Summary: A 65-year old woman presented to the emergency department with
abdominal pain that began earlier the same day. She complained of nausea
and loss of appetite. The patient had been recently diagnosed with
osseous metastatic lung cancer. Medications included only
acetaminophen/oxycodone for pain management. Her surgical history was
significant for a laparoscopic appendectomy with pathology-proven
appendicitis performed approximately 29 months prior to this visit.
admission, the patient’s physical examination revealed severe
generalized abdominal tenderness with more focal epigastric tenderness
and guarding without rebound. Routine laboratory studies revealed a
leukocytosis (white blood cell count = 17.7 cells/ microliter) with an
increased percentage of neutrophils (15%). Differential diagnosis
included gastroenteritis, inflammatory bowel disease, pancreatitis,
peptic ulcer and biliary disease. The emergency physician was concerned
about the patient’s abdominal pain and ordered a computed tomography
(CT) scan of the abdomen and pelvis following the administration of
intravenous and oral contrast agents.
CT images demonstrated a dilated blind-ending tubular structure
measuring 1.4 cm in diameter, and extending from the base of the cecum
with associated inflammatory fat stranding, consistent with an inflamed
appendiceal remnant (Figure 1). Residual staples from prior appendectomy
were noted at the distal aspect of the remnant. A sagittal reformatted
image showed an inflamed, appendiceal stump without free intraperitoneal
air or abscess formation (Figure 1). The patient underwent laproscopic
appendectomy with removal of a residual 4-cm-long inflamed appendiceal
stump. The pathology report described appendicitis within the residual
appendix without perforation.
A review of previous imaging studies
revealed a CT scan of the abdomen and pelvis performed for cancer
staging one month prior to the current visit. This scan showed a thin
appendiceal stump in the right lower quadrant with surgical clips from
prior appendectomy (Figure 2). A more remote CT scan of the abdomen and
pelvis performed approximately 29 months before revealed appendicitis
with an associated appendicolith. A laparoscopic appendectomy was
performed with pathology confirming the diagnosis (Figure 3).
Stump appendicitis is a rare entity that occurs as a result of
inflammation of the appendiceal remnant. It may occur from 2 months to
50 years following either laproscopic or open appendectomy.1,2
The true incidence of stump appendicitis is unknown; however, with the
recent wide availability and liberal utilization of CT for evaluation of
abdominal pain it is being recognized more often. The first documented
case was reported in 1945 by Rose, and since then several cases have
been reported in the surgical literature.3 It is now being
described with greater frequency by radiologists and emergency room
physicians, suggesting a greater acceptance and awareness for this
entity. CT findings include a dilated and inflamed tubular structure
arising from the cecum and separate from the adjacent small bowel. The
inflamed stump has been reported to range in length anywhere from .5 to
5.1 cm.2,4 Additionally, there may be signs of prior surgical
intervention with residual staples at the end of the stump or
inflammatory stranding in the right lower quadrant. Associated
complications such as free air or fluid collection can also be detected
Due to the seriousness of this illness, early recognition
is imperative. Cases reported prospectively may obviate serious
complications such as perforation or abscess formation.5-7
The clinical symptoms of stump appendicitis resemble that of acute
appendicitis: nausea, vomiting, abdominal pain, anorexia and
leukocytosis. Patients relate a history of appendectomy which may bias
physicians against the diagnosis of appendicitis.
In this case, CT was used to prospectively suggest the diagnosis of
stump appendicitis, with pathology confirming the diagnosis. We were
also fortunate to be able to show the elegant evolution of the disease
process with previous CT scans.
- Wright TE, Diaco JF. Recurrent appendicitis after laproscopic appendectomy. Int Surg. 1994;79:251-252.
- Mangi AA, Berger DL. Stump appendicitis. Am Surg. 2000;66:739-741.
- Rose TF. Recurrent appendiceal abscess. Med J Aust. 1945;32:652-659.
- Watkins BP, Kothari SN, Landercasper J. Stump appendicitis Case report and review. Surg Laparosc Endosc Percutan Tech. 2004;14:167-171.
- Rao PM, Sagarin MJ, McCabe CJ. Stump appendicitis diagnosed preoperatively by computed tomography. Am J Emerg Med. 1998;16:309-311.
- Thomas SE, Denning DA, Cummings MH. Delayed pathology of the appendiceal stump: a case report of stump appendicitis and review. Am Surg. 1994;60:842-844.
- Shin LK, Halperin D, Weston SR, Meiner EM, Katz DS. Prospective CT diagnosis of stump appendicitis. AJR 2005;184:S62-S64.