MSSP445: ENDOMETRIOSIS OF THE APPENDIX: WHEN APPENDICITIS IS LESS THAN STRAIGHTFORWARD
Justin G Hale, DO; Benjamin Scott, LT; Joel R Brockmeyer, MD; DD Eisenhower Army Medical Center
Objectives: We present a case report of a 49 year-old female with history of ulcerative colitis who originally presented to the General Surgery clinic after an incidental finding on CT was concerning for a dilated, fluid-filled appendix. She had been complaining of vague, diffuse abdominal pain consistent with her previous flares of ulcerative colitis over the past several days prior to presentation. She ultimately underwent a laparoscopic appendectomy without complication, which was notable for a grossly enlarged appendix without evidence of perforation or appendiceal mass. Pathology returned consistent with early acute appendicitis, as well as endometrial tissue along the outer wall of the appendix. We then performed a literature review regarding appendiceal masses and the occurrence of endometriomas and/or endometriosis of the appendix.
Methods: A Pubmed search was performed using the association of appendix and appendicitis and endometrioma. All of the papers were reviewed for relevance related to articles on appendicitis cases mentioning incidental pathology other than appendicitis in addition to articles discussing appendiceal masses and relative occurrence. Specific articles were also examined mentioning occurrence of endometriomas of the appendix and isolated endometrosis of the appendix.
Results: Our research demonstrated that between 2% to 6% of cases of appendicitis present due to an appendiceal mass, usually an inflammatory phlegmon. There are a variety of other causes, including primary malignancy, secondary malignancy, and combinations of pathologies that lead to the eventual removal of the appendix. A patient may have a combination of diseases that may manifest as appendiceal mass but are not related to malignancy. Specifically, endometriosis of the appendix is reported in less than 1% of females on post-appendectomy pathologic analysis. Although clinical specific symptoms may guide a provider to this diagnosis, there are few distinguishing symptoms that would point a provider towards a different underlying diagnosis, to include malignancy, for appendicitis.
Conclusion: Endometriosis of the appendix is rare, occurring in less than 1% of post-appendectomy pathology specimens of female patients. Further information is needed to determine when a patient has increased risk for an underlying pathology with presenting with appendicitis. This information, paired with histopathologic analysis of the appendix after appendectomy, will drive continued treatment and ideally lead to better screening tools for appendiceal masses.