where the appendix base was ligated and inverted into the caecum with a purse-string suture. Following an uneventful recovery and discharge, a barium enema identified a 2 cm filling defect in the caecal pole. A subsequent colonoscopy revealed only a tiny sessile polyp in the caecum with histology demonstrating normal colonic mucosa. This case report discusses the rare occurrence of an inverted appendix stump mimicking caecal pathology and the rationale of post-appendicectomy colonic investigation in the elderly patient.

The Incidence of Benign and Malignant Neoplasia Presenting as Acute Appendicitis

Acute appendicitis remains the most common surgical emergency encountered by the general surgeon. It is most often secondary to lymphoid hyperplasia, however it can also result from obstruction of the appendiceal lumen by a mass. We sought to review our experience with neoplasia presenting as appendicitis. We retrospectively reviewed all patients admitted with the diagnosis of appendicitis to our Acute Care Surgery Service from July 1, 2007 to June 30, 2009. Patient demographics, duration of symptoms, lab findings, computed tomography findings, and pathology were all analyzed. Over the 2-year period, 141 patients underwent urgent appendectomy Ten patients (7.1%) were diagnosed with neoplasia on final pathology, including four women and six men with a mean age of 46.9 years and mean duration of symptoms of 12.6 days. Final pathology revealed four colonic adenocarcinoma; three mucinous tumors; one carcinoid; one endometrioma; and one patient had a combination of a mucinous cystadenoma, a carcinoid tumor, and endometriosis of the appendix. Six patients had concurrent appendicitis. Colonic and appendiceal neoplasia are not unusual etiologies of appendicitis. These patients tend to present at an older age and with longer duration of symptoms.

Conservative management of elemental mercury retained in the appendix

INTRODUCTION

Few cases of mercury sequestration in the appendix appear in the literature. Based on these, both prophylactic appendectomy and non-surgical management have been recommended. We report a case in which a patient with mercury retained in the appendix was managed conservatively without developing mercurialism or appendicitis.

CASE REPORT

A 43-year-old man ingested approximately one tablespoon of elemental mercury after an argument with his wife. An initial abdominal radiograph showed mercury in the pylorus of the stomach and a follow-up x-ray at 72 hours showed mercury localized to the appendix. The patient was treated as an outpatient and examined several times over a 37-day period. He never developed signs of appendicitis. On a follow-up examination 7 months after the ingestion, he was radiographically free of mercury. Periodically throughout his clinical course, blood mercury levels were obtained. Only one, 6 days after ingestion, showed an elevated mercury level of 68 mcg/L (reference range <10 mcg/L). Despite this, the patient never developed signs or symptoms of mercury poisoning.

CONCLUSION

Patients in whom elemental mercury is retained in the appendix, who are without symptoms and have normal gastric mucosa, may be conservatively managed without surgery.

Origin of acute appendicitis: fecal retention in colonic reservoirs: a case control study

BACKGROUND

Appendicitis is encountered predominantly in Western, industrialized countries. Animal experiments and clinical studies have suggested an obstructive fecalith as a cause of acute appendicitis. It was hypothesized that patients with acute appendicitis would have a longer colonic transit time and more fecal retention reservoirs (coprostasis) than healthy control persons, thus favoring the occurrence of a fecalith in the appendix.

METHODS

Sixty-eight patients scheduled for appendectomy were included in this approved study. Before surgery, a plain abdominal radiograph was taken; at surgery, the degree of inflammation of the appendix was recorded, along with the presence or absence of a fecalith. Six weeks postoperatively, the patients underwent a colonic transit study. A cohort of 44 control persons over 18 years of age was selected at random to undergo the same marker study as the patients. The parameters studied were the number of radiopaque markers (h), the fecal retention or load (score 0-3) in the right, left, and distal colonic segments, and the number of fecaliths.

RESULTS

Twelve patients were excluded; i.e., 56 patients and 44 controls were eligible for most analyses. In the patient group, statistically significant correlations were found between fecal loading scores and the number of markers (transit time) both overall and within the left and distal colonic segments (all p < 0.05). In the control subjects, there was significance with regard to the distal segment. The median colon transit time was 25.0 h (range 1-107 h) in patients with appendicitis compared with 19.0 h (range 0-71 h) in controls (p = NS). The transit time was longer in the right, left, and distal colon in patients than in control subjects, although not to a statistically significant extent. The total and segmental fecal loads in the colon did not differ significantly between patients and controls. A fecalith occurred in 49.0% of the patients and was in most cases associated with a gangrenous or perforated appendix. If a fecalith was not found, this correlated to a significant extent with a high fecal loading score in the left colon (p = 0.04).

CONCLUSIONS

An obstructive fecalith occurred in one-half of the patients with acute appendicitis. The appendicitis patients had a colonic transit time similar to that in healthy controls. Furthermore, there was no difference in colonic fecal loading between patients and controls. In consequence, the occurrence of a fecalith could not be attributed to delayed colonic transit or fecal loading. However, we discovered greater amounts of feces in the colon of both patients and controls than would have been expected physiologically, and the role of these fecal reservoirs has yet to be understood.

Incidence and odds ratio of appendicitis as first manifestation of colon cancer: a retrospective analysis of 1873 patients

BACKGROUND AND AIM

Obstruction of the lumen of the appendix is the major cause of appendicitis. Tumors could obstruct this lumen and cause appendicitis in the elderly. The association between appendicitis and colon cancer has not been sufficiently investigated, and this study was designed to clarify this association.

METHODS

This was a retrospective study. Patients diagnosed with acute appendicitis from January 1998 to December 2003 at the Taipei Veterans General Hospital were surveyed. Patients found to have colon cancers immediately or subsequently after appendectomy were included and analyzed.

RESULTS

A total of 1873 patients were diagnosed as having appendicitis of whom 16 were found to have colon cancer. The incidence of appendicitis associated with colon cancer was 0.85%. The time from appendectomy to the recognition of colonic cancer was at a median delay of 5.8 months. From the Taiwan Cancer Research Annual Report, the incidence of colon cancer was 31.91/100,000 in the year 2000. The odds ratio of colon cancer incidence had a 38.5-fold increase among patients older than 40 with acute appendicitis.

CONCLUSIONS

In patients over 40 years who present with symptoms of acute appendicitis the possibility of a coexistent colonic neoplasm should always be kept in mind. These patients should undergo colonoscopy 6 weeks after surgery to exclude the possibility of a coexistent colorectal cancer.

Management of carcinoma discovered unexpectedly at operation for acute appendicitis

This review of 900 patients who underwent colon resection for carcinoma identified 33 patients who were explored with the preoperative diagnosis of appendicitis. In 19 patients, the appendix was acutely inflamed secondary to obstruction of the appendiceal lumen. The other 14 patients had perforating or obstructing cancer of the ascending colon or cecum. The clinical clues of a prolonged symptom history, weight loss, anemia, and a palpable mass were frequently, but not invariably, present. Results of contrast enema, computerized axial tomography, and colonoscopy in this select group were frequently misleading. The diagnosis is best made in the operating room by the thoughtful appendectomist. I recommend prompt resection and an appropriate cancer procedure in these patients. Carcinoma masquerading as appendicitis occurs more often than is generally realized and will be seen more frequently as our aging population increases.

Appendiceal filling by double-contrast barium enema

The barium enema is a safe and useful diagnostic modality in the evaluation of patients with suspected acute appendicitis. Complete appendiceal filling with barium virtually excludes this diagnosis. Frequently positive diagnostic information is obtained. Only 1 study in the literature documents the frequency of normal appendiceal filling by barium enema. The authors utilized the single-contrast technique. We recorded the frequency of normal appendiceal filling with the double-contrast technique and then compared our data with the previously published study to determine if there is a significant clinical disadvantage to the double-contrast technique when acute appendicitis is a diagnostic consideration.