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The sonographic appearance of a mucocele of the appendix in a 69-year-old woman is presented. The mucocele showed an atypical localisation in the right upper quadrant just below the gallbladder. This own observation is compared with other case reports in the literature. The value of ultrasound examinations in the diagnosis "mucocele of the appendix" is discussed.
Owing to their proximity to the true pelvis and their topography, mucoceles of the appendix frequently cause clinical symptoms which call a gynecologic condition to mind. Sonographically, the structures of mucoceles are often similar to those of ovarian tumors. Within 12 months four patients with mucoceles underwent surgery at Heidelberg University Gynecological Clinic following diagnosis of a gynecologic disease (two tentative diagnoses of ovarian carcinoma, one of advanced ovarian carcinoma, one chance finding during Wertheim's operation). The problems of this rare condition are discussed with reference to the clinical findings, the intraoperative site, and the different morphology and maturity. Pathoanatomically and biologically, however, the clinical picture is not uniform. In mucoceles there is an accumulation of mucus with cystic dilatation of the lumen of the appendix. This is usually due to a tumor, which may be anything from a simple mucous membrane hyperplasia with extreme mucous formation, or an adenoma, to a mucilaginous adenocarcinoma. The rupture of a mucocele or metastasization of a carcinoma often lead to peritoneal mucous spread or peritoneal metastasization: in their patterns of distribution these are similar to a pseudomyxoma peritonei or a metastasizing ovarian carcinoma.
The clinical features of mucocele of the appendix are nonspecific, and a correct preoperative diagnosis based on abdominal pain, a palpable mass in the right lower quadrant, and conventional radiography is rare. The diagnosis of appendiceal mucocele has become easier with the utilisation of the recent imaging techniques ultrasonography and computed tomography. Six patients with mucocele of the appendix are presented, and the characteristic radiological features and differential diagnosis are discussed.
Myxoglobulosis is a rare morphologic variant of appendiceal mucocele characterized by intraluminal mucinous globules of the appendix. Most reported cases have presented clinically as an acute abdomen or as an incidental laparotomy or autopsy finding. We report a case of myxoglobulosis in a 32-year-old man who presented with an extra-appendiceal mass following a 10-year symptomatic course. Laparotomy disclosed a pericecal collection of opaque, white globules originating from a perforated appendix walled off by fibrous adhesions. The globules exhibited some histologic and staining properties at variance with those described in previous reports. These findings suggest that myxoglobulosis may be more heterogeneous pathogenetically than the distinctive gross appearance of the lesion would indicate.
Endosalpingiosis within the muscularis propria of the distal vermiform appendix was discovered in an appendectomy specimen removed during exploratory laparotomy for inflammatory tubal disease. Endosalpingiosis has not been previously reported in the appendix. The pathogenesis and possible significance of this lesion are discussed.
This case report describes the clinical presentation and the radiographic, endoscopic, and pathologic findings in a patient with cystic fibrosis (CF) and intussusception of the appendix. This is the first time that intussusception of the appendix has been documented in a patient with CF. This disorder should be considered in the CF patient with cramping lower abdominal pain or rectal bleeding.
Gut associated lymphoid tissue in 15 normal appendices has been characterised in tissue sections using both morphological criteria and immunocytochemical techniques. A panel of monoclonal and polyclonal antibodies was used including antibodies to B-cells, T-cells, macrophages, HLA DR and immunoglobulins. The lymphoid tissue in the appendix was shown to bear a strong resemblance to that in lymph nodes with the exception of the region where the appendix follicles associate with the dome epithelium, which has no lymph node equivalent. This zone of cells between the lymphoid follicles and the dome epithelium termed the 'mixed cell zone' has been shown to contain an abundance of HLA DR-bearing cells, some of which have irregular nuclear morphology and resemble follicle centre cells. These cells were seen to extend into the epithelium of the dome but not the crypts. Using a monoclonal anti-B-cell antibody a population of B-cells was detected in the equivalent areas of mixed cell zone and epithelium and quantitative studies showed that these intraepithelial B-cells comprised approximately 4-5% of the cells in the epithelium. The mixed cell zone was also seen to contain T-cells, S-100 protein-containing macrophages and occasional lysozyme-containing macrophages. Plasma cells were rarely seen in this area.
The appendix was investigated as a possible habitat of Streptococcus milleri. Both normal and inflamed appendices were examined and the isolation rates compared. S. milleri was present in a quarter of the normal appendices and more than half of those associated with apendicitis--a difference that was statistically highly significant. The isolation rates throughout were indepencent of age. There was a pronounced connection between the presence of S. milleri in the appendix and the purulent manifestations of appendicitis. S. milleri was isolated from other abdominal sites associated with appendicitis. The frequency of isolation was increased by culture in an enrichment broth containing nalidixic acid and sulphadimidine.
The incidence, clinical features and pathology of nine cases of diverticula of the appendix in Malaysians are reported. The findings are discussed and compared with those previously reported. The pathogenesis of the lesion in eight cases is unknown. The rare association of lumenal obstruction by a carcinoid tumour and diverticulum formation in the appendix is seen in one case.
Tuberculosis of the appendix is rare. It is usually secondary to tuberculosis elsewhere in the abdomen. Tuberculosis of the appendix is not associated with any specific clinical features and diagnosis is revealed only after histopathological examination. Appendicectomy should be performed in all patients with abdominal tuberculosis subjected to laparotomy and all surgically removed appendices should be subjected to histopathological examination.
An 88 year old woman presented with a painful, irreducible right femoral hernia and small intestinal obstruction. At laparotomy, some distal small intestine was found to have twisted around an uninflamed appendix which was acting as a 'band', with its tip fixed in the femoral hernia sac. Although the association between the appendix and femoral hernia is well recognized, the production of small intestinal obstruction by this particular mechanism has not been previously reported.
Human appendix lymphoid cells (HAL) react very strongly to stimulation with concanavalin A, strongly to stimulation with phytohaemagglutinin, and weakly but definitely to stimulation with lipopolysaccharide. From the results of rosette formation assay, cytotoxicity tests with anti-T cell antiserum or anti-B cell antiserum, cell surface or intracellular immunoglobulin staining with fluorescein-conjugated rabbit anti-Fab of human immunoglobulin serum, and plaque-forming cell (PFC) assay, it was concluded that human appendix lymphoid tissue is a B cell pool but includes T cells. However, both direct and indirect PFC could not be significantly demonstrated against sheep red blood cells in a 5-day HAL culture.
A new case of appendicovesical fistula is reported. Usually a known cause is ulcerative colitis, morbus Crohn, malignancy of the appendix or as complication to perforated appendicitis, but in the described case there was no history of such previous illness. The only pathological finding was the presence of an abundant amount of nervous tissue in the appendix. It is concluded that a history of pneumaturia and/or recurrent urinary-tract infections must rise the suspicion of the presence of a fistula between the small or large intestine and the bladder.
Although we have progressed very well in creating large capacity, low pressure reservoirs, the construction of a simple and reliable continent outlet still remains a problem. The appendix vermiformis serves well as a continence mechanism for either the bladder or intestinal reservoirs for urine. The different surgical techniques described in the literature are reviewed and discussed in this context. Moreover, we report on our clinical and experimental results of using the appendix during the Mainz pouch procedure for continent urinary diversion.
Blood vascular beds of the human appendix were reproduced with a methacrylate casting medium and observed with a scanning electron microscope. The appendix received some small afferent arterial branches of the appendicular artery. These small arterial branches pierced the muscular layer and reached the submucosal plexus. Small arterioles arising from this plexus, climbed the mucosa and formed honeycomb-like capillary meshes at the luminal surface level. These capillaries were drained by the collecting veins, which descended the mucosa and joined the submucosal plexus. The large efferent veins arising from the submucosal plexus passed through the muscular layer and continued with the appendicular vein. In the mucosal and submucosal layers, several spherical basket-like casts of the germinal center (lymphoid follicle) were seen. In the parafollicular region (primary follicle), casts of postcapillary venules with prominent surface undulations were relatively frequently observed.
Intercellular spaces in the epithelium of the rabbit Peyer's patch and appendix were examined by scanning and transmission electron microscopy to elucidate their three-dimensional structure and their relationship to the reticular spaces in the underlying lymph nodule. Two types of intercellular spaces were distinguished: regularly arranged tubular channels and irregularly winding tunnels. The tubular channels were observed around normal enterocytes on the villi or internodular folds and apical portions of nodule domes. The channel spaces were lined with a successive arrangement of belt-like intercrestal surfaces of prismatic enterocytes and variously sized processes on the crests. The processes adjoining opposed crests formed a ladder-like structure or pectinate septa between neighboring channels. The irregularly winding tunnels were formed among processes of irregularly shaped cells corresponding to FAE cells (Bockman and Cooper, 1973) or M cells (Owen and Jones, 1974) in the nodule associated epithelium. In the appendix, the tunnels were frequently organized into two-story spaces, the adlumenal and basal spaces, which were incompletely separated by cytoplasmic processes. These tunnels continued by pores in the basement membrane to the reticular spaces in the underlying lymph nodules. Furthermore, the tunnels and the basement membrane pores constantly contained single or grouped free cells or their processes. The findings in the present study suggest that the tubular channels are intraepithelial compartments for the absorption of nutrients and fluid, and the irregular tunnels are an intraepithelial network of spaces for the housing of lymphoid cells coming from the underlying lymph nodule.
Three patients with a gas-filled appendix in association with acute abdominal symptoms are described. In each case the gas-filled appendix was located in the right lower quadrant. None of the patients had appendicitis. It is emphasized that this combination of findings is not neccessarily diagnostic of appendicitis. Clinical evaluation is important in assessing the significance of this sign.
Chronic (1-3 months' duration) appendiceal obstruction was induced in 11 rabbits to assess the pathologic consequences and to study the associated radiologic, sonographic, and CT findings. Three pathologic/radiologic groups resulted with approximately equal frequency. In group A, the abscess was characterized by inflammatory cells in the lumen and wall of the appendix without mucin production. Calcification was shown radiographically, and sonography showed an anechoic or complex pattern. Group B, the "mixed response," was characterized by an intact hyperplastic mucosa, mucin secretion, and inflammatory debris in the lumen. Occasional calcification was present radiographically, and sonography showed a complex or hypoechoic pattern. In group C, true mucoceles had an intact hyperplastic mucosa, a mucin-filled lumen, and minimal inflammation. These were anechoic on sonography except for mobile foci of inflammatory debris. Chronic obstruction of the appendix results in a spectrum of pathologic responses with varying degrees of either inflammation and mucosal destruction or mucosal hyperplasia and mucin secretion. An abscess results when infection overwhelms the host's inflammatory responses. If the bacteria are destroyed by these defenses, a mucocele forms. An intermediate situation occurs when there is a mixed response with chronic inflammatory changes and an intact mucosa. This finding supports the existence of chronic appendicitis in humans.