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INVERSION OF APPENDIX WITH APPENDICULO-CAECO-COLIC INTUSSUSCEPTION

AVINASH N KATARA*, MG RATHOD**, AJAY H BHANDARWAR***, TARUN SINGHAL****
*Lecturer; **Professor and Head; ***Associate Professor; ****Registrar, Department of General Surgery, Grant Medical College and Sir JJ Group of Hospitals, Mumbai - 400 008, India.

We present the case of a 37 year old woman with a complete inversion of the appendix resulting in an appendiculo-caeco-colic intussusception with clinical features of chronic, intermittent intestinal obstruction, an abdominal mass and bleeding per rectum. The patient was subjected to a laparotomy and an quartercolectomy was done. Histopathology suggested chronic inflammaory changes in the appendix. The intussusception of the appendix is a rare phenomenon, its incidence being 0.1%. [1] Discussed below is a case report followed by a discussion on appendiceal intussusception.

INTRODUCTION

A 37 year old female presented with pain in the abdomen since one month. The pain was a generalised dull ache with intermittent colic in the umbilical region and right iliac fossa. She also noticed a lump in the right iliac fossa occasionally with visible peristalsis. She had a few episodes of vomiting, the contents of which were mainly gastric in nature. She had been passing mucus in stools for a few weeks. There was no other significant complaints or past medical or surgical history.

On general examination, her vital parameters were stable. Abdominal examination revealed a lump in the right iliac fossa, approximately 5 cm in diameter, which was minimally tender on deep palpation. This lump was firm in consistency, mobile, and did not move with respiration. Rectal and vaginal digital examination did not reveal any abnormality.

Her haemogram, liver functions, renal profile and blood sugars were within normal limits. X-ray of her chest and abdomen did not detect any abnormality. An abdominal ultrasonography revealed a mass in the right iliac fossa with concentric hypo-hyperechoic rings seen in the subhepatic region on the right measuring 7 cm x 4 cm x 9 cm suggestive of an ileocaecal intussusception. A barium enema showed obstruction to the retrograde flow of barium with a filling defect in the ascending colon which had a coil-spring appearance and depicted a ‘claw sign’ suggestive of a colo-colic intussusception (Fig. 1). The lead point of the intussusception showed mucosal thickening, suggesting an inflammatory pathology.

Fig.1
Fig.1 Colo-colic intussusception showing
‘clew sign’ and spring will appearance

An elective laparotomy revealed the complete inversion of the appendix, with intussusception of the appendix and caecum into the ascending colon, forming a lump in the right iliac fossa. The caecum was easily reduced manually out of the ascending colon, but the appendix failed to submit to such manoeuverability (Fig. 2). The appendix was palpated as a firm structure through the caecal wall. The caecum was also slightly oedematous and inflamed, and a Quartercolectomy was performed. The distal 5 cm of the ileum, the caecum with its appendix and the proximal half of the ascending colon was resected and an ileo-ascending colonic anastomosis of the end to end double-layered variety was done. The resected specimen was cut open to reveal a red, congested, turgid, completely inverted appendix (Fig. 3). The post-operative period was uneventful and recovery was good.

Fig.2 Fig.3
Fig. 2 – Showing operated lump appendix is not
seen because it failed to submit even after monoeuvre.
Fig.3 The respected specimen showing a red, congested
inverted appendix on cutting open the specimen.

Histopathological studies of the specimen revealed chronic inflammatory changes in the appendix.

DISCUSSION

Intussusception of the appendix was first described in 1858.[2] Collins reported a 40 year study of 71,000 human appendiceal specimens, with an incidence of 0.1%.[1] Cases of intussusception or complete inversion of the appendix have been reported in the literature, and very adequate reviews of the condition have been published by McSwain (1941) and K Fraser (1943), and others.[3]

Several factors and conditions can contribute to the pathogenesis of appendicular intussusception. These can be broadly divided into anatomic and pathologic factors. The anatomical variations it can result from are a fully mobile appendix, a narrow thin mesoappendix, a poorly fixed high caecum, due to hyperperistalsis, etc. Several pathological conditions of the appendix can lead to its intussusception viz. foreign bodies in the appendix, inflammation of the appendix (including endometriosis), neoplasms, etc.[4,5] Cases have been reported where the intussuscepted appendix was either normal,[6] or was found to show a tubulovillous adenoma with carcinoma-in-situ,[7] mucocoele,[8] mucinous cystadenoma,[9] etc.

Four different groups have been described according to the clinical presentation. One group of patients can simulate acute appendicitis. A second variety of patients have symptoms and signs of acute intussusception. A third variety of patients complain of recurrent pain, nausea, vomiting or melaena. The fourth variety of patients are asymptomatic.[4,5] In children, intussusception is a common cause for intestinal obstruction. In contrast, in adults obstruction is infrequent and in a majority of cases, diagnosis is suggested by chronic, intermittent symptoms of intestinal obstruction, the presence of an abdominal mass and bleeding per rectum.[10]

Preoperatively, appendicular intussusception may be discovered radiologically. Barium enema finding include a round or finger like filling defect within the caecum with no visible appendix. The terminal ileum is normal.[4,5] In cases where there is a neoplasm of the appendix, radiology and endoscopy present a polypoid lesion of the caecum.[11]

Disvagination of the appendix has been described using a barium enema in cases of simple inversion.[11] The definitive treatment for appendicular intussusception is surgical. If simple, an attempt to reduce the appendix should be made before appendectomy. If irreducible, the caecum may be opened along the taenia coli and simple appendectomy done. When there is concern for primary appendicular or caecal neoplasm, or a compound ileocaecal-appendicular intussusception is present, ileocaecal resection and primary anastomosis should be done.[4,11-14]

REFERENCES


1.McKidd J. Case of invagination of the cecum and appendix. Edinb Med J 1858; 4 : 793-6.

2Collins DC. 71,000 human appendix specimens : a final report, summarizing 40 years study. Am J Proctol 1963; 14 : 365-81.

3.Hickinbotham P. Inversion of the appendix. Brit J Surg 1951; 39 : 84-5.

4.Nycum LR, Moss H, Adams JQ. Asymptomatic intussusception of the appendix due to endometriosis. South Med J 1999; 92 (5) : 524-5.

5.Lauwers GY, Prendergast NC, Wahl SJ, et al. Invagination of the vermiform appendix. Dig Dis Sci 1993; 38 : 565-8.

6.Patton KR, Ferrera PC. Intussusception of a normal appendix. Am J Emerg Med 2000; 18 (1) : 115-7.

7.Ohno M, Nakamura T, Hori H, et al. Appendiceal intussusception induced by tubulovillous adenoma with carcinoma-in-situ : report of a case. Surg Today 2000; 30 (5) : 441-4.

8.Kimura H, Konishi K, Yabushita K, et al. Intussusception of a mucocele of the appendix secondary to an obstruction by endometriosis : report of a case. Surg Today 1999; 29 (7) : 629-32.

9.Gockel I, Kupczyk-Joeris D, Gaedertz C, et al. Invagination of the vermiform appendix in mucinous cystadenoma. Chirug 1998; 69 (5) : 571-3.

10.Heithold DL, Tucker JG, Lucas GW. Appendiceal intussusception as a manifestation of mucinous cystadenoma : an interesting clinical entity. Am Surg 1997; 63 (5) : 390-1.

11. Schmidt FR, McCarthy JD. Intussusception of the appendix with endometriosis presenting as a caecal tumor. Arch Surg 1971; 103 : 515-7.

12.Jevon GP, Daya D, Qizilbash AH. Intussusception of the appendix : a report of four cases and review of the literature. Arch Pathol Lab Med 1992; 116 : 960-4.

13.Panzer S, Pitt HA, Wallach EE, et al. Intussusception of the appendix due to endometriosis. Am J Gastroenterol 1995; 90 : 1892-3.

14.Langsam LB, Raj PK, Galang CF. Intussusception of the appendix. Dis Colon Rectum 1984; 27 : 387-92.



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