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Description
A 58-year-old woman presented with acute abdominal pain and vomiting of 3 days duration. She had undergone laparotomy for appendicular perforation 25 years earlier. She had recurrent episodes of abdominal pain for the past 5 years and was being treated as a case of adhesive intestinal colic. Clinical examination revealed a distended and tender abdomen with an infra umbilical midline scar and maximal tenderness in the right iliac fossa associated with guarding and rigidity. Her pulse rate was 110/min; blood pressure 110/60 mm Hg and temperature was 100°F. Total white cell count was 18 400 mm3 (85% neutrophils). Urine analysis was unremarkable. Ultrasonography showed interloop fluid and dilated bowel loops in the right iliac fossa. Abdominal CT scan showed features of an inflammatory mass in the right iliac fossa with pericaecal fat stranding, a thickened caecal wall, dilated small bowel loops and fluid. Diagnostic laparoscopy revealed purulent peritoneal fluid, dense adhesions between omentum and laparotomy scar along with an inflammatory mass in the right iliac fossa. Laparoscopic dissection was difficult; hence the procedure was converted to a laparotomy. After meticulous dissection, the bowel loops were separated. The distal ileum adherent to the caecal wall was meticulously separated to reveal a small residual appendicular stump that was oedematous, inflamed and about 2 cm long (figure 1). The stump was excised after transfixing the base close to the caecal wall (figure 2). The postoperative period was uneventful. Histopathological report was confirmatory of appendicitis. The patient has been on regular follow-up for 1 year and is asymptomatic.
Learning points
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Stump appendicitis (SA) is a rare but potentially serious complication of appendectomy, with reported incidence of 1 in 50 000 cases. However, an increasing number of cases are being reported in the literature.1 ,2
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SA should be considered in the differential diagnosis of patients presenting with recurrent abdominal or right iliac fossa pain even with a history of previous appendectomy (laparoscopic or open).
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An appendicular stump smaller than 3 mm might help reduce SA. Completion appendectomy is the treatment of choice. Conservative management with antibiotics has been shown to be effective in treating SA.3
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More research is needed to identify strategies to prevent SA.
The residual inflamed stump of the appendix is clearly seen (arrow) after separation of the adherent small bowel.
The stump is transfixed at the base, almost flush with the caecal wall prior to excision.
Acknowledgments
The author would like to thank the MOSC medical college administration for the encouragement given in publishing this article.
Footnotes
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Competing interests None.
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Patient consent Obtained.
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Provenance and peer review Not commissioned; externally peer reviewed.