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Chronic Appendicitis: An Often Forgotten Cause of Recurrent Abdominal Pain

Published:November 21, 2012DOI:https://doi.org/10.1016/j.amjmed.2012.05.032
      To the Editor:
      A 28-year-old woman presented with a 3-day history of worsening abdominal pain localized to the right lower quadrant. Her symptoms began with a sharp discomfort originating along the right abdomen with associated radiation to the lower back. She recalled no inciting event and denied fevers, nausea, vomiting, diarrhea, hematuria, dysuria, or vaginal discharge. She reported compliance with a hormonal contraception vaginal ring prescribed for “menstrual pain.” On further questioning, the patient had experienced 6 similar episodes of right-sided abdominal pain over the past 2 years, each resolving spontaneously after 3-4 days with conservative measures. She was evaluated on several occasions for this pain with no clear diagnosis. At one point she was treated with antibiotics for a presumed urinary tract infection. She had never undergone computed tomography (CT) imaging.
      On presentation, the patient was afebrile. Her abdomen was soft with no peritoneal signs or palpable masses, but mild reproducible tenderness was noted in the right lower quadrant. Laboratory data revealed a white blood count of 6.11×10 k/uL, normal liver function tests and urinalysis, and an elevated erythrocyte sedimentation rate of 30 mm/h. Pelvic examination did not reproduce her pain, and a transvaginal ultrasound performed by her gynecologist 2 days prior was unremarkable for an ectopic pregnancy, ovarian cyst, or torsion. Given the recurring nature of her symptoms, accompanied by the lack of a specific diagnosis, the patient underwent a contrast-enhanced CT scan of the abdomen and pelvis, revealing a dilated 10 mm appendix without evidence of abscess or fluid collection, thereby suggestive of chronic appendicitis (Figure 1, Figure 2). The patient was referred for laparoscopic appendectomy. She was seen in follow-up 3 months later and reported no recurrence of symptoms.
      Figure thumbnail gr1
      Figure 1Axial computed tomography scan with contrast of the right lower quadrant in a 28-year-old woman with chronic abdominal pain demonstrating a thickened and ill-defined appendix (white arrow).
      Figure thumbnail gr2
      Figure 2Coronal computed tomography view of the abdomen and pelvis showing a dilated appendix (white arrow) without any associated appendicolith, fluid collection, or abscess.
      The diagnosis of classical acute appendicitis is generally straightforward, often manifesting as 48 hours of periumbilical pain localizing to the right iliac fossa with associated anorexia, abdominal guarding, and leukocytosis. Atypical and chronic presentations are less common but are believed to result from partial and transient obstruction of the appendix.
      • VanWinter J.T.
      • Beyer D.A.
      Chronic appendicitis diagnosed preoperatively as an ovarian dermoid.
      The incidence of chronic appendicitis is estimated at 1.5% of all cases.
      • Hawes A.S.
      • Whalen G.H.
      Recurrent and chronic appendicitis: the other inflammatory conditions of the appendix.
      This entity poses a diagnostic dilemma for clinicians because patients generally do not present with typical appendicitis symptoms. Oftentimes these patients are misdiagnosed, particularly sexually active females or those partially treated with antibiotics for other conditions, as was the case with our patient. Although no formal diagnostic criteria or management algorithm exists for chronic appendicitis, CT imaging is considered the most accurate test of choice for patients with an equivocal presentation.
      • Rao P.M.
      • Rhea J.T.
      • Noveline R.A.
      • et al.
      Helical CT technique for the diagnosis of appendicitis: prospective evaluation of a focused CT examination.
      Missing the diagnosis can have serious consequences, as there is a risk of abscess formation and infertility.
      • Mueller B.A.
      • Daling J.R.
      • Moore D.E.
      • et al.
      Appendectomy and the risk of tubal infertility.
      While it is generally not considered a surgical emergency, most patients with chronic appendicitis have resolution of pain with appendectomy.
      Our patient had an interesting presentation of right lower quadrant pain that went undiagnosed for 2 years despite immediate medical attention and a negative work-up. Her surgical pathology demonstrated a fibrotic and dilated appendix with adhesions, all suggestive of a chronic, ongoing inflammatory process. This case serves as a reminder to primary care physicians that appendicitis can resolve and reoccur spontaneously and should be included in the differential diagnosis for patients with chronic right lower quadrant abdominal pain. Appropriate imaging studies should be obtained if there is a high clinical suspicion, and timely surgical referral may be warranted for definitive management.

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