Teaching Case

A 47-year-old man presented to the emergency department with abdominal pain.

Abdominal examination revealed tenderness in the right iliac fossa and positive Blumberg sign.

The laboratory tests showed leukocytosis (13,7 x 10⁹/L), neutrophilia (11,59 x 10⁹/L) and elevation of C Reactive Protein (4,2 mg/dL).

He underwent appendicectomy 2 years ago.

Abdominal ultrasound (US) was inconclusive due to bowel gas; then, abdomen and pelvis CT was requested.

Non-enhanced CT scan revealed a blind-ending tubular structure near the cecum pole, with hyperdense material in its distal extremity (Figure 1). Contrast-enhanced CT on portal venous phase revealed enhancement and wall thickening (15 mm) of the tubular structure (Figures 2 and 3). There was evidence of wall perforation and a 21x14 mm organized fluid collection nearby (Figures 4 and 5). Surrounding fat stranding and ileo-colic enlarged nodes were also present (Figure 6).

Appendicectomy is the most common surgery worldwide [1]. Stump appendicitis is a rare surgical complication (1:50000) and refers to the acute inflammation of the appendiceal remnant due to incomplete removal of the appendix [1,2].

Clinical presentation is identical to regular appendicitis, with acute abdominal pain being the most common symptom. The diagnosis is often delayed due to past history of appendicectomy, increasing the risk of complications [3].

Imaging findings are similar to those of regular appendicitis. US can demonstrate the appendiceal remnant as a tubular structure arising from the right iliac fossa or retrocecal region from the caecum [1].

Contrast-enhanced CT has higher sensibility and specificity, and shows a tubular structure arising from the caecum, with wall thickening and stratification. The visualization of hyperdense material in the distal extremity is highly suggestive of the appendiceal remnant. Other findings include mesenteric fat stranding, and complications such as periappendiceal abscess and high rates of perforation (70%) [4,5].

Treatment involves surgical removal of the appendiceal stump [6]. Our patient underwent an urgent laparoscopy; the stump was resected and the abscess drained. The postoperative course was uneventful, and the patient was discharged 3 days after admission.

Stump appendicitis should be included in the differential diagnosis of patients presenting right iliac fossa pain and past history of appendicectomy [5,7].

Written informed patient consent for publication has been obtained.