The Case Files: A Diagnostic Pitfall: Stump Appendicitis
The Case Files
Dr. Irvine works in a private group in Nebraska. Drs. Neltner, Shellman-White, and Zimmer are all clinical assistant professors in emergency medicine at the Ohio State University Hospital East in Columbus, OH.
Acute abdomen is one of the most common surgical emergencies encountered by emergency physicians, and appendicitis is the most common cause requiring emergent surgical consultation and surgery. Stump appendicitis is a rare complication occurring after an incomplete appendectomy, and can be defined as an acute inflammation of the residual remnant of the appendix. Many physicians are unaware that stump appendicitis is a real entity, but it is so rare that they may not include it in their differential diagnosis, leading to possible delay in diagnosis and treatment.
A 25-year-old man presented to the emergency department with a chief complaint of abdominal pain for four hours that woke him from sleep at 1 a.m. The patient initially described the pain as diffuse abdominal pain that became more localized to the right lower quadrant during his stay in the ED. The patient reported nausea and vomiting, but denied fevers, chills, dysuria, hematuria, constipation, and diarrhea.
The patient's past medical history was significant for untreated hypertension and acute appendicitis, for which the patient had a laparoscopic appendectomy performed 14 months prior at our institution. He denied taking any medications and had no known drug allergies.
He was alert and did not appear to be in distress. The initial vital signs were pulse 74 beats/min, blood pressure 156/96 mm Hg, respiratory rate 16 breaths/min, oxygen saturation of 98% on room air, and a temperature of 36.3°C (97.4°F). His abdomen was tender to palpation at McBurney's point, and he had diffuse guarding. Laparoscopic scars were present from the previous appendectomy. Bowel sounds were present. He had no rebound tenderness, masses, or organomegaly. The remainder of the exam was unremarkable.
Urinalysis was normal, and the white blood cell count was 7,000 cells/mm3 with 81% neutrophils. The plain radiographs of the chest and abdomen were normal. A CT scan of the abdomen and pelvis were reviewed by radiology, and their interpretation of the scan revealed findings “suspicious for stump appendicitis, evidence of prior appendectomy, no abdominal free air, and fluid in the right lower quadrant with questionable dilation of the appendiceal stump.”
The patient was given intravenous antibiotics and taken to the operating room. Surgical exploration confirmed stump appendicitis. The operative report described a right iliac fossa mass containing pus. The inflamed appendiceal stump was 1×3 cm, and evidence of perforation at the base of the appendix was noted. The entire appendiceal remnant was excised. The patient did well following the surgery, and was discharged home on postoperative day two.
Patients presenting to the ED with abdominal pain require prompt diagnosis and definitive treatment to ensure decreased morbidity and mortality. Evaluating abdominal pain can be extremely challenging, and it is made more difficult when the patient has a history of prior appendectomy. Appendicitis after prior appendectomy is uncommon, but it is a real condition that needs to be considered when evaluating patients with abdominal pain.
Stump appendicitis is defined as the re-inflammation of residual appendiceal tissue left after a prior appendectomy. The first reported case was in 1945, and fewer than 50 cases have been reported in the literature worldwide since then. Any residual tissue or stump left after surgery can result in reinfection at a later date. It has been proposed that the increased use of laparoscopic techniques to treat appendicitis will lead to an overall increase in stump appendicitis. The majority of stump appendicitis cases to date, however, have occurred after an open appendectomy, and it would be difficult to show a statistically increased risk because of laparoscopic techniques and because the condition is so rare.
The incidence of recurrence can be minimized by accurate identification of the appendiceal base and by leaving the smallest stump possible. It has been suggested that the stump be no longer than 3 mm. Conversion to an open appendectomy is recommended if the base of the appendix cannot be accurately identified during laparoscopic surgery.
The presentation of patients with stump appendicitis is the same as with patients with acute appendicitis. Signs and symptoms will often include abdominal pain, nausea, vomiting, anorexia, and fever. The physical exam findings and the laboratory results should have no appreciable difference in patients with acute appendicitis and stump appendicitis.
All patients with a high index of suspicion for stump appendicitis should have a CT scan of the abdomen with contrast. CT findings that may be present include an enlarged appendiceal stump, cecal wall thickening, pericecal fat stranding, appendicolith, ileocecal mass, pelvic mass, and fluid in the paracolic gutter. Ultrasound in the hands of an experienced operator also may be extremely useful in identifying the inflammatory changes consistent with stump appendicitis.
All patients with stump appendicitis need to have laparoscopic or open appendectomy performed as soon as possible. Any delay will only increase the risk of rupture of the appendiceal remnant if it has not already occurred.
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