Annals of B Pod: Stump Appendicitis
/HISTORY OF PRESENT ILLNESS
A male in his 50s presents with right lower quadrant pain. The pain developed one day prior to presentation and was gradual in onset. He describes the pain as constant and sharp without radiation, rated at an 8/10. The pain has been worsening since symptom onset and has not been relieved with acetaminophen or ibuprofen. Of note, the patient had a prior appendectomy three months prior due to an acute suppurative appendicitis that was otherwise uncomplicated. He completed his course of antibiotics (ciprofloxacin and Augmentin) that was prescribed after surgery. He denies any fevers or chills, nausea, vomiting, constipation, diarrhea, or urinary symptoms. He does report having decreased oral intake associated with the pain.
Past Medical History: Chronic kidney disease, coronary artery disease, diabetes mellitus II, hypertensIon, hyperlipidemia
Past Surgical History: Appendectomy, cardiac drug-eluting stent placement
Past Social History: No alcohol, tobacco, or recreational drug use
Medications: Amlodipine, aspirin, atorvastatin, carvedilol, dulaglutide, humulin, jardiance, lisinopril, nitroglycerin
Allergies: Codeine, hydrochlorothiazide
Physical exam
Vitals: HR 97, BP 145/73, RR 18, SpO2 98% ORA, T 99.3F
The patient is a well-appearing male who is awake, alert, and oriented. Respiratory and cardiovascular exams are normal. Abdominal exam reveals point tenderness in the right lower quadrant with rebound and voluntary guarding but without distention. There are no other peritoneal signs on exam. There is also a well-appearing, healed surgical scar. The patient does not have any costovertebral angle tenderness bilaterally. Neurologic exam is non-focal and unremarkable. The skin is warm and well perfused with brisk capillary refill.
Notable diagnostics
CBC: WBC 19.2, Hgb 17.3
BMP: Na 136, K 4.3, BUN 38, Cr 1.63, Gluc 231
Lactate 1.8
Figure 1: CT abd/pelvis demonstrating blind ending structure arising from cecum (arrows) with diffuse fat stranding consistent with acute stump appendicitis
Computed Tomography (CT) Abdomen and Pelvis: A 3 cm long blind-ending structure with staple line at the tip arises from the cecum. Diffuse fat stranding throughout the pericecal mesentery. No organized or rim-enhancing fluid collection. No free intraperitoneal air. Acute stump appendicitis without evidence of perforation or abscess (Figure 1)
HOSPITAL Course
Acute Care Surgery was consulted from the ED and recommended admission for operative resection of a 3 cm remnant of the appendix. The patient was started on antibiotics (ceftriaxone and metronidazole) for his stump appendicitis, as well as IV fluids for hydration. The patient was taken to the OR and underwent a laparoscopic removal of the remnant. The procedure was converted to an open right hemicolectomy due to an unhealthy appearing cecum that was not amenable for anastomosis. The patient’s post op course was uncomplicated and his pain was controlled with oral medications. The patient was discharged on hospital day 5.
Discussion
Acute appendicitis is one of the most common causes of acute abdomen that present to the Emergency Department requiring surgical intervention. [1] Complications from acute appendicitis can be divided into both early and late. Early complications include wound infection and bleeding, whereas late complications include obstruction, hernia, and stump appendicitis (table 1). Stump appendicitis occurs when the remaining stump becomes inflamed and infected. [1] It is important to keep stump appendicitis in the differential for a post-appendectomy patient who presents with right lower quadrant or non-specific abdominal pain. The estimated incidence of stump appendicitis
Table 1: Early and late complications of acute appendicitis
is about 1 in 50,000, but true occurrence is thought to be higher because it is underrecognized. [2] Due to under-recognition, diagnosis is usually delayed, and having a high index of clinical suspicion is important to avoid serious complications, including perforation, peritonitis, or gangrene of the residual tissue.
Stump appendicitis may occur in patients who have undergone both laparoscopic or open appendectomies. [2] Known risk factors that have been cited in literature are remnant appendix tissue that is greater than 5 mm or specific positioning of the appendix such as retrocecal. [3] This may occur months to years after the initial appendectomy. A literature review by Kanona et al. found that the time frame to the development of stump appendicitis occurred in as little as 9 weeks up to 50 years. [3]
The most common presenting symptom is usually right lower quadrant pain, similar to that of acute appendicitis. [4] Other symptoms include generalized abdominal pain, fever, nausea, and vomiting, though none of these are specific. [5] Other clinical findings that may suggest a diagnosis of stump appendicitis include leukocytosis and increased inflammatory markers. Because the signs and symptoms of stump appendicitis are vague, it is difficult to diagnose.
Figure 2: Right lower quandrant sagittal image of blind ended tubular structure that is indicative of likely stump appendcitis. Above figure is a representative image and not from this particular patient case.
A clinical suspicion of stump appendicitis may be confirmed with various imaging modalities, abdominal ultrasound or CT imaging being most common. For ultrasound, it is recommended to scan the most tender area using a linear probe. Scanning in McBurney’s point may be done if pain is generalized or non-localizing. [6] When the appendix is visualized, care must be taken to scan along the entire length. A non-compressible blind-ended tubular structure may be indicative of stump appendicitis (Figure 2).
On CT, findings that are suggestive of stump appendicitis include a remnant appendix with periappendiceal or pericecal inflammation. [7] A representative slice (Figure 1) of the patient’s cross-sectional imaging in this case study showed a 3 cm blind-ending structure arising from the cecum with a staple line at the tip (red arrow). There was associated diffuse fat stranding throughout the pericecal mesentery (yellow arrow).
SUMMARY
Stump appendicitis is a very rare complication of appendicitis that
is often underdiagnosed due to the decreased awareness about this disease pathology. It occurs due to the inflammation of the residual remnant of a previously removed appendix. Symptoms are usually nonspecific and may mimic those of appendicitis. Prompt diagnosis using ultrasound or CT imaging decreases complications that may arise due to its underrecognition. As emergency physicians, it is important to keep stump appendicitis as a differential for abdominal pain in patients who have had a previous appendectomy.
AUTHORED BY Julius de castro, MD
Dr. de Castro is a PGY-3 in Emergency Medicine at the University of Cincinnati
EDITING BY DR. marlena wosiski-kuhn AND THE ANNALS OF B POD EDITORS
References
1. Kanona H, Al Samaraee A, Nice C, Bhattacharya V. Stump appendicitis: A Review. International Journal of Surgery. 2012;10(9):425-428.
2. Essenmacher A, Nash E, Walker S, Pitcher G, Buresh C, Sato S. Stump appendicitis. Clinical Practice and Cases in Emergency Medicine. 2018;2(3):211-214.
3. Dikicier, E., Altintoprak, F., Ozdemir, K. et al. Stump appendicitis: a retrospective review of 3130 consecutive appendectomy cases. World J Emerg Surg 13, 22 (2018).
4. Hadrich, Z, Mroua, B, Zribi, S, Bouassida, M, Touinssi, H. Stump appendicitis, a rare but serious complication of appendectomy: A case report. Clin Case Rep. 2021; 9:e04871.
5. Monsomboon, A., Nelson, B. P., Andrus, P., & Tsung, J. W. (2019). Point-of-care ultrasound diagnosis of Stump appendicitis in the emergency department. The Ultrasound Journal, 11(1).
6. Enzerra, M. D., Ranieri, D. M., & Pickhardt, P. J. (2020). Stump appendicitis: Clinical and CT findings. American Journal of Roentgenology, 215(6), 1363–1369.
