Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 2002  |  Volume : 8  |  Issue : 3  |  Page : 93-95
Colonoscopic removal of an appendiceal polyp


Department of Gastroenterology, King Fahad Hospital. Al Madidanah Al Munawarrah, Saudi Arabia

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Date of Submission06-Jun-2001
Date of Acceptance19-Dec-2001
 

How to cite this article:
Khawaja FI. Colonoscopic removal of an appendiceal polyp. Saudi J Gastroenterol 2002;8:93-5

How to cite this URL:
Khawaja FI. Colonoscopic removal of an appendiceal polyp. Saudi J Gastroenterol [serial online] 2002 [cited 2017 Jul 21];8:93-5. Available from: http://www.saudijgastro.com/text.asp?2002/8/3/93/33398


Benign polyps of the vermiform appendix are rare and usually discovered incidentally during surgery or at autopsy. A gross abnormality of the appendix is recognized in 5% of these cases [1] . The reported incidence of benign appendiceal polyps from various autopsy series ranges from 0.004% to 0.08% [2] . Lack of careful inspection of the appendiceal lumens by pathologists may be one of the reasons of such wide fluctuation in the reported incidences. Polyps might be discovered more frequently if the appendix could be cut along its entire length before fixation rather than by the usual multiple transverse cuts [3] . Appendiceal polyps are usually located in the proximal appendix and may be solitary or multiple [4] . Synchronous polyps in the colon have been described in up to 25% of the cases [2] . Multiple appendiceal polyps are well described in familial polyposis syndromes [4] . A case have been described where adeno-carcinoma of the appendix was the initial presentation of a patient with adenomatous polyposis [4] . Hamartomatous polyps of the appendix have also been described in Puetz-Jeghers syndrome [5] . Histologically mutinous cystadenomas are the most common benign polyps followed by villous adenomas and adenomatous polyps [6],[7] . A case of a pedunculated adenomatous polyp arising from the appendix is described. The polyp could only be visualized as it prolapsed through the appendiceal orifice into the caecal lumen. Intermittent complete retraction into the appendiceal lumen was observed repeatedly. The polyp was grasped with standard snare, pulled into the caecal lumen and an endoscopic polypectomy was safely performed.


   Case report Top


A 76-year old man with coronary artery disease, hypertension and diabetes mellitus was referred for evaluation of left flank pain of one-week duration. There was no history of right lower quadrant abdominal pain, fever, chills, nausea or vomiting. He had not noticed any change in his bowel habits. There was no blood in the stools. The physical examination was unremarkable except for guaiac positive brown stools. The hemoglobin was 15g/1, hematocrit was 47.3%. Electrolytes. liver enzymes and routine blood chemistries were all normal. Colonoscopy was performed to evaluate the source of the guaiac positive stools. Five polyps were noted scattered in the colon. The first was 2.5xlem pedunculated polyp in the sigmoid colon. A 0.5cm sessile polyp was located in the distal transverse colon and another 2x1.5cm sessile polyp at the hepatic flexure. Two small polyps were seen in the caecum. One of these polyps was located on the margin of the appendiceal opening while the second polyp was actually occupying the appendiceal orifice [Figure - 1]. This later polyp was protruding into the caecal lumen intermittently. A standard polypectomy snare was used to catch the stalk of the polyp. After the snare was tightened around the stalk the, polyp was gently pulled into the caecal lumen. A thin slender stalk originating from within the appendiceal lumen was clearly visualized [Figure - 2]. The question of a "pseudo-stalk" resulting from a partially inverted appendix was entertained. However, due to a clearly identifiable lumen and the slender nature of the stalk this was considered unlikely. The polyp was removed using coagulation current and a standard polypectomy technique. The residual stalk of the polyp gradually retracted inside the appendiceal orifice [Figure - 3] and finally disappeared entirely inside the appendiceal lumen. Histologically, this proved to be an adenomatous polyp. The polyp at the appendiceal margin and all others colon polyps were also removed. Post colonoscopy, the patient remained asymptomatic. There was no abdominal pain. He did not develop any signs to suggest local peritoneal irritation. The two sessile polyps were benign. The sigmoid polyp had a focus of invasive adenocarcinoma with the malignant cells extending into the resected stalk.

The patient was advised to have surgical resection of the sigmoid colon but he refused any surgical intervention at that time. Six months later he suffered from a massive cerebro-vascular accident and died.


   Discussion Top


Benign adenomatous polyps are amongst the rarest form of the appendiceal neoplasm and are usually discovered incidentally during surgery or autopsy. Clinical features vary from a presentation typical of acute appendicitis or chronic right lower quadrant pain, non-specific symptoms or melena. Occasionally the initial presentation is related to intussusception [7] . Larger polyps are more likely to be symptomatic because of their tendency to occlude the appendiceal lumen. The ultimate fate of the asymptomatic appendiceal polyps is not known. The risk of carcinoma in these polyps is probably similar to the colonic polyps [1],[8] . It has been suggested that such patients be subjected to the same surveillance program as those with colonic polyps [8] . Benign neoplasm of the appendix have rarely been seen or removed at colonoscopy. The commonest benign appendiceal neoplasm seen during colonoscopy are villous adenomas [9],[10] . The larger sized villous adenomas are sometimes associated with intussusception of the appendix or in-situ carcinoma [11],[12],[13] Adenomatous polyps of the appendix have also been visualized colonoscopically [14],[15] Minute appendiceal adenomas have been identified with the use of magnifying endoscopes [16],[17] . Bailey et al described a case of a caecal polyp, where intussusception of the appendix was suspected during the colonoscopic examination. Surgically, resected specimen showed a juvenile polyp, which was originating from the appendix and has resulted in a complete intussusception of the appendix [18] . Cipolletta et al described colonoscopic removal of a completely inverted appendix, which appeared as a 2.5cm caecal polyp. No signs of peritoneal irritation were noted and small carcinoid tumor was present in the appendix [19] . Weinstock et al reported colonoscopic removal of a 3cm caecal polyp with long stalk coming out of the appendiceal orifice [20]. An endoloop was applied to the stalk and the polyp was then removed by using a standard monopolar electrocautery. Histologically, this proved to be a hamartomatous juvenile polyp. In the case presented here, although the polyp was smaller in size, it also has a Long thin stalk coming out of the appendiceal orifice. A completely inverted appendix will appear as an oblong caecal polyp without any identifiable lumen and in case of a partially inverted appendix, the intussusception tip coming out of the appendiceal orifice will look like a thick stalk with the lumen hidden inside. Because both of these possibilities of pseudo-pedicle formation from invagination of the appendiceal wall were considered unlikely, a standard polypectomy (without an endoloop) was performed safely. Histologically, this proved to be an adenomatous polyp. This is so far the only reported case of endoscopic removal of an adenomas polyp originating from the appendix.

Endoscopists performing colonoscopy should examine the appendiceal orifice carefully during all colonoscopic examinations, especially if other polyps have been seen in the colon. Should a polyp be identified in the appendiceal orifice it should removed endoscopically. If endoscopic removal is considered unsafe for any reason. then laparoscopic appendectomy is recommended as adenomas of the appendix may have a similar prognostic significance to adenomas elsewhere in the large bowel [8].

 
   References Top

1.Colins DC. 71000 human appendix specimens: A final report summarizing forty years study. Am J Proctology 1963: 14: 365-81.  Back to cited text no. 1    
2.Wolf M and Ahmed N. epithelial Neoplasm of the Vermiform Appendix (exclusive of carcinoid). Cancer 1976; 37: 2511-22.  Back to cited text no. 2    
3.Sanes S and Pachin DF. Polyposis of the Vermiform Appendix - Report of case. Arch Surg 1942; 44: 912-7.  Back to cited text no. 3    
4.Parker GM, Stollman NH, Rogers A. Adenomatous polyposis coli presenting as Adenocarcinoma of the Appendix. Am J Gastroenterol 1996; 91: 801-2.  Back to cited text no. 4  [PUBMED]  
5.Kitchin AP. Polyposis of the small intestine with pigmentation of the oral mucosa- Report of two cases. Brit M J 1953; 1:658.  Back to cited text no. 5    
6.Jafari N. Christ M, Menaker GI. Sheridan JT. Villous Adenoma of Appendix: Report of a case and review of literature Am J Proct Gastro Col and Rec Surg 1979: 16: 30-3.  Back to cited text no. 6    
7.Aranha GV, Reyes CV. Primary epithelial Tumours of the appendix and reappraisal of the Appendiceal "Mucocele". Dis Col and Rect 1979: 22: 472-6.  Back to cited text no. 7    
8.Williams GR, du Bouly CE, Roche WR. Benign epithelial neoplasm of the appendix: Classification and clinical associations. Histopathology 1992: 21: 447-51.  Back to cited text no. 8    
9.Green PH, Pery E, Curry WT. Colonoscopic diagnosis of appendiceal villous adenoma Gastrintest Endosc 1992: 38: 522-3.  Back to cited text no. 9    
10.Morison JG, Lianeza PP, Potts Jr. Preoperative colonoscopic diagnosis of villous adenoma of the appendix. Report of a case and review of the literature. Dis colon Rectum 1988: 31: 398-400.  Back to cited text no. 10    
11.Sadahiro S, Ohmura T, Yamada Y et al. A case of Ceco-colic Intussusception with complete Invagination and Intussusception of the Appendix with villous Adenoma. Dis Colon Rectum 1991: 34: 85-8.  Back to cited text no. 11    
12.Ohno M. Nakamura T. Honi H et al. Appendiceal Intussusception induced by a Tubulo-Villous adenoma with carcinoma insitu: Report of a case. Surg Today 2000: 30: 441-4.  Back to cited text no. 12    
13.Hardin RD. Colonoscopic diagnosis of an appendiceal polyp with carcinoma in situ. J Clin Gastroenterol 1986: 8: 189-91.  Back to cited text no. 13    
14.Brozincky S. Polyp of the appendix. N Egl .J Med 1993; 329: 1709.  Back to cited text no. 14    
15.Kubo S, Akiho H, Sato T et al. Tubular Adenoma of the Appendix diagnosed before operation. J Clin Gastroenterol 1997: 25: 486-7.  Back to cited text no. 15    
16.Itaba S, Akahoshi K, Araki Y et al. Preoperative colonoscopic diagnosis of minute appendiccal adenoma: Report of a case. Endoscopy 1998: 30: 564.  Back to cited text no. 16    
17.Shimuzu Y. Tanaka M, Shibuya T et al.. A case of Adenoma of Appendix diagnosed by Magnifying Endoscopy. Nippon Shokakibyo Gakkai Zasshi 1984:, 81: 1628-33 (Japanese).  Back to cited text no. 17    
18.Baily DJ, Courington KR, Andres JM et al. Caecal Polyp and Appendiceal Intussusception in a Child with Recurrent Abdominal Pain: Diagnosis by Colonoscopy. J Pediatr Gastroenterol Nut 1987:6: 818-20.  Back to cited text no. 18    
19.Ciplletta L. Bianco MA. Rotondano G. Endoscopic appendectomy for a carcinoid tumour of the appendix. Am J Gastroenterol 2001: 96: 929-30.  Back to cited text no. 19    
20.Weinstock LB. Shatz BA, Swanson PE. McFarland E. at the Focal Point Juvenile Polyp emerging from the Appendix. Gastrointest Enodosc 1999: 49: 579.  Back to cited text no. 20    

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Correspondence Address:
Fazal Imtiaz Khawaja
Consultant Gastroenterologist, King Fahad Hospital. P.O. Box 1925, Al Madidanah Al Munawarrah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


PMID: 19861799

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