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African Health Sciences, Vol. 8, No. 3, Sept, 2008, pp. 196-198 Case Report Endometriosis of the Appendix Nasser S. Al Oulaqi 1, Ashraf F. Hefny1, Sandyia Joshi2, Khalid Salim1, Fikri M. Abu-Zidan3 Departments of Surgery 1 and Pathology 2, Al-Ain Hospital, and Department of Surgery Faculty of Medicine
and Health Sciences, United Arab Emirates
University3, Al-Ain, United Arab Emirates. Code Number: hs08041 Abstract Endometriosis is a well known cause of infertility. Endometriosis of the appendix is a very rare condition. To highlight this rare entity, we are reporting a case of a young lady who was admitted with recurrent attacks of lower abdominal pain associated with primary infertility. Preoperative diagnosis was acute appendicitis. Histopathological examination of the appendix revealed endometriosis. Endometriosis should be considered in the differential diagnosis of recurrent lower abdominal pain in young females especially with history of infertility. Key words: appendix, endometriosis, female, infertility. Endometriosis is the presence of ectopic endometrial tissues outside the lining of uterine cavity1. It is a well known cause of chronic pelvic pain and infertility in females. Endometriosis of the appendix is rare and may present with acute or chronic abdominal pain. Preoperative diagnosis is difficult. The definitive diagnosis is usually established following histopathological examination of the appendix. Laparoscopy is the procedure of choice for the diagnosis and surgical treatment of endometriosis2. Herein we report a case of appendiceal endometriosis clinically presenting with recurrent attacks of abdominal pain associated with primary infertility which was diagnosed preoperatively as acute appendicitis. Case Report A twenty-five year old lady was admitted complaining of right lower abdominal pain of one day duration. The pain was associated with nausea and vomiting. She had no vaginal discharge. Her menstrual cycles were regular, and she was on her 11th day of menstrual cycle. The patient had a history of primary infertility. On examination, the patient was not feverish, her pulse was 90 beat per minute, and her blood pressure was120/80 mmHg. Abdominal examination showed guarding and tenderness in the lower abdomen with positive rebound tenderness. White blood cell count, electrolytes, and urine analysis were normal. Pregnancy test was negative. Vaginal swab has shown no bacterial growth. Pelvic ultrasound has shown normal uterus and ovaries. The patient was discharged home and advised to be followed up in the gynecological clinic. Three months later, the patient was re-admitted having the same complaint, and she was on her 10th day of menstrual cycle. Gynecological examination revealed vaginal discharge with tender adnexa but no masses could be felt. Laboratory tests and pelvic ultrasound were normal. The patient was discharged home after two days. Four months later the patient was re-admitted with right lower abdominal pain associated with diarrhea without nausea or vomiting. She was on her fourth day of menstrual cycle and laboratory tests were also normal. Pelvic ultrasound examination has revealed a small cyst in the right ovary. Intravenous pyelography was normal. After five days the patient was discharged home and was advised to be followed up in both gynecology and psychiatric clinics. Nine months later, the patient was re-admitted with the same complaint for the fourth time. She was on her 17th day of menstrual cycle. Laboratory tests were normal. Open appendectomy was performed. Grossly, the appendix was normal with unremarkable serosa. There were no signs of endometriosis in other intra-abdominal locations of the operative field. Post operative period was uneventable. Histological examination of the appendix has shown unremarkable mucosa with few lymphoid follicles; the wall was irregularly thickened and showed endometrial glands and stromal cells embedded within the muscularis propria (Figure 1). Discussion Endometriosis is usually associated with dysmenorrhea, chronic pelvic pain, and infertility3. Although some women with intestinal endometriosis remain asymptomatic, some of them come to medical attention because of abdominal pain, bowel obstruction, or an abdominal mass4. Endometriosis of the appendix is rare. The prevalence of appendiceal endometriosis in patients with endometriosis is 2.8% 5. Involvement of the appendix may present as appendicitis, mucocele of appendix, or appendicular mass that may mimic a neoplasm. Perforation of the appendix may occur especially during the first two trimesters of pregnancy 4, 6, . Our patient had a history of primary infertility with recurrent attacks of incapacitating lower abdominal pain which was not related to her menstruation. Endometriosis was never suspected preoperatively8. Many patients with appendiceal endometriosis experience chronic pelvic pain with significant decrease in the quality of life. Long term symptoms resolution was noticed following appendectomy9. In one study of two hundred consecutive endometriosis operations with routine appendectomy, three occurrences of macroscopic appendiceal endometriosis were identified and proved on microscopic examination. In situ microscopic endometriosis of the appendix without macroscopic disease was not encountered10. In contrast, another study including 106 patients with routine appendectomy during laparoscopic treatment of ovarian endometriosis has shown gross abnormality only in 3.3% while microscopic examination has shown endometriosis of the appendix in 13.2% of patients 11. In our patient, gross inspection of the appendix didn't give any hint of the diagnosis while microscopic examination has shown features of endometriosis. Our patient had open appendectomy through gridiron incision with incidental finding of appendiceal endometriosis. Laparoscopic surgery may have been more useful in defining other locations of endometriosis. If the standard pathological evaluation by H&E stain failed to demonstrate the endometrial tissue, appendiceal endometriosis can be suspected by marked increase in the number of mast cells in the muscularis popria which is known as catamenial appendicitis9. The causes of infertility in patients with endometriosis remain uncertain. Laparoscopic ablation of endometriosis in combination with medical treatment improves fertility12. Appendectomy may be considered as part of the surgical ablation. Incidental appendectomy during surgical treatment of pelvic endometriosis is controversial10, 11. Preoperative counseling and obtaining consent for appendectomy is important5. In summary endometriosis of the appendix can mimic appendicitis and it should always be considered in the differential diagnosis of young women complaining of nonspecific recurrent lower abdominal pain especially with history of infertility. References
Copyright © 2008 - Makerere Medical School, Uganda The following images related to this document are available:Photo images[hs08041f1.jpg] |
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