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. 2017 Jan;12(1):23-29.

Unusual Entities of Appendix Mimicking Appendicitis Clinically - Emphasis on Diagnosis and Treatment

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Unusual Entities of Appendix Mimicking Appendicitis Clinically - Emphasis on Diagnosis and Treatment

Rikki Singal et al. Maedica (Bucur). 2017 Jan.

Abstract

Background: Abdomen is considered a magic box or a Pandora box where you will get different, unexpected pathologies along with rare entities. Appendicitis is the commonest emergency in surgery which presents challenges to surgeons because of a myriad list of differential diagnosis including both medical and gynaecological pathologies. Preoperative imaging plays an important role in diagnosis and management.

Aims and objectives: To study the rare atypical anatomical and surgical presentations of appendix in patients with clinical features of appendicitis. We focus on the clinical features and the role of investigations for the radiological part and management.

Material and methods: This study was done in M.M. Institute of Medical Sciences and Research, Mullana, Ambala, from November 2014 to July 2016. This was a retrospective study. We found 168 cases with the diagnosis of appendicitis, out of which 19 were with rare entities.

Results: Subjects of both genders were aged between 20 and 60 years. Out of 19, 15 were males and 4 females. Four patients were operated for inguinal hernia but incidentally we found appendix in the hernial sac termed as Amyand's hernia. Another patient presented with obstruction and appendix was forming a band diagnosed as torsion of appendix. Two most interesting cases were diagnosed as appendicular neuralgia and relieved by appendectomy. Out of 19 cases, 7 cases were operated for appendicitis diagnosed as appendicolith. In all the cases appendectomy was done without encountering any complications. Symptom free patients were operated for appendicular neuralgia. No malignancy was found in mucocele appendix at follow up. There were no complications by the 6-month follow-up.

Conclusion: As we came across with different entities of appendix presented with appendicitis, patients should be investigated before proceeding for surgery. In our study, there were incidental findings for which surgeons were not aware of the diagnosis and even for the patient. In inguinal hernia, ultrasonography was not done, diagnosis being made on clinical basis. Clinical and radiological investigations play an important part in early diagnosis and management.

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Figures

TABLE 1.
TABLE 1.
TABLE 1. Detailed presentation and operative fi ndings
FIGURE 1.
FIGURE 1.
FIGURE 1. Operative section showing appendicular band. Arrows indicate: a) caecum; b) band covering the small bowel loops; c) infl amed area at the tip of the appendix
FIGURE 2.
FIGURE 2.
FIGURE 2. Operative area revealed appendix in the hernial sac (the sac is held with the artery forceps and the appendix with the Babcock’s forceps)
FIGURE 3.
FIGURE 3.
FIGURE 3. Computed tomography showing giant lump in the iliac region
FIGURE 4.
FIGURE 4.
FIGURE 4. a) Operative section revealed whitish colour lump as mucocele appendix; b) gross specimen revealed mucous in the appendix (base is hold by artery)
FIGURE 5.
FIGURE 5.
FIGURE 5. a) High power view showing the mucinous lining of the appendix; b) section showing fl a! ened mucosa of the appendix which at places is lined by mucinous epithelium (H and E X 40X)
FIGURE 6.
FIGURE 6.
FIGURE 6. a) Ultrasonography revealed appendicolith in the appendix; b) the operative area showed laparoscopic appendectomy and the cut area revealed appendicolith; c) and d) operative specimen of appendectomy and appendicolith held with forceps
FIGURE 7.
FIGURE 7.
FIGURE 7. a) White arrow showed lith lying outside from the perforated appendix; b) white arrow showed appendicolith and black arrow showing artery passed through the perforated lumen; c) black arrow showed perforation in appendix and white arrow showed dilated appendix

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