Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 2005  |  Volume : 11  |  Issue : 1  |  Page : 45-47
Endometriosis of the appendix: A trap for the unwary


Department of Surgery, King Khalid University Hospital, Riyadh, Saudi Arabia

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Date of Submission11-Jul-2004
Date of Acceptance04-Nov-2004
 

How to cite this article:
Khairy GA. Endometriosis of the appendix: A trap for the unwary. Saudi J Gastroenterol 2005;11:45-7

How to cite this URL:
Khairy GA. Endometriosis of the appendix: A trap for the unwary. Saudi J Gastroenterol [serial online] 2005 [cited 2019 Jul 22];11:45-7. Available from: http://www.saudijgastro.com/text.asp?2005/11/1/45/33337


The anatomic variations of the appendix along with a wide spectrum of appendiceal affections frustrate the accurate diagnosis of appendicitis. Isolated endometriosis of the appendix is rare and its presentation as acute appendicitis is even uncommon [1] . Endometriosis affects the intestinal tract in 15-30% of patients with pelvic endometriosis [2) . The correct diagnosis is often delayed because intestinal endometriosis may masquerade clinically as regional enteritis, ischemic enteritis or colitis, diverticulitis or neoplasm [3],[4] . The incidence of endometriosis of the appendix is reported to be just under 1 % of the total endometriosis cases [5],[6] but because of its propensity to manifest with a wide spectrum of site-specific presentations, appendiceal endometriosis should be a diagnostic consideration in the evaluation of pre menopausal women with gastrointestinal complaints [7] .

This case report presents a lady with vague abdominal pain and ultimately was found to have endometriosis of the appendix at King Khalid University Hospital Riyadh, Kingdom of Saudi Arabia (KSA).


   Case Report Top


A 33-year-old unmarried lady was admitted through the Emergency Room with the complaint of lower abdominal pain of ten days duration. The pain was dull, continuous and not related to her menstrual cycles. Her past history was remarkable of having similar pain about six months back which prompted the treating gynecologist to perform diagnostic laparoscopy which was essentially normal. On admission, the patient was afebrile with normal vital signs. Abdominal examination showed deep tenderness in the lower abdomen with no rigidity, guarding, tenderness or any palpable mass. All hematological, biochemical and radiological investigations,including abdominal/pelvic ultrasound and CT scan were unremarkable. The patient underwent diagnostic laparoscopy, which revealed an appendicular mass (about 6X6 cm) and otherwise normal findings. An uncomplicated appendectomy followed. The histological result showed endometriosis of the appendicular apex [Figure - 1] and [Figure - 2]. The postoperative period was uneventful and the patient was discharged on the 4th day in a stable condition.


   Discussion Top


Endometriosis is a common cause of lower abdominal, pain and affects about 15% of females in the reproductive age [8] . Endometriosis of the gastrointestinal tract can be localized by the frequency of occurrence to the rectosigmoid (72%), recto vaginal septum (13%), small bowel (7%), cecum (4%), appendix (3%), and other intestinal sites (0.5%) [2] . Endometriosis is characterized by the ectopic growth of hormonally responsive endometrium outside the uterus. The most widely accepted mechanism for its development is the retrograde menstruation through the  Fallopian tube More Details into the peritoneum, with subsequent growth of the displaced cells [9] . Involvement of distant sites such as the pericardium or pleura is best explained by the vascular dissemination of endometrial cells. As with endometriosis elsewhere in the intestinal tract, endometriosis of the appendix may be asymptomatic [10] , may result in perforation or intussusception [11] The present case presented with nonspecific lower abdominal pain unrelated to her menstrual cycles. The diagnosis of endometriosis of the appendix is invariably incidental and histological. Transabdominal ultrasonography is reported to have a diagnostic sensitivity of up to 94% for acute appendicitis [12] , but transvaginal ultrasonography can also be beneficial in explaining endometriosis-related vague intestinal symptoms [13] CT and magnetic resonance imaging scans are usually nonspecific because of the small size of the endometriosis implants.

The appendix is a key organ in the evaluation of undiagnosed chronic pelvic pain [14] . Laparoscopy has emerged as a valuable tool in the management of unexplained abdominal pain. Laparoscopic visualization and diagnostic yield are of profound significance to women in whom gynecologic diseases such as endometriosis, pelvic inflammatory disease, ruptured ovarian follicles or tubal pregnancy may be the source of pain and mimic appendicitis [15] . Laparoscopic appendectomy itself is feasible and readily accepted therapeutic procedure [16] . Our patient was treated by laparoscopic appendectomy with favorable outcome. Definite diagnosis of appendicular endometriosis is made by surgical exploration and tissue analysis [17] . On histologic examination, secretory glands lined by cuboidal endometrial cells are seen surrounded by endometrial stroma embedded in fibrous tissue (17) . The serosal implants are functionally active and tend to bleed into various tissues leading to desmoplastic response, mucosal ulceration and ischemia. Such pathophysiological changes may lead to the varying presentations and diagnostic confusion.

In conclusion, endometriosis of the appendix may present as appendicitis and its related affections and the treating physician should have a high index of suspicion while managing women of reproductive age with chronic lower abdominal and pelvic pain.

 
   References Top

1.Babaknia A, Parsa H, Woodruff JD. Appendicitis during pregnancy. Obstet gynecol 1997; 50: 40-4.  Back to cited text no. 1    
2.Prystowsky JB, Stryker SJ, Ujiki GT, Poticha SM. Gastrointestinal endometriosis: incidence and indications for resection. Arch Surg 1988; 123: 855-8.  Back to cited text no. 2  [PUBMED]  
3.Shah M, Tager D, Feller E. Intestinal endometriosis masquerading as common digestive disorders. Arch Intern Med 1995; 155: 977-80.  Back to cited text no. 3  [PUBMED]  
4.Sievert W, Sellin JH, Stringer CA. Pelvic endometriosis simulating colonic malignant neoplasm. Arch Intern Med 1989; 149: 935-8.  Back to cited text no. 4  [PUBMED]  
5.Weed JC, Ray JE. Endometriosis of the bowel. Obstet Gynecol 1987; 69: 727-30.  Back to cited text no. 5  [PUBMED]  
6.Stefanidis K, Kontostolis S, Pappa L, Kontostolis E. Endometriosis of the appendix with symptoms of acute appendicitis in pregnancy. Obstet Gynecol 1999; 52: 850.  Back to cited text no. 6    
7.Yantiss RK, Clement PB, Young RH. Endometriosis of the intestinal tract. Am J Surg Pathol 2001; 25: 445-54.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Schenken RS. Endometriosis In: Scott JR, DiSaia PJ, Ham CB, Spellacy WN, eds. Danforth's obstetrics and gynecology ed. Philadelphia: Lippincort- Raven Publishers, 1999: 669.  Back to cited text no. 8    
9.Zondervan KT, Cardon LR, Kennedy SH. The gastrointestinal endometriosis. Curr opin obstet gynecol 2001; 13: 126-8.  Back to cited text no. 9    
10.Chiou YY, Pitman MB, Hahn PF, Kim YH, Rhea JT, Mueller PR. Rare benign and malignant appendiceal lesions: spectrum of computed tomography findings with pathologic correlation. J Comput Assist Tomogr 2003; 27: 297-306.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]
11.Yelon JA, Green JM, Hashmi HE Endometriosis of the appendix resulting in perforation: a case report. J Clin Gastroenterol 1993;16:355.  Back to cited text no. 11    
12.Rioux M. Sonographic detection of the normal and abnormal appendix. Am J Roentgenol 1994; 158: 773-8.  Back to cited text no. 12    
13.Whitford CM, Crade M. Transvaginal diagnosis of appendicitis. Am J Roentgenol 1994; 162: 469.  Back to cited text no. 13    
14.Agarwala N, Liu CY. Laparoscopic appendectomy. J Am Assoc Gynecol Laparosc 2003; 10: 166-8.  Back to cited text no. 14  [PUBMED]  
15.Minnie L, Varner D, Burnell A, Fatzer E, Clark J, Haun W. Laparoscopic versus open cholecystectomy. Prospective randomized study of outcomes. Arch Surg 1997; 132: 708-11.  Back to cited text no. 15    
16.Scott-Conner CEH, Hall TJ, Anglin BL, Muakkassa FF. Laparoscopic appendectomy: Initial experience in a teaching programme. Ann Surg 1992; 215: 660-8.  Back to cited text no. 16    
17.Oral E, Arici A. Pathogenesis of endometriosis. Obstet Gynecol Clin North Am 1997; 816-305.  Back to cited text no. 17    

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Correspondence Address:
Gamal Ahmed Khairy
Department of Surgery, King Khalid University Hospital, P 0 Box 2925, Riyadh 11461
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-3767.33337

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This article has been cited by
1 Endometriosis of the appendix: A diagnostic dilemma
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