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Anomalies of the appendix are extremely rare. The case presented here has not been previously described and is that of a "horseshoe" appendix in a 33-year-old man with sigmoid diverticulitis. This appendiceal variant cannot be classified into any of the existing categories of appendiceal anomalies.
Malignant epithelial tumours of the appendix are rare. They are mostly diagnosed by the pathologist rather than by the surgeon. Very frequently patients with these tumours present themselves with clinical signs of acute appendicitis. Right hemicolectomy is postulated to be the appropriate treatment of choice in all patients with adenocarcinomas of the appendix (colon type, cystic type). On the other hand this radical approach should be applied only to selected cases with carcinoid tumours.
Necrotizing arteritis of the vermiform appendix (NAVA) is an uncommon condition. There are conflicting reports in the literature about its relationship to systemic polyarteritis nodosa (PAN). In this study, 12 cases of NAVA are described, constituting 0.28% of histologically examined appendixes. Nine of the patients were followed up for a mean of 6.8 years. Systemic necrotizing arteritis was found in three cases, all of which were complicated by secondary ulceration or infarction of the colon. The results strengthen the association between NAVA and systemic PAN. However, it is more meaningful to relate NAVA to the broader group of necrotizing vasculitides rather than exclusively to classic PAN.
In a prospective study of 518 consecutive appendices removed at surgery for symptomatic appendicitis, 32 appendices showed evidence of chronic Schistosoma haematobium appendicitis (a frequency of 6.2%). As the diagnosis can only be confirmed by histology of the removed appendix, the authors believe that in endemic areas chronic S. haematobium appendicitis may not be as rare as the few recorded cases would seem to suggest. Appendiceal mucosal ulceration with chronic inflammatory infiltration and fibrosis of the appendiceal wall leading to chronic appendicitis may be due to intense deposition of ova in the appendix wall, particularly the submucosa, by the adult worm.
Diverticulosis of the appendix. Diverticulosis of the appendix is a rare condition. Cause of the danger of perforation, it is not an unimportant entity. We present six examples and review its pathogenesis, diagnosis and treatment.
Intussusception of the appendix in a 25-yr-old man was diagnosed preoperatively. Only six such cases have been reported. This patient presented with episodes of recurrent severe right lower abdominal pain, each episode separated by several uneventful months. The diagnosis was made by radiological visualization of a polypoid lesion with a dimple at the top in the caput cecum, and by the endoscopic appearance of the polypoid mass. A sessile polypoid mass (about 1 cm) that looked like foreskin and glans was observed by colonoscopy. The dimple at the top, like glans, was partially reddish, and the steeply sloped surface, like foreskin turned inside out, was smooth. The area of dimple at the top became discernibly smaller and the appearance changed as air was led into cecum. Appendectomy was without untoward events, and the patient no longer experienced such episodes. Although intussusception of the appendix is rare, it should be included in the differential diagnosis of acute abdominal syndrome.
A case of congenital absence of the appendix is reported by the authors. It is a very rare anatomic finding, the frequency of which is about 1 p. 100 000. The awareness of this malformation must not authorize young surgeon to forsake a difficult search of the appendix. The diagnosis should not be made unless the entire right colon and the ileo-cecal area are mobilized and thoroughly explored.
The case history of an eighty one year old white male with progressive cachexia and massive ascites is given. Autopsy revealed the rare finding of a primary adenocarcinoma of the appendix with multiple metastases as the cause of the rapidly deteriorating clinical condition. The incidence, clinical findings and therapeutic options in carcinoma of the appendix are discusses based on a review of the literature.
Of 834 children who had appendicectomy for appendicitis 77 (9.2%) had developed an appendix mass when first seen. Under 6 years of age 25% of appendicitis patients had an appendix mass at presentation and almost 60% of the masses seen were in patients under six years of age. Forty three of the 77 masses (55%) were palpable only under anaesthesia. The masses were all initially managed conservatively by bed rest, intravenous fluids and intravenous antibiotics. All but eight (10%) of the 77 patients responded to this form of treatment. Interval appendicectomy was planned for a date 4 weeks following discharge. The overall total average bed stay including interval appendicectomy was 16 days. There were no late complications or relaparotomies.
The history of two patients with a mucocele of the appendix is reported. It is stressed that in case of a tumour of the appendix the possibility of a malignant mucocele should always be considered. To prevent a peritoneal pseudomyxoma tumour spill should be avoided and great care should be taken in performing appendectomy. A survey of the literature is given.
22 cases of primary involvement of the appendix in Crohn's disease are reported in the literature. During the last 3 years we observed 4 cases. In three patients typical clinical signs of acute appendicitis were present. One case was found occasionally. The follow-up was 5-30 months. During this time none of our patients showed symptoms of granulomatous enterocolitis in other regions of the bowel. Reviewing the literature 3 of 26 patients (11.5%) showed lesions typical for Crohn's disease elsewhere in the intestine 3-48 months after appendectomy. But two cases had a follow-up of 5 years which time is considered indispensable before one can admit that the disease is really limited to the appendix.
Twenty-eight previously unreported cases of appendiceal diverticula were found in a 15-year retrospective review of records at five hospitals. The incidence is probably higher than is realized. Data drawn from the review indicated that the age of the patient and a history of previous attacks might be slight clues to distinguishing between diverticulum and acute appendicitis. Inflamed or not, rarely are these diverticula recognizable at the time of operation, but if the appendix is bulbous or club-shaped or there is increased thickening of the mesentery, the surgeon's suspicion should be aroused. In four of fourteen acute cases in the series, perforation had occurred-within 15 hours of the onset of symptoms in two cases. In four others there was abscess formation within the mesentery of the appendix.
Mukokela appendix--described by Rokitansky in 1842 for the first time--appears in 0,2% of appendectomy at Bulovka-Hospital Prague. Great mukokela appendix (12,5 x 5,5 cm), which resembled ovarial cyst on the right hand side, had been found for the first time in 20 years. The patient was a 63 old woman; she was cured in 9 days after appendectomy. The authors describe etiology, clinic and the case itself.
The rabbit's appendix is a pecular lympho-epithelial formation as it includes both areas of thymus-dependent lymphocytes (the interpolated sieved lamina) and non-thymus-dependent lymph nodes. The epithelium joining the intestine lumen and the lymphatic tissue contains cells that become permeable at the contact of lymphocytes. These "tranformed" enterocytes are crossed by antigenic molecules, bacteria, yeasts and evolutive forms of coccidia. Lymphocytes within--as well as reticular cells below the epithelium--catch large molecules, especially antigens, thus having a share in humoral immunity. Just as those of the intestine, the enterocytes of the appendix glandular area are informed at the level of the areas of epithelial mitosis and become resistant to certain infections such as coccidosis. This particular form of immunity we have named "epithelial immunity". Thick sections provide ultrastructural views physically showing information exchanges. Intercellular exchange by contiguous endoplasmic reticular canaliculi at the interface of two cells have thus been demonstrated. They have been as clearly observed between two epithelial cells at between two cells of connective origin and again between an epiethelial cell and a lymphocyte.
Various diseases can symptomatically resemble appendicitis. It has been proved that luminal obstruction is the most frequent cause of inflammation of the appendix. There are various causes of obstruction, such as scars, foreign bodies, tumors, granulomas, and dysfunction of coecocolon. Every appendix should therefore be histologically examined. The operative indication for appendectomy should not only include the time factor, but also anamnesis, complaints, and clinical presentation. It is inconsiderate to perform appendectomy as a prophylaxis against appendicitis. Finally, it is surprising that there have been almost no experimental studies on pathogenesis of appendicitis.
On a 20-year-old male patient and on a 67-year-old female patient, we incidentally detected as histologicbioptic findings after routine appendectomy a focal mucosal hyperplasia of the appendix. Basing on these cases we give a survey on the literature pertaining to these rate cases of mucosal alterations of the appendix published up to now, and discuss the problems of these mucosal hyperplasias.
Two cases of invagination of the Vermiform appendix associated with endometriosis are presented. Classification, incidence, etiology, symptomatology, diagnosis and treatment are discussed. The literature is reviewed in brief, and it is concluded that the possibility of invagination of the Vermiform appendix should be considered in obsure abdominal cases with recurrent right lower quadrant pain.
A specimen from the small intestine with multiple (three) classic carcinoid tumors and one appendiceal carcinoid tumor displaying argentaffinity, argyrophilia (Grimelius stain), and serotonin and neuron specific enolase immunoreactivity was examined by light microscopy with regard to the tumor cell histopathogenesis. The smallest tumor (diameter 0.5 cm) from the small intestine was cut into 512 and the appendiceal tumor into 511 serial sections, which were stained with the argyrophil technique. In the small intestine an increased number of endocrine cells and small proliferating aggregates of endocrine cells were observed among nonendocrine enterocytes in the crypts of Lieberkühn. They seemed to grow initially inside the crypts and to later infiltrate through the basement membrane into the lamina propria of the mucosa. This finding suggests that classic carcinoid tumors of the small intestine develop from mucosal endocrine (enterochromaffin) cells. Since proliferating argentaffin cells were also seen in the mucosal crypts in one of the other two carcinoid tumors (2 cm in diameter) in the same intestine specimen, it is suggested that when multiple carcinoid tumors occur in the small intestine they arise from multiple sites. There was no apparent connection between the mucosal crypts and the carcinoid tumor of the appendix. Thus in this particular case, the appendiceal carcinoid tumor did not appear to derive from the mucosal endocrine cells but from the subepithelial endocrine cells that are present in the lamina propria and submucosa of the appendix wall. Supporting this view is the fact that S-100 protein immunoreactive cells are found both in close relation to subepithelial endocrine cells and as an integral component of appendiceal carcinoid tumors.