Emergency right hemicolectomy for inflammatory cecal masses mimicking acute appendicitis

Abstract

Background: Unexpected inflammatory cecal masses of uncertain etiology, encountered in the emergency surgical departments can be indistinguishable, and appropriate operative management of these cases is a dilemma for the surgeons.

Methods: Over a 30-months period between January 2009 and June 2011, a series of 3032 patients who live in sub-urban underwent emergency surgery for clinical diagnosis of acute appendicitis and ileocecal resection or right hemicolectomy for inflammatory cecal mass were performed in 48 patients.

Results: 28 men and 20 women from suburban between ages 16-73 presented with right iliac fossa pain. The major presenting symptom was pain in the right iliac fossa (100%). On physical examination; tenderness at or near the McBurney point was detected in 44 (91,6%) patients. The range of the leucocyte level was between 8.000 to 24.000 and mean level is 16.000. After initial laparoscopic exploration, ileocecal resection or right hemicolectomy was performed conservatively because of the uncertainty of the diagnosis. Overall 32 patients underwent ileocecal resection and 16 patients underwent right hemicolectomy. Pathology revealed appendicular phlegmon in 18 patients, perforated cecal diverticulitis in 12 patients, tuberculosis in 6 patients, appendiceal and cecal rupture in 4 patients, malign mesenquimal neoplasm in 4 patients, non-spesific granulomatous in 2 patients and appendecular endometriosis in 2 patients.

Conclusion: Most inflammatory cecal masses are due to benign pathologies and can be managed safely and sufficiently with ileocecal resection or right hemicolectomy. The choice of the surgical procedure depends on the experience of the surgical team.

Figure 1

Cecal Diverticulitis: Axial pre-contrast CT image shows mesenteric inflammation adjacent to the distal ileum and cecum, minimal free peritoneal fluid and free air wall thickening and multiple small diverticula in the distal ileum.

Figure 2

Small bowel and cecal tuberculosis: Contrast-enhanced CT scan shows wall thickening in several distal small bowel loops and cecum.

Figure 3

Non-spesific granulomatous: small segment in the terminal ileal wall thickening and inflammation in the adjacent fatty tissue and reactive lymph nodes.

Figure 4

An unexpected ileocecal mass (red arrow). Final pathology of the specimen is malign mesenquimal tumor.

Figure 5

Ileocecal Tuberculosis. Tuberculous granulomatous lesions showing caseous necrosis in the centre, and a prominent cuff of lymphocytes and plasma cells at the periphery.