

Central Annals of Emergency Surgery Bringing Excellence in Open Access

Case Report *Corresponding author Calafell Joel, Department of Surgery, University of Connecticut School of Medicine, 13 Byrne Ct unit B Diverticulitis of the Appendix: Farminqton, CI 06032, USA, Tel: 305-321-4413; Email:

Submitted: 10 October 2017 Rare but Real Accepted: 04 December 2017 Calafell Joel* and Kevorkian Noubar Published: 06 December 2017 Department of Surgery, University of Connecticut School of Medicine, USA Copyright © 2017 Joel et al.

Abstract ISSN: 2573-1017

Diverticulosis of the appendix is a very rare entity that clinically presents OPEN ACCESS similar to acute or chronic appendicitis. Diagnosis is almost always made at time of appendectomy or on pathology.

INTRODUCTION

It was first described by Kelynack in 1873 and classifies it as acquired and congenital. Acquired is rare cause of acute appendicitis with a range of 0.004% to 2.1% [1]. Congenital is even rarer with few case reports presented and an incidence of 0.014% [1]. Treatment of appendiceal diverticulitis and diverticula are the same as appendicitis, but must be done more urgently as there is an associated with perforation and neoplasm. The neoplasms usually seen are carcinoid and mucinous adenomas.PRESENTATION We now present OF CASE a case from our Community Hosptial.

We present the case of a healthy 30 year old female admitted with a two day history of abdominal pain. The pain gradually shifted to the right lower quadrant, with no other associated Figure 1 symptoms. Her physical exam was typical for acute appendicitis. Cross section of the specimen showing 2 diverticula. She had no leukocytosis, however she had radiographic findings consistent with early acute appendicitis. She underwent a Laparoscopic Appendectomy; the tip of her appendix was enlarged and inflamed while the base was found to be mildly hyperemic. The patient had an uneventful recovery. Upon histologic evaluation, her appendix had Goblet cell hyperplasia in two large diverticuli at the distal aspect with polymorphonuclear infiltration (Figure 2) suggestive of acute appendiceal diverticulitis.DISCUSSION No occult neoplasm was demonstrated (Figure 1).

Appendiceal diverticulitis is mainly diagnosed during surgery or on pathology, but rarely on preoperative imaging. In review of Figure 2 the literature Abdullgaffer, Sohn, and Collins reporting 0.014%, Polymorphonuclear infiltration. 3.7%, and 1.4% respectfully [4,12,13]. Histologically 2 types are recognized: acquired and congenital. Acquired diverticuli are usually seen at the distal end of the appendix. They are usually Diverticuli can be seen with ultrasound, but is highly range from 2-5 mm and described as pseudo diverticuli, as they dependent on the sonographer’s skill. Ct scan can be helpful by only the mucosa and sub mucosa herniate through a defect in visualizing the inflamed diverticulum. Non-inflamed are difficult the muscle layer. A herniation of all three layers is seen in the to locate, unless they are unusually large. congenital form, which is located on the antimesenteric edge of the appendix. Our patient’s appendix was pseudo diverticuli thus While it clinically mimics acute appendicitis, it is associated being classified as acquired diverticuli [14]. with an increased incidence of appendiceal neoplasms and a Cite this article: Joel C, Noubar K (2017) Diverticulitis of the Appendix: Rare but Real. Ann Emerg Surg 2(5): 1024. Joel et al. (2017) Email:



Central Bringing Excellence in Open Access

higher risk of perforation. Yamana et al., reports a 33% risk of Clinical characteristics of 12 cases of appendiceal diverticulitis: a perforation compared to 9.8% seen in usual appendicitis [5]. comparison with 378 cases of acute appendicitis. Surg Today. 2012; 42: 363-367. Along with an increased rate of perforation, a higher rate of neoplasm is seen, especially mucinous adenomas and carcinoid 5. Phillips BJ, Perry CW. Appendiceal diverticulitis. Mayo Clin Proc. 1999; tumors. The increased risk is variable with Dupre et al., reporting 74: 890-892.

47.8% while Marcacuzco only reported 7.1% [2,15] Hence a 6. George DH. Diverticulosis of the vermiform appendix in patients with cautious approach since diverticuli are commonly missed and cystic fibrosis. Hum Patho. 1987; 18: 75-79. ø ruptureCONCLUSION of the appendix can lead to peritoneal seeding. 7. Delikaris P, Stubbe Teglbjaerg P, Fisker-S rensen P, Balslev I. Diverticula of the vermiform appendix. Alternative of clinical presentation and significance. Dis Colon Rectum. 1983; 26: 374-376.

Appendiceal diverticulitis while rare should be listed in the 8. Palmer G, Seidal T, Weibull H. Perforated diverticulum of the appendix. differential diagnosis for every patient with right lower quadrant Eur J Surg. 1992; 158: 507-508. pain. Accurate and cautious appendectomy is needed to obtain 9. Fitzer PM, Rao KG, Bundrick TJ. Diverticulosis of the appendix : high quality specimen as associated neoplasm can be present. radiographic and clinical features. South Med J. 1985; 78: 1512-1514. Hence the strong opinion that even if diverticuli are found incidentally a prophylactic appendectomy should be performed 10. Place RJ, Simmang CL, Huber PJ. Appendiceal diverticulitis. South Med J. 2000; 93: 76-79. given a proven increased risk of perforation and co-existing neoplasm.REFERENCES 11. Collins DC. A study of 50,000 specimens of the human vermiform appendix. Surg Gynecol Obstet. 1955; 101: 437-445.

12. Sohn TJ, Chang YS, Kang JH, Kim DH, Lee TS, Han JK. Clinical 1. Kelynak TN. HK Lewis. A Contribution to the Pathology of the characteristics of acute appendiceal diverticulitis. J Korean Surg Soc. Vermiform Appendix. London. 1893; 60–61. 2013; 84: 33-37. ó 2. Dupre MP, Jadavji I, Matshes E, Urbanski SJ. Diverticular disease of 13. Escobar F, Valentın N, Valbuena E, Marvel Bar n. Diverticulitis the vermiform appendix: a diagnostic clue to underlying appendiceal apendicular, revision de la literaturacientıfica y presentacion de 2 neoplasm. Hum Pathol. 2008; 39: 1823-1826. casos. Rev Colomb Cir. 2013; 28: 223-228.

3. Abdullgaffar B. Diverticulosis and diverticulitis of the appendix. Int J 14. MarcacuzcoQuinto AA, Manrique MA, Calvo PJ, Loinaz C, Justo I, Surg Pathol. 2009; 17: 231-237. Caso O. Clinical implications of diverticular disease of the appendix. 4. Yamana I, Kawamoto S, Inada K, Nagao S, Yoshida T, Yamashita Y. Experience over the past 10 years. Cir Esp. 2016; 94: 44-47.

Cite this article Joel C, Noubar K (2017) Diverticulitis of the Appendix: Rare but Real. Ann Emerg Surg 2(5): 1024.

Ann Emerg Surg 2(5): 1024 (2017) 2/2