Endometriosis of the appendix: Report of three cases

Acute abdominal pain in women of reproductive age: keys to suggest a complication of endometriosis

Although endometriosis is a common gynecological condition in women of reproductive age, a complication of endometriosis is rarely considered as the differential diagnosis of acute abdominal pain in that context. However, acute events in women with endometriosis can represent life-threatening conditions, which require emergent treatment and often surgical management. Mass effect of endometriotic implants can give rise to obstructive complications, specifically occurring in the bowel or in the urinary tract, while inflammatory mediators released by ectopic endometrial tissue can lead to inflammation of the surrounding tissues or to superinfection of the endometriotic implants. Magnetic resonance imaging is the best imaging modality to reach the diagnosis of endometriosis, but an accurate diagnosis is possible on computed tomography, especially in the presence of stellar, mildly enhanced, infiltrative lesions in suggestive areas. The aim of this pictorial review is to provide an image-based overview of key findings for the diagnosis of acute abdominal complications of endometriosis.

Inverted appendix in a patient with colon cancer: a case report and long-term follow-up

Appendiceal inversion is a rare entity that can potentially mimic serious pathology and provide diagnostic uncertainty. They are mostly diagnosed intraoperatively or during endoscopies and scans for other reasons. We report a case of an asymptomatic patient treated for colon cancer without previous history of appendectomy. We provide long-term follow-up and aim to review the relevant literature.

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.

Vermiform Appendix and the Potential for Missed Pathologies

Introduction

The appendix is considered an appendage of little value and is often treated disdainfully, be it as part of evolutionary process, on a grossing table, under a microscope or while archiving specimens and slides. It is only recently, with data indicating its importance in gut immunity and as the origin of pseudomyxoma, that its space in a human body appears vindicated.

Aim

Our aim was to screen the histopathologic spectrum of appendix lesions observed in our hospital for rare, incidental or clinico-radiologically uncertain lesions that would help emphasize a necessary seriousness in its sampling.

Method

All appendectomy specimens over ten years were screened for diagnosis other than acute/chronic/resolving appendicitis and pseudomyxoma peritonei. Among the recorded rare diagnoses, one representative case each, based on interesting history or pathology, was selected for discussion.

Observation

Forty-three lesions were found to meet inclusion criteria comprising 12 varied etiologies. Among these, 25 had a normal-appearing appendix and 27 were not suspected on radiology or on clinical/surgical assessment. Histopathology comprised, among others, neoplastic entities such as (Diffuse large B-cell) lymphoma, metastasis, carcinoid as well as interesting non-neoplastic diagnoses such as pinworm infestation (in the elderly) and (post-menopausal) endometriosis.

Conclusion

Sampling and histopathologic assessment of the appendix should be compulsory, careful and representative. Each specimen must be treated as harboring a potential pathology, until microscopically proven otherwise because missed “rare” diagnoses could delay therapy or alter key management decisions as cancer staging.

Ileocecal intussusception as the initial presentation of endometriosis: case report

Cecal endometriosis is a rare entity that can present as nonspecific acute abdominal pain and can be complicated by ileocolic intussusception, which is extremely infrequent. We present the case of a 33-year-old woman with no relevant pathological antecedents who consulted for abdominal pain for 5 days, associated with rebound tenderness and abdominal guarding on the right lower quadrant and a palpable mass during the physical examination. Computed tomography was realized and emergency surgery performed due to suspected ileocolic intussusception. The laparoscopic examination identified an ileocolic intussusception associated with a tumor. Conversion to open surgery was needed, and an oncological right hemicolectomy with ileotransverse anastomosis was carried out. Histopathological study reported ileocolic intussusception and a focus of cecal endometriosis. Currently, the patient does not have recurrences. Ileocolic intussusception secondary to deep endometriosis requires great diagnostic presumption in women of childbearing age with acute abdomen diagnosis.

A Rare Case of Endometriosis of the Small Bowel

Endometriosis of the small bowel is a rare clinical event. The clinical condition presents with vague abdominal symptoms and is usually not diagnosed acutely, unless clinicians have a high index of suspicion. Most patients are diagnosed after multiple clinical encounters. We present a case of endometriosis causing small bowel obstruction diagnosed postsurgically.

Endometriosis: A Clinicopathological Study in a Tertiary Care Hospital

Background  Endometriosis (EM) is an estrogen-dependent disease characterized by the presence of endometrial gland and stroma outside the uterus. It is commonly seen in the reproductive age group and is a leading cause of infertility. Patients present with chronic pelvic pain, menstrual abnormalities, dyspareunia, or mass per abdomen. Surgical excision is the treatment of choice with postoperative medications and progesterone agents.

Aims and Objectives  This study aims at determining the distribution of EM in terms of age, parity, symptoms, site, morphological features. We also analyzed the management of EM in these cases.

Methodology  This is a retrospective study done in a tertiary care hospital in Mangalore, India. The case records of 77 histopathologically confirmed cases of EM during the 7 years between June 2012 and May 2019 were studied. Demographic profiles, parity, presenting complaints, site of the lesion, morphological features, treatment given, follow-up, and recurrence were noted and analyzed.

Results  Of the 77 patients with EM, the most common age group was the fourth decade (40%). The majority (31, 40.25%) of the patients in this study were nulliparous. Chronic pelvic pain was the most common symptom. The most frequent site was ovary.

Conclusion  The most frequent site of EM is ovary, leading to infertility. With the advent of laparoscopy, early diagnosis and excision have been feasible. The histopathological examination should be done for confirmation. Awareness of this disease among health care professionals is necessary whenever a woman in reproductive age presents with chronic pelvic pain and infertility.

Emergency surgery for appendectomy and incidental diagnosis of superficial peritoneal endometriosis in fertile age women

RESEARCH QUESTION

This study aimed to evaluate the presence of superficial peritoneal endometriosis (SUP) in women referred to emergency surgery for right iliac fossa (RIF) pain and undergoing an appendectomy, considering which factors may be useful to suspect and identify endometriosis.

DESIGN

An observational case-control study was conducted on a group (n = 149) of fertile age women. After surgery, Group A was selected upon the diagnosis of endometriosis (n = 34); Group B (n = 115) represented the controls. Demographics, comorbidities and clinical findings were registered and analysed.

RESULTS

Appendicitis of various grades of severity was diagnosed in all patients, but SUP was also identified in 23%, of which 14.7% also presented with endometriosis of the appendix. Women in Group A reported chronic pelvic pain, dysmenorrhoea, dyspareunia and oral contraceptive use more frequently. At multivariate analysis, factors associated with endometriosis were: age <40 years, autoimmune disorders, multiple allergies, abdominal chronic pain, associated gynaecological pain symptoms, Alvarado score ≤6, and inconclusive ultrasound findings.

CONCLUSIONS

The incidental finding of SUP in fertile age women presenting with an acute RIF pain and undergoing emergency surgery is a relevant observation. Clinical history and symptoms should guide surgeons in performing a correct diagnosis and in referring the patient to the gynaecology specialist.

Appendiceal Endometriosis Presenting as Possible Cecal Mass

BACKGROUND

Endometriosis is endometrial tissue located outside of the uterus. Endometriosis is rarely found in the appendix and can present very similar to acute appendicitis and is often indistinguishable on physical exam and imaging. The diagnosis is typically made after an appendectomy on pathology.

CASE SUMMARY

A 45-year-old female presented with right sided abdominal pain and CT revealed a possible cecal or appendiceal lesion. Colonoscopy revealed a submucosal non-obstructing cecal mass. In the operating room, the appendix was completely adherent to the cecum and a laparoscopic ileocecectomy was performed. Pathology revealed endometriosis of the appendix and cecum.

DISCUSSION

Endometriosis of the appendix is a rare condition reported in less than 1% of females that is diagnosed after an appendectomy is performed for suspected appendicitis or other pathology. This diagnosis is made based on the finding of endometrial glands and stroma in the appendix. This can present as acute appendicitis or appendiceal or peri-appendiceal mass on imaging. When symptomatic, pain can align with the menstrual cycle and hemoperitoneum may be encountered intra-operatively. Treatment can be appendectomy, ileocecectomy, or right hemicolectomy if malignancy is suspected. In the patient we described, an ileocecectomy was performed with the intention of converting to a right hemicolectomy if the frozen section pathology had revealed malignancy. This case illustrates the importance of having a broad differential when diagnosing patients with abdominal pain, especially in women of childbearing age.

CONCLUSION

Appendiceal endometriosis should be considered in females of childbearing age with abdominal pain or cecal/appendiceal mass on imaging.

Endometriosis of the Vermiform Appendix Presenting as Acute Appendicitis

Endometriosis is characterized by the growth of endometrial tissue outside the uterine cavity. Endometriosis of the appendix is rare and its preoperative diagnosis is difficult. We report the case of a postmenopausal woman who presented with right lower quadrant abdominal pain concerning for acute appendicitis. Histopathological examination of her appendix revealed endometriosis and her abdominal pain resolved after appendectomy.

A rare case of right lower quadrant pain

Endometriosis of the appendix is a very rare entity and commonly affects females in childbearing age. Clinical presentation might be confusing varying from asymptomatic to acute abdominal pain and often mimicks acute appendicitis or chronic pelvic pain. Diagnosis is generally made after pathological examination as operative findings are usually non-specific. This condition poses a diagnostic challenge to radiologists and surgeons altogether and we therefore report a case of a middle aged female who presented with both right lower quadrant and right lower back pain. Recent literature is reviewed and radiological findings discussed.

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 duplex appendix: A case report and review of the literature

BACKGROUND

Duplication of the appendix is an infrequent congenital malformation with a complex classification. The horseshoe appendix is a subtype of the duplex appendix and is rarely reported in the literature. Endometriosis is a common gynecological disease that rarely occurs in the appendix. Moreover, horseshoe appendix combined with endometriosis has not been previously reported.

CASE SUMMARY

Here, we describe a 44-year-old woman who was admitted with a 1-d history of migratory lower right quadrant pain. Physical examination was consistent with the signs of acute appendicitis. The patient underwent an emergency exploratory laparotomy. The distal tip of the appendix was in contact with the cecum by another base, or "horseshoe appendix". In addition, a small intestinal mass and an ovarian mass were identified. Subsequently, appendectomy, partial resection of the small intestine, and right oophorectomy were successively performed. The histopathology confirmed the diagnosis of acute inflammation of the duplex appendix with endometriosis, small intestine endometriosis, and ovarian endometriosis.

CONCLUSION

Surgeons need to be aware of the possibility of the duplex appendix when performing an appendectomy, and this study emphasizes the importance of exploring the entire abdomen.

An inverted appendix found on routine colonoscopy: A case report with discussion of imaging findings

Appendiceal inversion is an uncommon incidental finding on colonoscopy that can mimic pathologic processes such as colon polyps and neoplasms due to its mass-like appearance. Endoscopic removal of these lesions has been associated with a higher risk of peritonitis and bleeding. Awareness of appendiceal inversion may potentially decrease unwarranted interventions as well as its associated risks. Although there are many reported cases of iatrogenic appendiceal inversion due to the traditional inversion-ligation technique performed during open appendectomy, there are few reported cases of asymptomatic appendiceal inversion without a known history of iatrogenic inversion. Here, we present a case of an asymptomatic patient with appendiceal inversion and no prior history of appendectomy. Furthermore, we discuss management and characteristic imaging findings of appendiceal inversion that may help to distinguish it from similarly appearing pathologic conditions.

Appendectomy Scar Endometriosis: A Case Report

Scar endometriosis is one of the rare cases of surgery, which specifically occurs in gynecological surgeries. It is important to do a correct diagnosis in such rare cases to have an efficient treatment. The disease is commonly observed in child-bearing women with clinical manifestations such as acute abdomen or chronic and cyclic pelvic pain. Herein we reported a case of appendectomy scar endometriosis.

Abdominal Pain in the Female Patient: A Case of Concurrent Acute Appendicitis and Ruptured Endometrioma

General surgeons are often asked to evaluate acute abdominal pain which has an expanded differential diagnosis in women of childbearing age. Acute appendicitis accounts for many surgical emergencies as a common cause of nongynecologic pelvic pain. In some rare instances, acute appendicitis has been shown to occur simultaneously with a variety of gynecologic diseases. We report a case of concurrent acute appendicitis and ruptured ovarian endometrioma.

Sigmoid colon endometriotic mass. A rare cause of complete large bowel obstruction

Large bowel obstruction is a rare complication of gastrointestinal endometriosis. A 32-year-old female patient presented to the emergency department with complaints of diffuse abdominal pain and constipation for 10 days with progressive abdominal distention and vomiting. Plain abdominal x-ray showed grossly dilated large bowel up to the sigmoid colon with no gas in the rectum. Abdominal computed tomography revealed hugely dilated large bowel up to the sigmoid colon, with sigmoid soft tissue mass. Flexible sigmoidoscopy showed a non-ulcerating sigmoid mass, with complete obstruction of the sigmoid colon, which impeded the further advancement of the scope. She underwent exploratory laparotomy with provisional diagnosis of complete large bowel obstruction due to sigmoid tumor. Sigmiodectomy with end colostomy was performed. Histopathology revealed endometrial glands with stroma in muscularis properia of the sigmoid colon mass. Endometriosis should be considered in women of reproductive age presenting with symptoms of large bowel obstruction.

Endometriosis of the Vermiform Appendix within a Hernia Sac Infiltrating the Pubic Bone

Purpose. Appendicular endometriosis mimicking appendicitis is a rare finding. Inguinal tumor in the course of appendicular endometriosis located within an inguinal hernia sac and infiltrating the periosteum of the pubic bone has not yet been described. Case Report. This paper describes a case of a rapidly enlarging, solid, unmovable, very painful upon palpation inguinal tumor, in a 36-year-old nulliparous woman. During surgery, a hard (approximately 4 cm in diameter) tumor infiltrating the periosteum of the right pubic bone and continuous with the inguinal hernia sac was dissected. The distal segment of the vermiform appendix was an element of the dissected tumor. Histological examination revealed endometriosis of the distal vermiform appendix. After 6 months of hormone treatment, she was referred for reoperation due to tumor recurrence. Once again histological examination of the resected tissue revealed endometriosis. There was no further recurrence of the disease with goserelin therapy. In addition to the case report, we present a review of the literature about endometriosis involving the vermiform appendix and the inguinal canal (Amyand's hernia). Conclusion. This case expands the list of differential diagnoses of nodules found in the inguinal region of women.