Saturday, 6 August 2016

Stump Appendicitis


Our objective is to present three cases of stump appendicitis, a rare surgical emergency. Stump appendicitis is a delayed complication following incomplete appendectomy. There have been fifty one cases reported in the literature thus far. This entity should be part of the differential diagnosis of any patient complaining of right lower quadrant pain with a previous surgical history of appendectomy. Failure to diagnose and delay of treatment may result in stump perforation and intra-abdominal sepsis. We report three cases of stump appendicitis in adults, presenting with right lower quadrant pain confirmed by computed tomography (CT) studies.

First described in 1945 by Rose, stump appendicitis (SA) results from re-inflammation of residual appendiceal tissue after an appendectomy. While appendicitis is one of the most common causes of emergent surgical intervention for acute abdominal pain, stump appendicitis (SA) is exceedingly rare. The true incidence of stump appendicitis remains unknown. In one review, only 51 cases of SA were reported until that point, with age range of 8-72. Despite its rarity, missed SA may result in perforation, sepsis and stump gangrene. While the majority of cases are reported in journals of surgery, there is a paucity of cases in Emergency Medicine. We report three cases of SA which have presented to our community emergency department.

A 45 year old female with no past medical or surgical history presented in June 2009 to the ED with right lower quadrant (RLQ) pain, nausea and vomiting starting 6-8 hours prior. Vital signs were blood pressure of 111/69 mm Hg, pulse 91 beats per minute, and afebrile, with the patient reporting pain to be 3/10. Patient had an elevated white blood cell count (WBC) of 23,000/mcL and neutrophils at 92 %, indicating acute inflammation. CT findings were consistent with acute appendicitis. Laparoscopic appendectomy was performed removing an inflamed appendix 6cm in length and 1 cm in diameter. Patient was discharged after an unremarkable surgery and recovery.

This patient presented to the emergency department (ED) again in March 2010 with RLQ pain, nausea and constipation. Vitals were blood pressure of 129/80 mm Hg, pulse of 118 beat per minute, temperature of 99.4 degrees Fahrenheit. Patient reported pain to be 5/10 and the CT scan showed inflammation around the appendiceal stump. Laboratory findings included elevated WBC count at 13,100/mcL and CRP elevated at 13.4 mg/dl. The appendiceal stump was removed via laparoscopic technique measuring 3.1cm x 1.1cm x 0.7 cm. Patient again recovered well in the post-operative period

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