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Vermiform appendix is an unusual site of diverticulosis. We present 3 examples of this entity and briefly review its pathogenesis and clinical significance. As a general rule, appendiceal diverticula are multiple, acquired naturally, and rarely associated with complications.
Colonoscopy is a widely used procedure with low morbidity and mortality. A case of cecal volvulus following colonoscopy is presented. This potentially lethal complication should be considered in patients with persistent abdominal pain following colonoscopy because it is easily diagnosed radiographically and requires emergency surgical intervention.
Three girls and 4 boys with the final diagnosis of ruptured appendicitis underwent 19 sonographic studies, 5 before any therapy was instituted and 14 follow-up studies. Four abscesses identified before treatment and 2 seen postoperatively were ovoid, irregularly marginated, and contained low-amplitude echoes. Gastrointestinal ileus with gas-and fluid-filled loops of bowel made the studies technically difficult. Follow-up studies also showed fluid collections distant from the original abscesses. The complete resolution of the abscess was followed sonographically in 1 patient treated with antibiotics. Ultrasound can be useful in confirming or suggesting the diagnosis of ruptured appendicitis in the child with abdominal pain, but careful attention to detail is necessary in these technically difficult studies.
Villous adenoma of the appendix is a rare neoplasm and intussusception of the appendix is a rare pathologic condition. A very rare case seen in a 35-year-old male with pain in the right lateral abdomen is reported. In this patient, the appendix along with the villous adenoma intussuscepted and invaginated into the cecal lumen, and presented as cecocolic intussusception. A polypoid lesion was diagnosed in the cecum by fiberoptic colonoscopy. Unlike polypoid lesions at other sites in the large intestine, polypoid lesions of the cecum may accompany intussusception and invagination of the appendix. Consequently, caution is required in performing endoscopic polypectomy in cases of polypoid lesions of the cecum.
Volvulus is a rare cause of intestinal obstruction in the U.S. Sigmoid colon volvulus is the most frequent, followed by cecal volvulus. The simultaneous occurrence of cecal and sigmoid colon volvulus is extremely unusual. We are reporting what to our knowledge is the third case.
Mucosal spots, or "freckles," surrounding the appendiceal orifice are an endoscopic feature of the cecum. These are clusters of 1 to 2 mm round or oval slightly raised spots, each with a pale center and an erythematous border. They correlate microscopically with subepithelial and submucosal lymphoid follicles. The freckling pattern, identified in about one third of colonoscopies, was seen best with the videoendoscope and was identified more commonly in patients with systemic illness. Recognition of mucosal freckling around the appendiceal orifice helps identify the cecum and may be useful in the evaluation of cecal and appendiceal pathology.
A review of 561 cases of cecal volvulus that were published between 1959 and 1989 along with 7 new cases, was performed to characterize the clinical and laboratory profile and to evaluate the various surgical options in treating this life-threatening condition. The age and sex distribution of these patients have changed over the years and shifted toward older patients (mean, 53 years) and female predominance (female:male ratio, 1.4:1). The clinical presentation was usually of distal closed-loop small bowel obstruction. Forty-six percent of the plain abdominal radiographs were suspected for cecal volvulus, but only 17 percent were diagnostic. Barium enema had a high rate of accuracy (88 percent) and was associated with minimal complications. True volvulus was 6 times more common than bascule, and gangrenous cecum was found in 20 percent of cases. Detorsion alone and cecopexy had almost similar complications, mortality, and recurrence rates (15, 10, and 13 percent, respectively), whereas, resection, which was performed primarily for gangrenous cecum, had higher rates. However, the highest rates of complications (52 percent), mortality (22 percent), and recurrence (14 percent) were noticed after cecostomy. These data suggest that resection should be reserved for patients with necrotic cecum and that detorsion is sufficient for patients with viable cecum. Cecostomy should be abandoned.
PURPOSE: Two clinical cases of internal herniation through the foramen of Winslow are presented. The first case concerns herniation of the cecum and ascending colon. In the second patient, the ileum was herniated through the foramen epiploicum. METHODS: Preoperative assessment of clinical and radiologic findings suggested diagnosis. RESULTS: Final diagnosis was only made at laparotomy. Reduction of hernia could be performed by pulse traction, and no signs of intestinal necrosis were seen. CONCLUSION: Herniation through the foramen of Winslow should be taken into account when making a differential diagnosis for upper gastrointestinal tract obstruction.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with a variety of gastrointestinal side effects. Effects on the large intestine have been reported with increasing frequency. Recognition of NSAID-induced colonic lesions has been confounded by variable clinical presentations, variable pathologic findings, and unfamiliarity of this entity among clinicians. We have recently seen three cases of NSAID-induced cecal ulcerations in patients undergoing right colectomy. A correct preoperative diagnosis was not made in our patients, one of whom presented with an acute abdomen and two in whom there was an inability to rule out carcinoma. The gross, radiographic, and histologic findings in each case consisted of a characteristic transverse ulceration with thin diaphragm-like scarring. NSAID-induced cecal ulcers can have a variety of presentations to the general surgeon, are likely to be misdiagnosed preoperatively, but may be recognized based on characteristic gross features evident by radiography and colonoscopy, along with a careful history. Review of recent literature suggests that laparotomy can be avoided when diagnosis is considered, but operation is indicated for complications, such as hemorrhage, obstruction, or perforation, and when carcinoma cannot be adequately excluded.
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In a cystic fibrosis (CF) patient a right lower quadrant (RLQ) mass may be a difficult diagnostic problem. Most frequently it is due to a distal intestinal obstruction syndrome also called meconium ileus equivalent, but the possibility of intussusception and appendiceal abscess should also be considered. We describe three CF patients with an appendiceal abscess seen in a 4-year period. All three patients had a palpable RLQ mass. Chronicity and obliteration of the appendiceal lumen with abnormally viscid mucus may lead to concealed perforation and be responsible for the atypical presentation.
PURPOSE: The role and effectiveness of catheter tube cecostomy as a means of colonic decompression are not clearly defined. Our aim was to clarify the clinical indications, functional performance, and concomitant morbidity associated with tube cecostomy. METHOD: This was a retrospective chart review of patients receiving catheter tube cecostomy at the Mayo Clinic over an 11-year period. RESULTS: Sixty-seven patients (median age, 69 years) had catheter tube cecostomy placement. Clinical indications for tube cecostomy were colonic pseudo-obstruction, distal colonic obstruction, cecal perforation, cecal volvulus, preanastomotic decompression, and miscellaneous usage. Operation was emergent in 43 (64 percent) patients and elective in 24 (36 percent) patients. Tube cecostomy was the primary procedure in 47 (70 percent) patients and complimentary in 20 (30 percent) patients. Minor complications were seen in 30 patients (45 percent), including pericatheter leak, superficial wound infection, tube occlusion, skin excoriation, premature tube dislodgement, colocutaneous fistula, and ventral hernia. No patient required reoperation for tube-related morbidity. CONCLUSIONS: Catheter tube cecostomy is of therapeutic value in select clinical situations including refractory colonic pseudo-obstruction, cecal volvulus, cecal perforation, or distal colonic obstruction. Proper patient selection, careful tube placement, and vigilant postoperative tube care should provide adequate function with minimal morbidity.
This case study describes a 61-year-old patient who had previously undergone sigmoid polypectomy. A follow-up colonoscopy revealed a polyp prolapsing into the colonic lumen through the base of the appendix. A laparoscopic-assisted appendectomy was performed, in which the cecum was exteriorized through the trocar hole so that a wide excision of the base could be performed. Fifty-eight polyps were observed in the appendix, but the base was free of polyps. Histologic studies reveal well-differentiated villous adenomatous polyposes. The patient was symptom free four years after surgery.
Cecal volvulus is a rare cause of intestinal obstruction after major abdominal surgery. A case of cecal volvulus occurring in the early postoperative period after left colon resection for malignancy is presented. Clinical evaluation and plain abdominal radiographs suggesting cecal volvulus prompted laparotomy and correction. Delay in diagnosis results in high mortality, and treatment depends largely on the viability of the involved intestine. This report describes the second case of cecal volvulus complicating a left colectomy. It was treated by detorsion and reperitonealization cecopexy.
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PURPOSE: Spontaneous nonocclusive ischemic colitis involving only the right colon is an infrequent occurrence. Because this problem is less recognized than its counterpart involving the left colon, the correct diagnosis may not be considered. The purpose of this article was to describe the presentation and management of this unusual clinical problem. METHODS: Five cases of nonocclusive ischemic cecal necrosis are described. Four of the patients presented with right-sided abdominal pain, tenderness, and leukocytosis. The preoperative diagnosis was incorrect in all patients, although cecal necrosis was considered in one. Two patients were thought to have. appendicitis, two were thought to have carcinoma, and one was thought to have a perforated viscus. Each patient underwent a right hemicolectomy and four survived. RESULTS: Each of the patients had ischemic cecal necrosis without evidence of emboli or vasculitis. Although cecal gangrene may occur after systemic hypotension, no such event preceded these patients' presentation. We believe that the patients we treated had a form of nonocclusive ischemic colitis, which occasionally affects only the right colon. CONCLUSION: Ischemic necrosis of the cecum is an infrequent variant of ischemic colitis that should be considered in the differential diagnosis of the elderly patient presenting with right lower quadrant pain.
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