Endoscopy 2007; 39: E20
DOI: 10.1055/s-2006-944919
Unusual cases and technical notes

© Georg Thieme Verlag KG Stuttgart · New York

Appendicitis with a palpable mass

S. L. Yan1 , Y. T. Liu1 , D. A. Chou2
  • 1Division of Gastroenterology, Dept. of Internal Medicine, Show Chwan Memorial Hospital, Changhua, Taiwan
  • 2Division of General Surgery, Dept. of Surgery, Show Chwan Memorial Hospital, Changhua, Taiwan
Further Information

D. A. Chou, M. D.

Division of General Surgery, Dept. of Surgery

Show Chwan Memorial Hospital
542 Chung-Shan Road, Section 1
Changhua 500
Taiwan

Fax: +886-4-7233190

Email: yslcsmc@hotmail.com

Publication History

Publication Date:
07 February 2007 (online)

Table of Contents

A 65-year-old woman presented with intermittent right lower quadrant pain that had persisted for more than 2 weeks. The pain was described as cramping, and was unrelated to food intake or defecation. Five days before admission, a tender mass had become palpable over the right lower quadrant. There had been no fever episodes before she came to the hospital. The physical examination was unremarkable except for a palpable, tender mass over the ileocecal area. The laboratory data were within reference ranges, except for a white blood cell count of 11 700/mm3 (normal: 4500 - 10 000/mm3). Tumor markers, including carcinoembryonic antigen, CA199, and CA125, were normal. Abdominal ultrasonography revealed a heterogeneous mass lesion over the right lower quadrant. Contrast-enhanced computed tomography (CT) showed cecal wall thickening and an ill-defined pericecal mass lesion with marginal enhancement (Figure [1]). Because a cecal tumor could not be excluded, colonoscopy was performed, demonstrating mucosal bulging, edema, and hyperemia, with a spontaneous discharge of pus at the appendiceal orifice (Figure [2]). A diagnosis of appendicitis with abscess formation was made. Conservative treatment with intravenous antibiotics was administered, and the abdominal mass was not palpable 2 weeks later. The clinical course was uneventful, and the patient remained asymptomatic during the ensuing 3-month follow-up period.

Zoom Image

Figure 1 Contrast-enhanced abdominal computed tomography, showing cecal wall thickening and an ill-defined pericecal mass lesion with marginal enhancement (arrow).

Zoom Image

Figure 2 Colonoscopic image showing mucosal bulging, edema, and hyperemia at the appendiceal orifice, with a spontaneous discharge of pus.

Acute appendicitis is the clinical diagnosis of an inflammatory reaction in the appendix, relying on a detailed history and physical examination. However, up to one-third of patients suspected of having acute appendicitis may present with atypical clinical findings [1]. In addition, 2 - 6 % of the patients may present with a palpable mass [2]. With a concern about possible cecal malignancy, surgeons may be faced with a dilemma when deciding on the appropriate form of management. CT and transabdominal ultrasonography have been reported to demonstrate excellent accuracy in the diagnosis of suspected appendicitis [3]; however, cecal carcinoma may present as a pericecal inflammatory mass, due to a perforation [4]. Colonoscopy therefore appears to be helpful for diagnosing appendicitis when imaging studies are nondiagnostic. With regard to the treatment of appendicitis with abscess formation, a conservative approach with routine follow-up has been recommended [5]. Appendectomy is suggested only when symptoms recur.

Endoscopy_UCTN_Code_CCL_1AD_2AG
Endoscopy_UCTN_Code_CCL_1AD_2AD

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References

  • 1 Berry J Jr, Malt R A. Appendicitis near its centenary.  Ann Surg. 1984;  200 567-575
  • 2 Hoffmann J. Contemporary management of appendiceal mass.  Br J Surg. 1993;  80 1350
  • 3 Horton M D, Counter S F, Florence M G, Hart M J. A prospective trial of computed tomography and ultrasonography for diagnosing appendicitis in the atypical patient.  Am J Surg. 2000;  179 379-381
  • 4 Poon R T, Chu K W. Inflammatory cecal masses in patients presenting with appendicitis.  World J Surg. 1999;  23 713-716
  • 5 Tingstedt B, Bexe-Lindskog E, Ekelund M, Andersson R. Management of appendiceal masses.  Eur J Surg. 2002;  168 579-582

D. A. Chou, M. D.

Division of General Surgery, Dept. of Surgery

Show Chwan Memorial Hospital
542 Chung-Shan Road, Section 1
Changhua 500
Taiwan

Fax: +886-4-7233190

Email: yslcsmc@hotmail.com

#

References

  • 1 Berry J Jr, Malt R A. Appendicitis near its centenary.  Ann Surg. 1984;  200 567-575
  • 2 Hoffmann J. Contemporary management of appendiceal mass.  Br J Surg. 1993;  80 1350
  • 3 Horton M D, Counter S F, Florence M G, Hart M J. A prospective trial of computed tomography and ultrasonography for diagnosing appendicitis in the atypical patient.  Am J Surg. 2000;  179 379-381
  • 4 Poon R T, Chu K W. Inflammatory cecal masses in patients presenting with appendicitis.  World J Surg. 1999;  23 713-716
  • 5 Tingstedt B, Bexe-Lindskog E, Ekelund M, Andersson R. Management of appendiceal masses.  Eur J Surg. 2002;  168 579-582

D. A. Chou, M. D.

Division of General Surgery, Dept. of Surgery

Show Chwan Memorial Hospital
542 Chung-Shan Road, Section 1
Changhua 500
Taiwan

Fax: +886-4-7233190

Email: yslcsmc@hotmail.com

Zoom Image

Figure 1 Contrast-enhanced abdominal computed tomography, showing cecal wall thickening and an ill-defined pericecal mass lesion with marginal enhancement (arrow).

Zoom Image

Figure 2 Colonoscopic image showing mucosal bulging, edema, and hyperemia at the appendiceal orifice, with a spontaneous discharge of pus.