INVERSION OF APPENDIX WITH APPENDICULO-CAECO-COLIC
AVINASH N KATARA*, MG RATHOD**, AJAY H BHANDARWAR***,
*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%.  Discussed below is a case report
followed by a discussion on appendiceal intussusception.
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
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 Colo-colic intussusception
‘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
– Showing operated lump appendix is not
seen because it failed to submit even after monoeuvre.
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.
Intussusception of the appendix was first described in 1858.
Collins reported a 40 year study of 71,000 human appendiceal specimens, with
an incidence of 0.1%. 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.
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, or
was found to show a tubulovillous adenoma with carcinoma-in-situ,
mucocoele, mucinous cystadenoma, 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.
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.
Disvagination of the appendix has been described using a barium enema in cases
of simple inversion. 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]
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