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CASE REPORT 1

T his 63 year old Caucasian man with past medicalhistory significant for hypertension, arthritis,prostate cancer status post radiation therapy, and a

family history of colon and pancreatic cancer presentedto the emergency department with right lower quadrantpain. The WBC count was 10.1, Hct 41, Plt 213, Amy-lase 34 and Lipase 83. CT scan of the abdomen revealeda dilated appendix with thickened wall and severestranding changes consistent with appendicitis. The

appendix was grossly inflamed on open appendectomywithout evidence of perforation. Histopathologyrevealed fibrous obliteration of the lumen of the appen-dix consistent with appendicitis and periappendicitis.His postoperative course was uneventful, and he wasd i s c h a rged 48 hours after surg e r y.

Three months later, on routine screeningcolonoscopy he was noted to have a 1.5-cm soft massarising from and within the appendiceal orifice. Theremainder of the colon was only notable for left-sideddiverticulosis. The full extent of the mass could not beexposed from the residual lumen of the appendicularstump, and it was judged that a complete and safeendoscopic resection was not feasible. Biopsy of thececal mass revealed tubular villous adenoma withmarked focal dysplasia. (Figure 1A). The preoperative

Adult Onset Appendicitis: Colonscopy Should be Part of the Routine Evaluation in the Early Postoperative Period

A CASE TO REMEMBER

Anubha Sinha, M.D., Arthur J. DeCross, M.D.,Michelle Nazareth, M.D., Charlotte K. Ryan, M.D.,Uma Sundaram, M.D., Digestive Disease Unit,Department of Medicine, University of Rochester,New York.

Anubha Sinha, Arthur J. DeCross, Michelle Nazareth, Charlotte K. Ryan, Uma Sundaram

We report two cases of small colonic carcinomas that presented clinically as appendici-tis and yet were undetected at open or laproscopic appendectomies. Both tumors weresubsequently diagnosed on postoperative colonoscopy. The diagnosis of colonic neoplasm may be missed at the time of appendectomy due to a reluctance to explore theabdomen or due to the limitations of the incision used. Literature review supports thatlesions of this small size are not diagnosed perioperatively with either barium enemasor CT scans. We therefore recommend evaluation of the colon with colonoscopy to ruleout obstructing neoplasm when older patients present with appendicitis.

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Adult Onset Appendicitis

CEA level was 1.8. The patient underwent laparo-scopic ileocecectomy. Surgical pathology confirmed atubulovillous adenoma measuring 2.0 × l.7 × 1.4 cmwith marked dysplasia and a focus of carcinoma in situthat measured 3 × 2 mm (Figure 1 B). The margins ofresection were free of adenocarcinoma, and regionallymph nodes were negative for metastases. The post-operative course was uneventful, and patient was dis-charged a week later.

CASE REPORT 2A 50-year-old Caucasian woman with an unremarkableprior medical history presented to the emergency depart-ment with complaints of abrupt onset right lower quad-rant pain. She denied nausea, vomiting, and fevers.Abdomen was soft with severe right lower quadrant ten-derness without peritoneal signs. WBC 9.5, Hct 38, Plt279, TB 0.6, AST 22, ALT 30, ALK 81. CT scan of theabdomen suggested acute inflammation of the appendix,with fluid and edema involving the lateral cecum suspi-cious for ruptured appendix and inflammatory cecitis.She received intravenous antibiotics, and diagnosticlaparoscopy and laparoscopic appendectomy done thesame evening revealed abnormal adherent fatty tissueoverlying the cecum and ascending colon with a non-perforated appendix. The rest of the bowel appeared nor-mal, including terminal ileum. The surgical team com-mented that they could not determine the acuity ofinflammation laparoscopically, and thus the adherent fatwas not removed. Surgical pathology revealed fibrousobliteration of the lumen of the appendix with no evi-dence of acute appendicitis. The post-operative coursewas uneventful, with an immediate and rapid clinicalimprovement, and she was discharged a week later. Shewas lost to surgical follow-up at that point.

Eight months later, she presented to her primarycare physician with complaints of right lower quadrantpain, temperature of 101°F and chills, but without nau-sea, vomiting or diarrhea. The WBC was 9.4, Hct 37, Plt344, TB 0.7 AST 19, ALT 20 ALK 100 and CEA 0.7.She was started on empiric oral antibiotics without anyimprovement. She was subsequently admitted to thehospital, and started on IV antibiotics. Physical examwas notable for moderate to severe right lower quadranttenderness with guarding, but without generalized peri-

toneal signs. A repeat CT scan showed increased thick-ening of the cecum (compared to prior) with haziness inthe adjacent abdominal fat. No abscesses or collectionswere noted. Improvement was monitored in the physicalexam of her abdomen, and when relatively softer andless tender (about 5 days), her bowel was prepped andcolonoscopy was performed. This revealed a 2-cm fri-able mass at the appendiceal orifice, extending into theresidual lumen of the appendicular stump. As in the firstcase, this lesion was not felt to be suitable for endo-scopic resection. Biopsy revealed a tubulovillous ade-

Figure 1A. Tubulo villous adenoma with focus of severe dys-plasia (glandular architecture is approaching a cribriformpattern).

Figure 1B. Carcinoma in situ depicted by a cribriform pattern.

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A CASE TO REMEMBER

Adult Onset Appendicitis

noma; carcinoma was not present in the initial biopsy(Figure 2A). A right hemicolectomy was subsequentlyperformed, and an extrinsic inflammatory mass at thececum was noted. The rest of the bowel showed noabnormalities, and the pelvic organs were normal. Sur-gical pathology examination revealed a 1.2 × 1 × 0.9 cmwell to moderately differentiated adenocarcinoma of thecolon arising in a preexisting villous adenoma, withtransmural invasion through the muscularis propria(Figure 2B). The serosal surface was free of tumor, andthere was no evidence of vascular invasion or lymphatic

spread, with 15 regional lymph nodes negative formetastases, consistent with TNM stage II (Dukes B2).Her postoperative course was uneventful.

DISCUSSIONAcute appendicitis is a common clinical entity with anapproximate incidence of about 90 cases per 100,000population per year, the highest incidence being foundin young adults, peaking between ages 10 and 19 yearsold (1,3). The lifetime risk of appendicitis is about 7%,but after the age of 50 years, the risk of appendicitisdecreases to 1 in 35 for women and 1 in 50 for men(2,3). Obstruction of the appendicular lumen is themost frequent precipitant of appendicitis. In children,this is most often caused by fecaliths and lymphoidhyperplasia. Colonic neoplasms become more frequentin patients over the age of 50, and even distal obstruct-ing neoplasms may be associated with about 3% ofcases of appendicitis in this age group (4). In a reviewof 561 Swedish patients aged 40 years and older oper-ated on because of acute appendicitis, Arnbjornssondiscovered that 2.9% were readmitted within 3 yearsbecause of a carcinoma of the colon or rectum. As theincidence of carcinoma of the colon and rectum in thepopulation of Sweden of the same age group was only0.1% he suggested that the relationship between appen-dicitis (presenting in older patients) and carcinoma ofthe colon was significant (6). The association of right-sided colonic neoplasia and appendicitis was first notedby Shears in 1906. Since then the association has beenwell recognized, although it has been described that inabout half of these cases, the involvement between aproximal neoplasia and appendicitis went unrecognizedat the time of appendectomy. Costello and Saxtonreported a review of 122 cases of cecal cancer, in which25% of cases presented as appendicitis. In half of thesecases, treatment of appendicitis was noted to precedediscovery of the cancer (7). Thomas subsequentlyreported that in a study of 29 patients with cecal carci-noma presenting as appendicitis, 18 out of the 29 casesdid not have the cecal carcinoma recognized or diag-nosed at the first operation (appendectomy) (8). It iscommonly reported that there is an average delay of 4–6months after appendectomy until diagnosis of colon

Figure 2A. Tubulo villous adenoma characterized by multi-ple glands with stratified hyperchromatic nuclei.

Figure 2B. Invasive adenocarcinoma. Malignant gland withnuclear pleomorphism infiltrate through a fibrous stroma.

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carcinoma, in related case report series (5). Of interest,Peck discussed the poor performance of preoperativediagnostic testing in 32 patients who presented withappendicitis and subsequently found to have colon car-cinoma. Ten of the patients had Barium enemas, whichwere either limited exams due to poor preparation orinterpreted as compatible with appendicitis based oncecal wall thickening. (2) CT scans did not alter thepreoperative diagnosis of appendicitis and in 4 cases aperforated cecal carcinoma was interpreted as appen-diceal abscess (2). Video colonoscopy was not avail-able during the time period of the study.

The mechanism by which colonic carcinoma mightprecipitate appendicitis is not entirely clear, but it isrecognized that obstruction of the actual appendiceallumen is not required. Distension of the cecum from adistal colonic lesion can be responsible for decreasedblood flow resulting in ischemia, necrosis and perfora-tion of the appendix (6, 10). When the association ismissed, the carcinoma may present in a variety of waysp o s t o p e r a t i v e l y, including weight loss, bleeding, ane-mia, obstruction, or persistent fecal carcinomatous fis-tula. (10) The delay in the diagnosis of colonic neopla-sia after appendectomy may have far reaching conse-quences because of the greater chance that regional ordistant metastasis may have occurred during this time(9). Survival chances may also be adversely impacteddue to the possibility of early dissemination of malig-nant disease through the breaching of intestinalintegrity and tumor cell spillage. In the presence of per-foration, or after the bowel wall has been breached, thechance of local recurrence increases to 28%–30% (9).

The diagnosis of a colon tumor at the time ofappendectomy may be missed because of reluctance toexplore the abdomen in the setting of acute appendici-tis or because of limitations of the incision used pro-hibiting palpation of the colon. Given the weight of theassociations described above, it would be recom-mended to explore the colon to rule out an obstructingneoplasm when the older patient presents with appen-dicitis. Certainly, when a normal appendix is discov-ered during an operation in response to the clinical orradiographic suggestion of appendicitis, the need foradequate visualization and palpation of the cecum andremaining colon becomes essential (2). In both of thepatients that we presented, the diagnosis of colon car-

cinoma was not made either at the time of open orlaparoscopic appendectomy. Since colon cancer ismore frequent after the age of 50, and acute appen-dicitis is less frequent in people over the age of 50, anypatient presenting with signs of acute appendicitis overthe age of 50 should be examined carefully to excludecarcinoma of the colon. We feel that our cases illus-trate that colonoscopy should be considered the imag-ing study of choice in these situations, given the smallsize of the lesions involved. Whereas colonoscopy eas-ily detected these lesions, our experience is that lesionsof this size would likely have been missed on a bariumenema. The lesions were certainly otherwise asympto-matic, without other clinical or laboratory signs orsymptoms to herald their presence, and they wereclearly missed during surgery and pre-operative CTscanning. The widespread acceptability, ease andavailability of colonoscopy, as emphasized in the lastfew years for the routine screening of small colon neo-plasias, leads us to conclude that colonoscopy shouldbe part of the routine post-operative work up in olderpatients presenting with appendicitis. ■

References1. Korner H, Sondenaa K, Soreide JA, et al. Incidence of Acute

Non-perforated and Perforated appendicitis: Age Specific andSex Specific analysis. World J Surg, 1997; 21: 313-317.

2. James J. Peck JJ. Management of carcinoma discovered unex-pectedly at operation for acute appendicitis. Amer J Surg, 1988;155, 683-685.

3. Adiss DG, Shaffer N, Fowler BS, et al. The Epidemiology ofappendicitis and appendicitis in the United States. Amer J Epi -dem, 1990; 132: 4-6: 910-925.

4. Collins DC. Left sided colonic lesions masquerading as appen-dicitis. Am J Gastroenterol, 1961:36:521-524.

5. Hill J, Leaper D J.Acute appendicitis and carcinoma of the colon,J Roy Soc Med, 1986; 79, 678-680.

6. Arnbjornsson E. Acute Appendicitis as a sign of colorectal can-cer. J Surg Oncol, 1982; 20:17-20.

7. Costello O, Saxton J. Appendicitis and cancer. Post GraduateMedicine, 1951; 9:482-486.

8. Thomas JF. Carcinoma of the cecum: acute appendicitis as pre-senting symptoms. Tex Med, 1953:49:222.

9. Persad RA, Gillatt DA. Appendicitis and occult carcinoma of thececum. Brit J Clin Pract, 1990; 44, No. 11, 726-728.

10. Sumpio BE, Ballantyne GH, et al. Perforated Appendicitis andobstructing colonic carcinoma in the elderly. Dis Colon Rect,1986;29:668-670.

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