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Appendicular Diverticulosis with Appendicitis Syed Muhammad Hammad Alam

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Appendicular Diverticulosis with Appendicitis Syed Muhammad Hammad Alam CASE REPORT Appendicular Diverticulosis with Appendicitis Syed Muhammad Hammad Alam ABSTRACT Appendicular diverticulosis is one of the very rare diseases which is also difficult to diagnose, especially clinically, due to its silent course and non-specific symptoms. It comes under the notation usually due to its complications like diverticulitis or perforation, but sometimes it also presents with acute appendicitis. This report describes a 44-year male patient who presented with the complain of right iliac fossa pain and was clinically diagnosed as acute appendicitis; but intra- operatively, it was found that the appendix also had diverticulosis along with appendicitis. Key Words: Diverticulosis. Appendicitis. Diverticulitis. INTRODUCTION tenderness and cough impulse. Groin and genitals were Appendicular diverticulosis is a disease in which multiple unremarkable. Clinically, patient was diagnosed as outpouchings arise from the appendicular wall. acute appendicitis. On investigations, hemoglobin was 13.9 g/dL and leucocyte count was 7,800/µL, in which Appendicular diverticulosis is one of the rare diseases of neutrophils were 57%. On ultrasound abdomen, a non- vermiform appendix; having incidence of only 0.8% in compressible target lesion of about 12.8 mm diameter appendectomy patients.1,2 It was first reported in 1893, was seen in right iliac fossa. In the light of clinical and since then very few case reports have been findings and investigations, the final diagnosis of acute published on this disease.3 Etiology and pathology of appendicitis was established and plan for operative appendicular diverticulosis are still poorly understood; it management was made. may be due to the rarity of the disease. Clinically, appendicular diverticulosis presents with pain in the right During operation for appendectomy, it was found that iliac fossa and mostly misdiagnosed as acute appendix showed multiple diverticula (Figure 1) with appendicitis. Correct diagnosis is usually made either appendicitis as well. Diverticula were six in number and intraoperatively or on histopathological examination of were present all around the circumference of appendix, resected appendix.1,2,4-6 i.e. not limited to mesenteric or anti-mesenteric border. The diverticula were neither inflamed nor had any Here, I report a case of appendicular diverticulosis which adhesions with the surrounding structures. There was presented as appendicitis. no perforation or any collection of pus around them; however, the appendix was grossly inflamed, edematous CASE REPORT and thickened. Appendectomy was performed unevent- A 44-year male patient of Asian origin; working in a fully. Patient recovery was excellent; and he was plastic factory for the last 18 years, presented in surgical discharged from the hospital after 2 days of stay. The OPD with complain of pain in the right lower abdomen patient was followed-up in OPD till 14th postoperative for the last 2 days. Pain was mild, continuous, non- day and then on phone for a year, to ensure that he did radiating with no other associated symptoms like fever not develop any complication. and vomiting. There was a previous history of similar pain 2 years back which had subsided spontaneously in 2-3 days. There was no significant family history. On examination, he was well oriented and hemodynamically stable. His general physical examination was unremarkable. On systematic examination, his abdomen was soft, having mild tenderness in the right iliac fossa with no rebound Department of Surgery, Dr. Hassan Ghazzawi Hospital, Jeddah, Saudi Arabia. Correspondence: Dr. Syed Muhammad Hammad Alam, Specialist General Surgeon, Department of Surgery, Dr. Hassan Ghazzawi Hospital, Jeddah, Saudi Arabia. E-mail: [email protected] Figure 1: Intraoperative photograph of inflamed appendix showing multiple Received: January 02, 2016; Accepted: August 15, 2016. diverticula. Journal of the College of Physicians and Surgeons Pakistan 2017, Vol. 27 (3): 183-184 183 Syed Muhammad Hammad Alam confirmed that diverticulitis is the cause of appendicitis. No standardized differentiating criteria are available until now in the medical literature to recognize the primary event; some reports have discussed the importance of distance between inflamed portion of appendix and diverticulitis. If distance is appropriate between the two, then both are separate and independent events. But if inflammation is confluent, then either diverticulitis is the primary event and involvement of appendix (appendicitis) is secondary or vice versa.5 However, to support and prove the authenticity of this criterion, more scientific tools and studies are needed. Appendicular diverticulosis, along with its complications like diverticulitis, is a separate entity from appendicitis. Both have distinct etiology and disease process, but Figure 2: Histologic section of appendix showing lack of muscularis and serosal layers in the wall of diverticulum (arrow head). (Hematoxylin & Eosin can mimic each other clinically and may be found x 40). concurrently. Moreover, the therapeutic management for The appendectomy sample was sent for histo- both is the same, i.e. appendectomy. pathological examination. Microscopy showed focal infiltration of acute inflammatory cells with numerous REFERENCES eosinophils in the wall of appendix. No malignancy was 1. Käser SA, Willi N, Maurer CA. Prevalence and clinical detected. Focally, the appendicular wall showed implications of diverticulosis of the vermiform appendix. J Int outpouchings of mucosa and sub-mucosa with Med Res 2013; 41:1350-6. attenuated to absent muscularis propria and serosa 2. Manzanares-Campillo M del C, Pardo-García R, Martín- (Figure 2). There was no significant inflammation noted Fernández J. Appendicular pseudodiverticula and acute in diverticula. appendicitis: Our 12-year experience. Rev Esp Enferm Dig 2011; 103:582-5. DISCUSSION 3. Kelynack TN. A contribution to the pathology of the vermiform Appendicular diverticulosis is a rare entity, with an inci- appendix. London, England: HK Lewis; 1893:60. dence of 0.8% in most of the studies.1,2 The incidence 4. Friedlich M, Malik N, Lecompte M, Ayroud Y. Diverticulitis of the varies between 0.004 to 2.1% in appendectomy appendix. Can J Surg 2004; 47:146-7. patients.4,6,7 Mean age for presentation of this disease is 5. Al-Brahim N, Al-Kandari I, Munahai M, Sharma P. 35.0 ±10.2 years with higher prevalence in males, Clinicopathological study of 25 cases of diverticular disease of varying between 69.2 - 96%.2,5 the appendix: Experience from Farwaniya Hospital. Patholog Res Int 2013; 2013:404308. Presentation of appendicular diverticulosis with appendicitis, as in this case, is the second most common presentation 6. Lobo-Machín I, Delgado-Plasencia L, Hernández-González I, Brito-García A, Burillo-Putze G, Bravo-Gutiérrez A. Appendiceal 2,5 of appendicular diverticulosis. Most common diverticulitis and acute appendicitis: Differences and presentation is the acute appendicular diverticulitis with similarities. Rev Esp Enferm Dig 2014; 106:452-8. acute appendicitis, while appendicular diverticulitis with 7. Zubieta-O'Farrill G, Guerra-Mora JR, Gudiño-Chávez A, normal appendix and only diverticulosis without any Gonzalez-Alvarado C, Cornejo-López GB, Villanueva-Sáenz complications are less common presentations. E. Appendiceal diverticulum associated with chronic By critically analyzing the data from previous case appendicitis. Int J Surg Case Rep 2014; 5:961-3. reports and series, including this case report as well, we 8. Sreeramulu PN, Agrawal VP, Venkatachalapathy. Appendicular found that in appendicular diverticulosis, diverticulitis is diverticulosis: A case report. IJBAR 2012; 03:595-6. not the etiological factor of appendicitis, as is commonly 9. Halder SK, Khan I. An Indian female presenting with misunderstood.8,9 Even in patients having both diverti- appendicular diverticulitis: A case report and review of the culitis as well as appendicitis concurrently, it is not literature. Cases J 2009; 2:8074. 184 Journal of the College of Physicians and Surgeons Pakistan 2017, Vol. 27 (3): 183-184.
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