The inside-out appendix

The inside-out appendix Surgery 163 (2018) 967 Contents lists available at ScienceDirect Surgery journal homepage: www.elsevier.com/locate/ymsy Images in Surgery a, b Amir H. Davarpanah *, and Jamal Bokhari Department of Radiology, Emory University School of Medicine, Atlanta, GA Department of Radiology, Yale University School of Medicine, New Haven, CT ARTICLE INF O Article history: Accepted 22 September 2017 Available online 5 January 2018 A 30-year-old woman with no notable medical history pre- sented with 24-hour history of abdominal pain, nausea, and vomiting. She had been chronically constipated for which she had taken laxatives and had some loose stools on the day of admis- sion. She had been afebrile. The physical examination was unremarkable except for lower abdominal tenderness. Laboratory works demonstrated no abnormalities. Computed tomographic imaging (Fig 1) of the abdomen revealed a blind-ending tubular filling defect (arrow) within the cecum, containing mesenteric fat and located inferior to the ileocecal valve (arrowhead). Laparotomy revealed appendiceal intussusception (Fig 2). An ileocecectomy was performed and histopathologic examination of the specimen con- firmed a completely inverted appendix with reversal of all histologic layers and scattered mural endometriosis. Appendiceal inversion, the so-called “inside-out” appendix, is a rare phenomenon that presents a diagnostic dilemma for sur- Fig. 1. Abdominal computed tomography shows complete appendiceal invagina- geons, because it is difficult to diagnose preoperatively, resulting tion into the cecal cavity (arrow) below the ileocecal valve (arrowhead). in overzealous resection for suspected malignancy. A variety of con- ditions such as appendiceal neoplasm, inflammation, and infestation could serve as the lead point for intussusception. Appendiceal en- dometriosis usually is asymptomatic but can mimic appendicitis and could be considered in the differential diagnosis of the young women complaining of nonspecific intermittent lower abdominal pain es- pecially with history of infertility. The preferred method of treatment is surgical resection with hormonal treatment of extraperitoneal en- dometriosis. The patient had a good response to the surgery with no complications. All authors claim no conflicts of interest or disclosures. * Corresponding author. Department of Radiology, Emory University School of Medicine, 1364 Clifton Rd. NE, Atlanta, GA 30329. Fig. 2. Resected specimen reveals an appendix completely inverted into the cecal E-mail address: amir.davarpanah@emory.edu (A.H. Davarpanah). lumen. https://doi.org/10.1016/j.surg.2017.09.024 0039-6060/© 2017 Elsevier Inc. All rights reserved. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Surgery Elsevier

The inside-out appendix

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Elsevier
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Copyright © 2017 Elsevier Inc.
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0039-6060
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10.1016/j.surg.2017.09.024
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Abstract

Surgery 163 (2018) 967 Contents lists available at ScienceDirect Surgery journal homepage: www.elsevier.com/locate/ymsy Images in Surgery a, b Amir H. Davarpanah *, and Jamal Bokhari Department of Radiology, Emory University School of Medicine, Atlanta, GA Department of Radiology, Yale University School of Medicine, New Haven, CT ARTICLE INF O Article history: Accepted 22 September 2017 Available online 5 January 2018 A 30-year-old woman with no notable medical history pre- sented with 24-hour history of abdominal pain, nausea, and vomiting. She had been chronically constipated for which she had taken laxatives and had some loose stools on the day of admis- sion. She had been afebrile. The physical examination was unremarkable except for lower abdominal tenderness. Laboratory works demonstrated no abnormalities. Computed tomographic imaging (Fig 1) of the abdomen revealed a blind-ending tubular filling defect (arrow) within the cecum, containing mesenteric fat and located inferior to the ileocecal valve (arrowhead). Laparotomy revealed appendiceal intussusception (Fig 2). An ileocecectomy was performed and histopathologic examination of the specimen con- firmed a completely inverted appendix with reversal of all histologic layers and scattered mural endometriosis. Appendiceal inversion, the so-called “inside-out” appendix, is a rare phenomenon that presents a diagnostic dilemma for sur- Fig. 1. Abdominal computed tomography shows complete appendiceal invagina- geons, because it is difficult to diagnose preoperatively, resulting tion into the cecal cavity (arrow) below the ileocecal valve (arrowhead). in overzealous resection for suspected malignancy. A variety of con- ditions such as appendiceal neoplasm, inflammation, and infestation could serve as the lead point for intussusception. Appendiceal en- dometriosis usually is asymptomatic but can mimic appendicitis and could be considered in the differential diagnosis of the young women complaining of nonspecific intermittent lower abdominal pain es- pecially with history of infertility. The preferred method of treatment is surgical resection with hormonal treatment of extraperitoneal en- dometriosis. The patient had a good response to the surgery with no complications. All authors claim no conflicts of interest or disclosures. * Corresponding author. Department of Radiology, Emory University School of Medicine, 1364 Clifton Rd. NE, Atlanta, GA 30329. Fig. 2. Resected specimen reveals an appendix completely inverted into the cecal E-mail address: amir.davarpanah@emory.edu (A.H. Davarpanah). lumen. https://doi.org/10.1016/j.surg.2017.09.024 0039-6060/© 2017 Elsevier Inc. All rights reserved.

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SurgeryElsevier

Published: Apr 1, 2018

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