Appendiceal Intussusception into Cecum

Clinical history: A 25-year-old male patient complained about three-day epigastric abdominal pain. His body temperature was normal and he did not have any other symptoms such as vomiting or diarrhea. In clinical observation, he had got a tightness feeling when we pressed at Mac-Burney point. No sign of peritoneal reaction was recorded. His blood test was done and the white blood cell count was not high.

[[{"type":"media","view_mode":"media_crop","fid":"13802","attributes":{"alt":"","class":"media-image","id":"media_crop_258546624272","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"580","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 600px; width: 578px; margin: 6px 3px;","title":" ","typeof":"foaf:Image"}}]]

Figure 1.A. Ultrasound longitudinal section showing fluid - filled, enlarged appendix; B. Ultrasound transversal section revealing enlarged appendix; C. Ultrasound findings showed a mass at the appendix base protruding into the cecum.

[[{"type":"media","view_mode":"media_crop","fid":"13803","attributes":{"alt":"","class":"media-image","id":"media_crop_1819665513862","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"581","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 485px; width: 578px; margin: 6px; border-width: 1px; border-style: solid;","title":" ","typeof":"foaf:Image"}}]]

Figure 2. Colonoscopic findings revealed the mass protruding into the cecum at the Garlach valve.

[[{"type":"media","view_mode":"media_crop","fid":"13804","attributes":{"alt":"","class":"media-image","id":"media_crop_8602406835977","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"582","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 440px; width: 578px; margin: 6px;","title":" ","typeof":"foaf:Image"}}]]

Figure 3. Computed tomography showing enlarged, fluid-filled appendix and part of appendix base protruding into the cecum.

[[{"type":"media","view_mode":"media_crop","fid":"13806","attributes":{"alt":"","class":"media-image","id":"media_crop_2164961145426","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"584","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"margin: 6px;","title":" ","typeof":"foaf:Image"}}]]

Figure 4. The appendix specimen.

[[{"type":"media","view_mode":"media_crop","fid":"13807","attributes":{"alt":"","class":"media-image","id":"media_crop_6424098144600","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"585","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"margin: 6px;","title":" ","typeof":"foaf:Image"}}]]

Figure 5. Histologic examination showing the congestion and haemorrhage with fibrosis tissue and a chronic inflammatory infiltration composed of lymphocytes and macrophages. Immunohistochemical result: CD117 (-), NSE (-), Actine (+) in muscular tissue.

Findings: Abdominal ultrasound showed an enlarged appendix with cross-diameter of 15 mm and a fluid-filled lumen (Figure 1 a, b). There was an abnormal mass at the base of the appendix emerging into cecum lumen (Figure 1c). Colonoscopy showed a mass which looked like a finger covered with mucosa protruding into the cecum (Figure 2).

Subsequently, computed tomography findings showed fluid-filled, enlarged appendix and there were signs of a mass protruding into the cecum lumen from the appendix base (Figure 3).

Finally, the operation was performed. The appendix was large and its proximal part was emerged into the cecum (Figure 4). The histopathological result revealed a chronic inflammatory condition of the appendix (Figure 5).

Diagnosis: Appendiceal intussusception into the cecum.

Discussion: In our case, the cause for the appendiceal intussesception is still unknown. However, it could be explained that chronic inflammatory condition had caused disorder immanent peristalsis. Meanwhile, there was a difference between the wall thickness of the distal part and the proximal part of the appendix. All that factors had lead to intussuseption of the appendix base into the cecum.

In conclusion, colonoscopy is a useful diagnostic tool for evaluation of unexplained abdominal pain. It is accurate and profitable in diagnosing of appendiceal intussusception and helps selecting the appropriate treatment methods (1).

 Ly Van Phai, MD; Le Thi Quynh Nhu, MD; Nguyen Thien Hung, MD; Phan Thanh Hai, MD
Medic Medical Center, Ho Chi Minh City, Vietnam

References
Minoru Takahashi, Toshio Sawada, Takahiro Fukuda, Taiki Furugori and Hiroyuki: complete appendiceal intussusceptions induced by primary appendiceal adenocarcinoma in tubular adenoma: case report.

Hamid Tavakkoli, Sayed Mohammad Sadrkabir, Parvin Mahzouni: Colonoscopic diagnosis of appendiceal intussusception in a patient with intermittent abdominal pain: case report.
Langsam LB, Raj PK, Galang CF. Intussusception of the appendix. Dis Colon Rectum 1984; 27: 387-392.

Duncan JE, DeNobile JW, Sweeney WB. Colonoscopic diagnosis of appendiceal intussusception: case report and review of the literature. JSLS 2005; 9: 488-490.

Ram AD, Peckham C, Akobeng AK, Thomas AG, David TJ, Patel L. Inverted appendix mistaken for a polyp during colonoscopy and leading to intussusception. J Cyst Fibros 2005; 4: 203-204.