Intususcepción apendicular por foco endometriósico: un caso clínico / Appendiceal intussusception caused by endometriosis: a clinical case

Resumen Objetivo: Reportar el caso de una paciente con intususcepción apendicular (IA), condición infrecuente, secundario a foco de endometriosis, patología que en los últimos años ha presentado un aumento en su incidencia. Material y Método: Historia clínica, imágenes preoperatorias e intraoperatorias obtenidas de la ficha clínica. Resultados: Mujer de 35 años con dolor abdominal crónico de 4 meses de evolución. Se realiza estudio colonoscópico evidenciando lesión de 15 x 8 mm en ostium apendicular intususceptada al lumen cecal, y enteroclisis por tomografía axial computarizada (TC) que confirma IA. Se realiza una resección ileocecal laparoscópica demostrando la invaginación del apéndice con biopsia que muestra un foco de endometrioma. Discusión: La IA es una condición infrecuente con una incidencia cercana al 0,01% en la población general. Las patologías benignas son la principal causa (77%), siendo la endometriosis la causa más frecuente. Conclusión: La IA por endometriosis es anecdótica, con sintomatología poco específica. Los estudios disponibles pueden orientar adecuadamente la presencia de IA, sin embargo, en algunas ocasiones puede confundirse con patologías neoplásicas, donde cobra importancia la cirugía para dilucidar la etiología.

Objective: To report the case of a patient with appendicular intussusception (AI), an infrequent condition secondary to a focus of endometriosis, a pathology that has increased incidence in recent years. Material and Method: Clinical case, history and images obtained from the clinical file and intraoperative records with the consent of the patient. Results: A 35-year-old woman with abdominal pain. Colonoscopy study showing a 15 × 8 mm lesion in the appendicular ostium intussuscepted to the cecal lumen, and a computerized tomography (CT) enteroclysis confirming AI. A laparoscopic ileocecal resection is performed, demonstrating invagination of the appendix secondary to an endometrioma focus. Discussion: AI is a rare condition, with an incidence close to 0.01% in the general population. Benign pathologies are the main cause (77%), endometriosis being the most frequent cause. Conclusion: AI due to endometriosis is anecdotal, with unspecific symptoms. The available studies can adequately guide the presence of AI, however, on some occasions it can be confused with neoplastic pathologies, where surgery is important to elucidate the etiology.

Duplicación del apéndice vermiforme. Reporte de caso / Vermiform appendix duplication - case report

Dar a conocer una presentación inusual de una patología frecuente. Se presenta caso de paciente masculino de 27 años con cuadro clínico de apendicitis aguda. Se realiza apendicetomía abierta en la cual se identifican dos apéndices vermiformes. Se confirma el diagnóstico por medio de anatomía patología, una con apendicitis aguda perforada y otra con peri-apendicitis. Es importante el conocimiento de esta patología para que se pueda reconocer y evitar errores de juicio durante el procedimiento quirúrgico y futuras complicaciones para el paciente. (AU)

Report an unusual presentation of a common pathology. A case of a 27-year-old male with a clinical picture of acute appendicitis is presented. An open appendectomy is performed in which two vermiform appendages are identified. The diagnosis is confirmed by pathology, one with perforated acute appendicitis and the other with peri-appendicitis. Knowledge of this pathology is important so that errors of judgment can be recognized and avoided during the surgical procedure and future complications for the patient. (AU)

Impact of the appendiceal position on the diagnosis and treatment of pediatric appendicitis / Impacto da posição do apêndice sobre o diagnóstico e tratamento de apendicite da infância

ABSTRACT Objective: To investigate how symptoms vary according to the appendiceal position in pediatric patients and to demonstrate that the laparoscopic approach is safe and effective in any appendiceal location by comparing each location to another. Methods: The medical records of 1,736 children aged 14 or younger who underwent laparoscopic appendectomy over a period of 14 years were analyzed retrospectively. Patients were divided according to the position of the appendiceal tip into four groups: anterior, pelvic, retrocecal and subhepatic. The Kruskal-Wallis and chi-square tests were used with the Bonferroni correction, with a significant p<0.05. Results: The appendiceal location was anterior in 1,366 cases, retrocecal in 248 cases, pelvic in 66 cases and subhepatic in 56 cases. There were no significant differences between the groups in terms of patient age and gender. Abdominal pain was the only symptom with statistically significant differences between the groups. The rate of perforated appendicitis was higher in the subhepatic and pelvic positions. Intraoperative complications and conversions were not statistically significant. Technical difficulties and operative time were higher in subhepatic position. The rate of postoperative complications was similar between the different locations, except for bowel obstruction, which was higher in pelvic appendicitis. Conclusions: The clinical symptoms of appendicitis hardly ever change with the position of the appendix. The laparoscopic approach is safe and effective, regardless the appendiceal location.

RESUMO Objetivo: Investigar como os sintomas variam de acordo com a posição do apêndice em pacientes pediátricos e demonstrar que a laparoscopia é segura e eficaz em qualquer posição do apêndice, comparando-as. Métodos: Os prontuários de 1.736 pacientes pediátricos com idade ≤14 anos submetidos à apendicectomia laparoscópica em um período de 14 anos foram analisados retrospectivamente. Os pacientes foram divididos de acordo com a posição do apêndice: anterior, pélvica, retrocecal e sub-hepático. Os testes de Kruskal-Wallis e do qui-quadrado foram usados com a correção de Bonferroni, sendo significante p<0,05. Resultados: A posição do apêndice era anterior em 1.366 casos, retrocecal em 248 casos, pélvica em 66 casos e sub-hepática em 56 casos. Não houve diferenças significativas entre os grupos quanto às variáveis idade e sexo. A dor abdominal foi a única variável com diferenças estatisticamente significantes entre os grupos. A taxa de apêndice perfurado foi superior nas posições sub-hepática e pélvica. As complicações intraoperatórias e a taxa de conversão não foram estatisticamente significativas. As dificuldades técnicas e o tempo cirúrgico foram superiores em posição sub-hepática. A taxa de complicações pós-operatórias foi semelhante entre as diferentes posições, exceto a obstrução intestinal, que foi superior em posição pélvica. Conclusões: Os sintomas da apendicite dificilmente variam com a posição do apêndice. A laparoscopia é segura e eficaz, independentemente da posição do apêndice.

Diferenciar la apendicitis con o sin fecalito ¿puede cambiar el enfoqueterapéutico?: Resultados preliminares / Differentiating between appendicitis with or without fecalith to change the therapeutic approach: Preliminary results

Antecedentes: el manejo de los pacientes con apendicitis aguda fue clásicamente quirúrgico. En la era de los antibióticos se plantean nuevos paradigmas terapéuticos. La diferencia en el origen de la apendicitis podría establecer el tratamiento por elegir. Objetivo: analizar si la presencia de fecalito en una apendicitis puede condicionar un tratamiento quirúrgico o solo con antibióticos. Material y métodos: análisis descriptivo observacional de las diferencias intraoperatorias y anatomopatológicas de los pacientes operados por apendicitis aguda, divididos en 2 grupos según presentaran fecalito o hiperplasia linfoidea como causa de origen. Se utilizó la prueba de Chi2 para la comparación de ambos grupos, tomando un valor de p<0,05. Resultados: el grupo de apendicitis por fecalito presentó un estadio más avanzado de la enfermedad, con líquido libre con más frecuencia (el 67% de los pacientes con apendicitis aguda por fecalito vs. el 18% en el grupo de apendicitis aguda por hiperplasia), en más de una localización (solo el grupo con fecalito presentó líquido en el fondo de saco de Douglas o en el resto del abdomen, en el 50% y 16,7% respectivamente), con características que variaron entre seroso y purulento y anatomopatológicamente presentaron mayor afectación de las capas histológicas (en el grupo hiperplasia la afectación hasta la mucosa fue 63,6% vs. 16,7%, mientras que en el grupo fecalito fue más frecuente la afectación hasta la serosa 66,6% vs. 27,3%). Conclusiones: los pacientes con apendicitis aguda por hiperplasia linfoidea tendrían menos complicaciones intraabdominales en el posoperatorio y podrían ser buenos candidatos a tratamiento médico solo con antibióticos, evitando la cirugía.

Background: Surgery is the traditional approach for patients with acute appendicitis. In the antibiotic era, new therapeutic paradigms are being proposed. The difference in the cause of appendicitis could establish the treatment of choice. Objective: to analyze if the presence of fecalith in an appendicitis can condition a surgical treatment or only with antibiotics. Material and methods: This observational analysis describes the intraoperative and pathological differences between patients undergoing surgery for acute appendicitis, divided into two groups according to the presence of fecalith or lymphoid hyperplasia as cause of the condition. The chi square test was used to compare the fecalith group versus the lymphoid hyperplasia group using a p value < 0.05. Results: The presence of fecaliths was more commonly associated with advanced stage of inflammation, presence of free peritoneal fluid (67% vs. 18% in the lymphoid hyperlasia group) and in more than one site (50% in the Douglas' pouch and 16.7% in the rest of the abdominal cavity). In this group, peritoneal fluid varied between serous and purulent and more appendiceal layers were involved (63.6% of mucous layer involvement in the lymphoid hyperplasia group vs. 16.7%, while serous compromise was more common in the fecalith group: 66.6% vs. 27.3%). Conclusions: Patients with acute appendicitis due to lymphoid hyperplasia could have lower rate of post-operative complications or could be good candidates for medical treatment with antibiotics alone, avoiding surgery.

Apendicetomía no terapéutica: revisión de 1 año en el Centro Hospitalario Pereira Rossell, Montevideo, Uruguay / Non-therapeutic appendectomy: 1-year review at the Pereira Rossell Hospital Center, Montevideo, Uruguay / Apendicectomia não terapêutica: revisão de 1 ano no Centro Hospitalar Pereira Rossell, Montevidéu, Uruguai

Objetivos: La apendicitis aguda es una de las patologías quirúrgicas más frecuentes en pediatría y la apendicectomía un procedimiento históricamente probado para su tratamiento. Sin embargo, se ha llamado la atención sobre la morbilidad y costos que implican los casos de apendicectomías no terapéuticas (ANT). Realizamos un estudio para determinar la proporción de ANT en nuestro hospital, analizar sus características y plantear hipótesis de trabajo que nos permitan disminuir su incidencia. Métodos: Se realizó un análisis retrospectivo incluyendo todos los pacientes que fueron intervenidos quirúrgicamente desde el 1/1/13 hasta el 31/12/13 con diagnóstico clínico presuntivo de apendicitis aguda, en el Hospital Pediátrico del Centro Hospitalario Pereira Rossell. Se analizaron la edad, el sexo, la vía de abordaje, los hallazgos intra-operatorios, el diagnóstico anátomo-patológico y el uso y los resultados del hemograma y la ecografía. Resultados: En el período mencionado se realizaron 287 apendicectomías en pacientes con diagnóstico de apendicitis aguda, de los cuales 146 (50,87%) fueron operados por medio de un abordaje convencional y 141 (49,13%) por abordaje laparoscópico. El índice de ANT fue de 10,1% siendo similares las tasas para ambas vías de abordaje (10,27% convencional vs 9,92% laparoscópica). Por otra parte, se evidenció una mayor incidencia de ANT en el sexo femenino (16,6% vs 5,8%). Respecto a la franja etaria, la tasa de ANT fue mayor entre los pacientes de 11-15 años(12,19%), mientras que para las edades comprendidas entre 6-10 años fue de 8,08% y para los pacientes de 0-5 años fue de 4,16%. De los 29 pacientes que presentaron apéndice sano, 12 presentaban adenitis mesentérica, una paciente presentaba una rotura folicular y una paciente presentaba una peritonitis de causa médica. En 15 pacientes no se encontraron otras alteraciones. Conclusiones: El índice de apendicectomías no terapéuticas en nuestro hospital fue del 10,10% en el año 2013. La experiencia internacional y algunos trabajos nacionales demuestran que este resultado es mejorable. Se plantea la utilización de algoritmos clínicos para mejorar la presunción diagnóstica y hacer el mejor uso de los recursos diagnósticos disponibles, así como la instauración de un sistema de registro y análisis prospectivo de los resultados clínicos en apendicitis aguda.

Objectives: Acute appendicitis is one of the most frequent pediatric surgical diseases and appendectomy is a historically proved treatment. However, attention has been directed at morbidity and costs of negative appendectomy (NA). Here we analyze the incidence of NA at our hospital and its characteristics in order to propose a working hypothesis that allows a decrease in its incidence. Methods: A retrospective analysis including all patients who underwent surgery from 01/01/13 to 31/12/13, with presumptive clinical diagnosis of acute appendicitis, in the Pediatric Hospital of the Pereira Rossell Hospital Center, was done. Age, sex, surgical approach, operative findings, pathologic diagnosis and the use and results of laboratory and ultrasound, were analyzed. Results: In the referred period, appendectomies were performed in 287 patients with diagnosis of acute appendicitis, of which 146 (50.87%) were operated by a conventional approach and 141 (49.13%) by laparoscopic approach. The NA were 10.10%, with similar rates for both approaches (10.27% vs 9.92%, conventionalvs laparoscopic).A higher incidence of of NA was evident in girls, (16,6% vs 5,8% conventionalvs. laparoscopic ).With respect to the age group, the rate of NA was higher among 11-15 years old patients (12,19%), while for those aged between 6-10 years it was 8.08 % and for patients aged 0-5 years it was 4.16%. Of the 29 patients who had a healthy appendix, 12 had mesenteric adenitis, one patient had a follicular rupture and other had a medical peritonitis. In 15 patients no other abnormalities were found. Conclusions: The NA rate at our Hospital was 10.10% during 2013. The international experience and some national works prove that this result is improvable. We propose the utilization of clinical scores in order to improve clinical diagnostic and rational use of ancillary resources and the installation of a prospective registry and analysis system of results in acute appendicitis.

Objetivos: A apendicite aguda é uma das patologias cirúrgicas mais frequentes em pediatria e apendicectomia, um procedimento historicamente comprovado para seu tratamento. Entretanto, a atenção e a morbidade e os custos envolvidos em casos de apendicectomias não terapêuticas (ANT) chamaram a atenção. Realizamos um estudo para determinar a proporção de ANT em nosso hospital, analisamos suas características e propomos hipóteses de trabalho que nos permitem reduzir sua incidência. Métodos: Realizamos uma análise retrospectiva, incluindo todos os pacientes submetidos à cirurgia de 1/1/13 a 12/31/13 com diagnóstico clínico presumível de apendicite aguda no Hospital Pediátrico do Centro Hospitalar Pereira Rossell. Analisamos a idade, sexo, abordagem, achados intra-operatórios, diagnóstico anatomopatológico e o uso e resultados de hemograma e ultra-som. Resultados: no período mencionado, foram realizadas 287 apendicectomias em pacientes com apendicite aguda, dos quais 146 (50,87%) foram operados por abordagem convencional e 141 (49,13%) por abordagem laparoscópica. O índice ANT foi de 10,1% com taxas semelhantes para ambas as abordagens (10,27% versus 9,92% laparoscópicas). Por outro lado, houve maior incidência de ANT no sexo feminino (16,6% vs 5,8%). Em relação à faixa etária, a taxa de ANT foi maior entre os pacientes com idades entre 11-15 anos (12,19%), enquanto que para as idades 6-10 anos foi de 8,08% e para pacientes de 0 -5 anos foi de 4,16%. Dos 29 pacientes com apêndice saudável, 12 apresentavam adenite mesentérica, um paciente apresentava ruptura folicular e um paciente apresentava peritonite de grau médico. Não foram encontradas outras alterações em 15 pacientes. Conclusões: A taxa de apendicectomias não terapêuticas em nosso hospital foi de 10,10% no ano de 2013. A experiência internacional e alguns estudos nacionais mostram que esse resultado pode ser melhorado. O uso de algoritmos clínicos para melhorar a presunção diagnóstica e fazer o melhor uso dos recursos diagnósticos disponíveis, bem como o estabelecimento de um sistema de registro e análise prospectiva dos resultados clínicos em apendicite aguda.

Intra-Appendiceal Air at CT: Is It a Useful or a Confusing Sign for the Diagnosis of Acute Appendicitis?

OBJECTIVE: To investigate the significance of intra-appendiceal air at CT for the evaluation of appendicitis. MATERIALS AND METHODS: We retrospectively analyzed 458 patients (216 men, 242 women; age range, 18-91 years) who underwent CT for suspected appendicitis. Two independent readers reviewed the CT. Prevalence, amount, and appearance of intra-appendiceal air were assessed and compared between the patients with and without appendicitis. Performance of CT diagnosis was evaluated in two reading strategies: once ignoring appendiceal air (strategy 1), and the other time considering presence of appendiceal air as indicative of no appendicitis in otherwise indeterminate cases (strategy 2), using receiver operating characteristic (ROC) analysis. RESULTS: Of the 458 patients, 102 had confirmed appendicitis. The prevalence of intra-appendiceal air was significantly different between patients with (13.2%) and without (79.8%) appendicitis (p < 0.001). The amount of appendiceal air was significantly lesser in patients having appendicitis as compared with the normal group, for both reader 1 (p = 0.011) and reader 2 (p = 0.002). Stool-like appearance and air-fluid levels were more common in the appendicitis group than in the normal appendix for both readers (p < 0.05). Areas under the ROC curves were not significantly different between strategies 1 and 2 in reader 1 (0.971 vs. 0.985, respectively; p = 0.056), but showed a small difference in reader 2 (0.969 vs. 0.986, respectively; p = 0.042). CONCLUSION: Although significant differences were seen in the prevalence, amount, and appearance of intra-appendiceal air between patients with and without appendicitis, it has a limited incremental value for the diagnosis of acute appendicitis.

Sensibilidad y especificidad del examen físico para el diagnóstico de apendicitis / Sensitivity an specificity of physical exam for the diagnosis of appendicitis

La apendicitis aguda es la emergencia quirúrgica más común en todo el mundo. En nuestra sala de emergencias, la discriminación inicial para el diagnóstico de la apendicitis se realiza basada únicamente en el examen físico del paciente. El objetivo del estudio es determinar la precisión del examen físico estandarizado para el diagnóstico de apendicitis aguda en el servicio de emergencia del Hospital General San Juan de Dios Diseño, lugar y partcipantes: todos los pacientes mayores de 12 años prospectvamente evaluados de abril a junio 2015 en el servicio de emergencia,cuyo motvo de consulta fue dolor abdominal y sospecha de apendicits. Se documentó la impresión clínica del examinador en base a la anamnesis y elexamen fsico estandarizado, la histopatología de los pacientes operados y el seguimiento a las 48h y a los 30 días de todos los pacientes.Resultados: se evaluaron 85 pacientes. El 61% de los pacientes fueron clasifcados por el investgador sin cuadro clínico de apendicits aguda. La sensibilidaddel examen fsico estandarizado para el diagnóstco de apendicits es de 75%, la especifcidad de 93%, el valor predictvo positvo de 92%, el valorpredictvo negatvo de 79%. El porcentaje de falsos positvos es de 3% y el porcentaje de falsos negatvos es del 12%.Conclusiones: el examen fsico estandarizado no es lo sufcientemente sensible para hacer el diagnóstco de apendicits aguda, por lo que es necesarioagregar estudios complementarios, así como considerar un período de observación intrahospitalaria antes de dar egreso a los pacientes basados únicamenteen el examen fisico.(AU)

Acute appendicits is the most common surgical emergency visit worldwide. In our emergency department, the inital evaluaton for thediagnosis of appendicits is made based solely on the physical examinaton. The aim of the study is to determine the accuracy of standardized physicalexaminaton for the diagnosis of acute appendicits in the emergency department of San Juan de Dios General Hospital.Design, Setng, and Partcipants: All patents over 12 evaluated from April to June 2015 in the emergency department, whose main complaint wasabdominal pain and suspected appendicits. Clinical diagnosis, histopathology and follow-up at 48h and 30 days for all patents were collected.Results: A total of 85 patents were studied, 61% were negatve for appendicits by clinical diagnosis. Standardized physical examinaton for the diagnosisof appendicits has 75% sensitvity, 93%specifcity, 92%positve predictve value, 79% negatve predictve value. The false positve rate is 3% andfalse negatve rate is 12%.Conclusions: the standardized physical examinaton is not sensitve enough for the diagnosis of acute appendicits. It is necessary to consider addingfurther studies as well as an observaton period before hospital discharge.

Correlation between the Alvarado Scale and the macroscopic aspect of the appendix in patients with appendicitis / Correlação entre a Escala de Alvarado e o aspecto macroscópico do apêndice em pacientes com apendicite

Objective: To evaluate the possible association between the scale of Alvarado (EA) and macroscopic appearance (MA) of the appendix in patients with acute appendicitis. Methods: after receiving the diagnosis of acute appendicitis, EA data were collected. During appendectomy, MA data were collected. Data from patients without appendicitis were excluded. The Spearman correlation test was used to compare EA with Appendix MA (p < 0.05). Other variables were represented by simple frequency. The confidence interval (CI) of 95% was calculated for the correlation test. Results: Data were collected from 67 consecutive patients. The mean age was 37.1 ± 12.5 years and 77.6% of patients were male. The Spearman correlation test used for EA and MA was + 0.77 (95% CI 0.65-0.85, p < 0.0001). Conclusion: although correlation was not perfect, our data indicate that a high score on the scale of Alvarado in patients with appendicitis is correlated with advanced stages of the inflammatory process of acute appendicitis. .

Objetivo: avaliar a possível associação entre a escala de Alvarado (EA) e o aspecto macroscópico (AM) do apêndice em pacientes com apendicite aguda. Métodos: depois de receberem o diagnóstico de apendicite aguda, os dados da EA foram coletados. Durante a apendicectomia, os dados do AM foram coletados. Dados de pacientes sem apendicite foram excluídos. O teste de correlação de Spearman foi utilizado para comparar EA e o AM do apêndice (P<0,05). Outras variáveis foram representadas por frequência simples. O intervalo de confiança (IC) de 95% foi calculado para o teste de correlação. Resultados: os dados foram coletados de 67 pacientes consecutivos. A média da idade foi 37,1 ± 12,5 anos e 77,6% dos pacientes foram masculinos. O teste de correlação de Spearman usado para EA e AM foi + 0,77 (IC 95% 0,65 a 0,85, P<0,0001). Conclusão: apesar de a correlação não ser perfeita, nossos dados indicam que uma pontuação elevada da escala de Alvarado em pacientes com apendicite está correlacionada com estágios avançados do processo inflamatório da apendicite aguda. .

Mucocele apendicular asintomático: reporte de caso clínico / Asintomatic appendiceal mucocele: a clinical case report

El mucocele apendicular es un tipo de patología tumoral de baja incidencia. Su diagnóstico frecuentemente es incidental y su manejo es quirúrgico en base a la histología. CASO CLÍNICO: Paciente de sexo masculino, 83 años, diagnosticado de mucocele apendicular de presentación asintomática como hallazgo incidental en una Tomografía Computarizada (TC) de abdomen pelvis. Se realizó seguimiento radiológico cada 6 meses. Cuatro años más tarde, se vuelve sintomático con presencia de dolor en hemiabdomen inferior derecho, de intensidad moderada asociado a dificultad en la marcha y compromiso de estado general. Sele realizó una TC abdomen-pelvis que mostró una lesión quística retrocecal, de mayor tamaño con respecto al examen previo, que contacta con la corteza anterior del tercio inferior del riñón derecho. En el Hospital Clínico Universidad de Chile (HCUCh) se le realiza una hemicolectomía derecha, que requiere de nefrectomíaparcial debido a adhesión de la masa al riñón derecho. Post-cirugía, el paciente evoluciona con diversas complicaciones; entre ellas una sepsis de foco abdominal por un absceso perirrenal, un urinoma con fistula enteral e infecciones recurrentes que prolongaron la estadía hospitalaria. DISCUSIÓN: El mucocele apendicular carece de estudios en base a los que se pueda predecir como evolucionará al ser diagnosticado siendo asintomático. Debido a complicaciones el paciente es sometido a hemicolectomía en lugar de apendicectomía estándar que era la indicada según histología. Por esto, es necesario considerar en estos pacientes, controles radiológicos a menor intervalo de tiempo e incluso tratamiento quirúrgico precoz, con objetivo de evitar complicaciones propias del mucocele...

Appendiceal mucocele is a low incidence tumor, being the cause of between 0.07 to 0.3 percent of all appendectomies. Its diagnosis is often incidental and surgical treatment is based on histology. CASE REPORT: Male patient, 83 years old, diagnosed of appendiceal mucocele presenting as asymptomat icincidental finding in abdominal - pelvic CT performed for other reason. Radiological follow-up was performed every 6 months. Four years later becomes symptomatic with presence of moderate intensity pain in lower right abdomen associated with difficulty in walking and overall commitment. Pelvis CT showed are trocecal cystic lesion, larger compared to the previous review, which contacts the anterior cortex of the lower third of the right kidney. In Clinical Hospital University of Chile (HCUCh) he underwent a right hemicolectomy, requiring partial nephrectomy due to the adhesion of the right kidney. Post- surgery, the patient evolved with various complications including abdominal sepsis for perirenal abscess, urinoma with enteral fistula and recurrent infections that prolonged hospital stay. DISCUSSION: As the mucocele low incidence pathology lacks studies based on that it can predict how it will envolve being asymptomatic. Due to complications, the patient is underwent to hemicolectomy instead of standard appendectomy indicated by histology. Therefore, it is necessary to consider in these patients, radiological controls shorter time interval and even early surgical treatment, in order to avoid complications of mucocele...

A Case of IgG4-Related Sclerosing Mesenteritis Associated with Crohn's Disease / 대한소화기학회지

Sclerosing mesenteritis (SM) is a rare disease characterized by chronic nonspecific mesenteric inflammation and fibrosis of unknown etiology. Some tumefactive SM shows diffuse accumulation of IgG4-positive plasma cells and is considered as a part of the spectrum of IgG4-related disease. An association between inflammatory bowel disease and IgG4-related disease has been indicated. A 45-year-old woman visited our hospital due to weight loss with intermittent lower abdominal discomfort. Pelvic ultrasound revealed a mass-like lesion in the abdominal wall and pelvis MRI demonstrated a 5.9 cm sized wall-enhancing mass with heterogeneous signal intensity from right adnexa to the abdominal wall. Tumor resection and adhesiolysis was done because of severe adhesion with the small bowel, colon, bladder, uterus, and abdominal wall. Appendectomy was also performed due to adhesion and edematous change. Histological examination of the resected mass showed findings that were compatible with IgG4-related SM. The resected appendix showed chronic granulomatous inflammation without evidence of tuberculosis. She was diagnosed with Crohn's disease after undergoing colonoscopy and CT enterography. Herein, we report a rare case of IgG4-related SM that occurred in conjunction with Crohn's disease.

Presentación clínica y detalles morfológicos de la endometriosis en apéndice cecal / Clinical and morphological features of endometriosis in appendix cecal

La endometriosis es la presencia de glándulas y estromaendometriales fuera del útero, siendo la localizaciónapendicular extremadamente rara y generalmenteasintomática, llegándose al diagnóstico incidentalmente,luego de una intervención quirúrgica por apendicitisaguda. A veces simula patologías del tracto digestivo odel aparato genital, incluyendo masas tumorales sospechosasde malignidad. Presentamos tres casos de endometriosisapendicular, dos con clínica de apendicitisaguda. En el tercero había dolor abdominal tipo cólicoen hipogastrio durante la menstruación, con imagentomográfica de tumor pericecal, demostrándose en elestudio histopatológico endometriosis tanto en apéndicececal como en ciego. En los otros dos casos, la anatomíapatológica demostró en uno apendicitis aguda juntoa la endometriosis y en el otro periapendicitis reactiva ala endometriosis. Es nuestro objetivo indicar la importanciaclínico-patológica de la endometriosis a nivel delapéndice cecal, que si bien es de baja incidencia y generalmentese halla incidentalmente, obliga a tenerla encuenta, debido a que en algunos casos puede simulardiversos procesos patológicos abdominales, especialmentetumores...

Endometriosis is the presence of endometrial glands andstroma outside the uterus, appendix location beingextremely rare and usually asymptomatic, incidentallyleading to the diagnosis, after surgery for acuteappendicitis. Sometimes simulated digestive tractdiseases or genital tract, including tumor massessuspicious of malignancy. We present three cases ofappendiceal endometriosis, two with symptoms of acute appendicitis. In the third had abdominal cramping painin lower abdomen during menstruation, with pericecaltomographic imaging of tumor, histopathologydemonstrated in the Appendix both cecal endometriosisas ceccum. In the other two cases, the pathologydemonstrated in an acute appendicitis with endometriosisand other reactive periappendicitis endometriosis. Itis our objective to indicate the clinicopathologicalsignificance of endometriosis at the appendix, whichalthough low incidence and is usually incidentally,requires it to account, because in some cases cansimulate different pathological processes abdominalespecially tumors...

Invaginación intestinal recurrente secundaria a apéndice cecal invaginado: caso clínico / Recurrent intussusception secondary to invaginated cecal appendix. Case report

Introducción: La invaginación intestinal es una patología de causa idiopática en el 95 por ciento de los casos, encontrándose en el 5 por ciento restante algún factor desencadenante que la justifique. Las recurrencias se presentan en un 7 a 12 por ciento de los casos y se asocian a múltiples causas. El objetivo de este trabajo es presentar el caso de un paciente con invaginación intestinal recurrente y analizar la causa de la recurrencia. Caso clínico: Paciente de 1 año y 4 meses de edad, sexo masculino, con antecedente de primer episodio de Invaginación intestinal operado a los 4 meses de edad. Presenta segundo episodio de invaginación a los 9 meses de edad, la cual se trató con desinvaginación neumática y a los 16 meses de edad presentó su tercer episodio, manejandose con desinvaginación hidrostática. Ocho horas post procedimiento el paciente presentó nueva invaginación; se realizó reducción manual quirúrgica. Se encontró una invaginación ileocólica con un remanente apendicular intracecal actuando como cabeza invaginante. Se reseco remanente y se envió a biopsia. Conclusiones: La invaginación intestinal recurrente se asocia a factores anatómicos desencadenantes, por lo cual al presentar recurrencias se debe tener en consideración una posible causa orgánica, ante lo cual se recomienda el tratamiento quirúrgico.

Introduction: Intussusception is an idiopathic pathology that accounts for 95 percent of cases found; the remaining 5 percent is caused by some triggering events. Recurrences occur in 7 to 12 percent of cases and are associated with multiple causes. The aim of this research is to present the case of a patient with recurrent intussusception and analyze the cause of the recurrence. Case report: The patient was a 16 month-old male infant with a history of first episode of intussusception surgery at 4 months old. His second intussusception episode took place at 9 months of age, which was treated with pneumatic reduction process; at 16 months of age he presented his third episode, which was treated with hydrostatic reduction process. 8 hours post procedure, the patient had a new intussusception condition and surgical manual reduction was performed. Ileocolic intussusception was found with an appendiceal intrathecal remnant acting as the invaginating head. Remnant was removed and sent for biopsy. Conclusions: Recurrent intussusception is associated with triggering anatomical factors; therefore, in the case of recurrences, a possible organic cause should be considered and surgical treatment is recommended.

Appendicular endometriosis as a cause of chronic abdominal pain alone in the right iliac fossa: case report and literature review

Endometriosis is a disease characterized by the presence of ectopic endometrial glands and stroma. Although its etiology is undefined, it is suggested to be a result of coelomic metaplasia, retrograde menstruation, to provide a genetic component, or to be one that occurs due to blood or lymphatic spread. The involvement of the gastrointestinal tract is common. However, appendicular endometriosis is a rare condition. It is usually asymptomatic. Recurrent pain in the right iliac fossa is an unusual clinical manifestation. There are no non-invasive complementary tests to confirm the diagnosis. Laparoscopy is the main option for research, due to its diagnostic and therapeutic features. A histopathological examination is necessary for the diagnosis. Although surgical and drug therapies have special indications, the combination therapy showed lower symptom recurrence. This study reports a case of appendicular endometriosis that was diagnosed and treated in the service of Coloproctology of the Base Hospital at Faculdade de Medicina of São Jose do Rio Preto. There is also a literature review about this situation. (AU)

Endometriose é uma doença caracterizada pela presença de estroma e glândulas endometriais ectópicas. Apesar de sua etiologia não definida, sugere-se que seja decorrente de metaplasia celômica, menstruação retrógada, apresente componente genético, ou ocorra devido à disseminação linfática ou sanguínea. O acometimento do trato gastrointestinal é comum; no entanto, a endometriose apendicular é condição rara e se apresenta com maior frequência de forma assintomática. Dor recorrente em fossa ilíaca direita é uma manifestação clínica incomum. Não há exames complementares não invasivos que confirmem o diagnóstico. A laparoscopia é a principal opção durante a investigação, por sua característica diagnóstica e terapêutica. O diagnóstico pode ser feito apenas após um exame histopatológico. Embora as terapias medicamentosa e cirúrgica apresentem indicações particulares, a terapêutica combinada mostra menor recorrência dos sintomas. O objetivo do trabalho é relatar um caso de endometriose apendicular diagnosticado e tratado na Disciplina de Coloproctologia do Hospital de Base da Faculdade de Medicina de São José do Rio Preto, além de revisar a literatura acerca dessa situação. (AU)

Invaginación apendicular / Cecal appendix invagination

Cecal appendix invagination was first described by Mc Kidd in 1858, however, due to its low frequency and nonspecific presentation, it is usually a radiological or intraoperative finding. During surgery, the therapeutic approach may vary from an appendectomy to a right hemicolectomy. The selected technique will depend of the suspected diagnosis, which will undoubtedly also influenced by surgeon experience. We present a case of a male patient aged 57 years old, with the intraoperative finding of appendiceal intussusception. The laparoscopic dissection of the cecum revealed an inflammatory appendix, soft to palpation with graspers. A large section of the appendix base with linear stapler was made. The final biopsy and surgical specimen showed an appendiceal inflammation without atypia.

La invaginación del apéndice cecal fue descrita por primera vez en 1858, sin embargo, debido a su baja frecuencia y presentación inespecífica suele constituir un hallazgo radiológico o intraoperatorio. En este último caso la conducta terapéutica puede variar desde la apendicectomía hasta la hemicolectomía, ya que se debe plantear a la neoplasia cecal dentro de los diagnósticos diferenciales y, en virtud de ello, la decisión operatoria puede obligar a la hemicolectomía derecha. Esta decisión se verá influida también por la experiencia del cirujano. Se presenta el caso de un paciente de sexo masculino de 57 años de edad con el hallazgo intraoperatorio de invaginación apendicular. Se realizó una disección amplia del ciego por vía laparoscópica y a la palpación con las pinzas el apéndice y el ciego impresionaban de consistencia blanda, no tumoral. Debido a estos hallazgos se decidió realizar la apendicectomía realizando una sección amplia de la base apendicular con stapler lineal cortante. La biopsia definitiva de la pieza operatoria informó un proceso inflamatorio apendicular sin hallazgos sugerentes de atipías.

Double appendix: report of a case

A 30-year-old female presented to the surgery outpatient department with complaint of pain in right iliac fossa of one day duration. The pain was associated with nausea and vomiting. On examination, there was localized tenderness and rigidity in the right iliac fossa with positive rebound tenderness. Multiple pigmentation of skin in the abdomen, accessory nipple and scoliosis were also noted. Laboratory investigation revealed neutrophilic leukocytosis. Ultrasound abdomen showed an appendix measuring 4 cm in length and a fibroid uterus. Diagnostic laparoscopy revealed an inflamed appendix with a small blind structure in continuity with the cecum. Operative diagnosis of double appendix was made. Microscopic examination confirmed double appendix with features of appendicitis and periappendicitis in the bigger appendix. We report this case because of it rarity. The surgical resident should be aware of this rare congenital anomaly to avoid missing the other appendix in appendectomy procedures and avoid its medico-legal consequences

Management of appendiceal abscess. a 10-year experience in central Saudi Arabia

To study the outcome of patients with appendiceal abscess [AA] following immediate operative and non-operative management in terms of complications and hospital stay. Medical records of all adult patients treated for AA between July 2002 and June 2011 in the Department of Surgery, King Saud Medical City, Riyadh, Kingdom of Saudi Arabia were reviewed. We identified 2 main groups of patients with the diagnosis of AA. The first group of patients were managed by CT-guided percutaneous drainage and parenteral antibiotics [non-operative management [NOM group]]. The second group were patients who underwent surgical intervention [operative management [OM]]. The outcome was determined in terms of complications, recurrence rate, and hospital stay. Eighty AA patients were managed during the study period. Forty-two patients [52.5%] received NOM, while 38 patients [47.5%] underwent immediate OM. The complication rate was significantly higher in the OM group compared with the NOM group [44.7% versus 11.9%; p=0.0012]. Successful NOM was achieved in 92.8% of patients. The overall mean hospital stay of the NOM group was 8.54 +/- 2.25, and the OM group was 10.86 +/- 4.32 days [p=0.003]. Non-operative management is associated with significantly lower complication rate and shorter hospital stay than OM

Prevalencia de enfermedad diverticular del apéndice cecal en pacientes apendicectomizados por apendicitis aguda / Diverticular disease of the appendix in appendectomies

Introduction: Diverticular disease of the appendix is an infrequent finding in the study of surgical specimens from patients operated on for clinically suspected acute appendicitis. Our aim was to determine the prevalence of diverticular disease of the appendix in patients who underwent appendectomies based on the clinical diagnosis of acute appendicitis. Material and Method: Design: Cross-sectional study. Inclusion criteria: Patients who underwent appendectomies based on a clinical diagnosis of acute appendicitis. Studyperiod: january 2000 to december 2008. Sampling: Non-probabilistic sampling of consecutive cases. Methodology: A review was conducted of the clinical records and surgical specimens from patients who underwent appendectomies based on a clinical diagnosis of acute appendicitis. Results: Within the study period, 11.472 appendectomies were performed based on a clinical diagnosis of acute appendicitis. Ninety-four patients presented diverticular disease of the appendix (0.8 percent). The median age was 40 years and 62.8 percent were male. The disease appeared as: appendicular diverticulitis (45.7 percent), appendicular diverticulosis with acute appendicitis (28.7 percent), appendicular diverticulitis with acute appendicitis (17.0 percent), appendicular diverticulosis (5.3 percent), and appendicular pseudodiverticulosis with acute appendicitis (3.2 percent). Operative morbidity was 12.7 percent. One patient presented an adenocarcinoma of the appendix associated with diverticular disease. Conclusion: The prevalence of diverticular disease of the appendix is low in our population and the characteristics are different to reported by other authors.

Introducción: La enfermedad diverticular del apéndice cecal es un hallazgo infrecuente en apendicectomizados por sospecha clínica de apendicitis aguda. Nuestro objetivo es evaluar la prevalencia de enfermedad diverticular del apéndice cecal en pacientes apendicectomizados por sospecha clínica de apendicitis aguda. Material y Método: Diseño de estudio: Estudio de corte transversal. Criterios de inclusión: Pacientes apendicectomizados por sospecha clínica de apendicitis aguda. Período de estudio: enero de 2000 a diciembre de 2008. Muestreo: No probabilístico de casos consecutivos. Metodología: Se realizó una revisión de los registros clínicos y de las piezas quirúrgicas de los pacientes sometidos a apendicectomía por diagnóstico clínico de apendicitis aguda. Resultados: Se estudiaron 11.472 apendicectomías. Noventa y cuatro pacientes presentaron enfermedad diverticular del apéndice (0,8 por ciento). La mediana de edad fue 40 años y el 62,8 por ciento fue género masculino. La enfermedad se presentó como: diverticulitis apendicular (45,7 por ciento), diverticulosis apendicular con apendicitis aguda (28,7 por ciento), diverticulitis apendicular con apendicitis aguda (17,0 por ciento), diverticulosis apendicular (5,3 por ciento) y pseudodiverticulosis apendicular con apendicitis aguda (3,2 por ciento). La morbilidad operatoria fue 12,7 por ciento. Un paciente presentó un adenocarcinoma del apéndice cecal asociado a la enfermedad diverticular del apéndice. Conclusión: La prevalencia de enfermedad diverticular del apéndice cecal es baja en nuestra población y con características que difieren a lo reportado por otros autores.

Pathologic evaluation of appendectomy specimens in children: is routine histopatholgic examination indicated?

Acute appendicitis is the most common cause of abdominal surgery in children. Similarity between signs and symptoms of appendicitis and other common pediatric illnesses, atypical manifestations of appendicitis in young children, and children's inability to give precise explanation for their symptoms contribute to considerable delay in proper diagnosis and increased rate of perforation. Current study reports the surgical and pathological findings of appendectomies in the largest Children's Hospital in Iran. It also evaluates whether common protocol for pathologic evaluation following appendectomy is beneficial. Pathologic reports of 947 appendectomies, performed with the presumptive diagnosis of acute appendicitis, were gathered. Correlation between surgical and pathologic findings was assessed. Demographic characteristics of patients between surgical and pathological subgroups were also compared. The mean age of participants was 6.9 +/- 3.5 years. Eighty seven [25.5%] children had abnormal pathological findings and normal surgical report. None of miscellaneous findings including appendicular carcinoid tumor 3 [0.3%], oxyuriasis 2 [0.2%], and mycobacterial infection 4 [0.5%] were recognizable during the surgery. Of all pathologically confirmed cases with perforated appendicitis, 9.7% were not detected during the surgery. In current study, acute appendicitis was the most common pathological diagnosis, however, high normal appendectomy rate along with noticeable proportion of surgically missed perforated appendicitis and unusual histopathologies strongly supported routine histological examination