Appendiceal diverticulitis: an uncommon diagnosis in acute abdomen

Abstract
Introduction: Diverticulosis and diverticulitis of appendix vermiformis is a rare
pathologic entity, diffcult to diagnose because of the indolent evolution and the nonspecific
symptoms. Despite its rarity, this condition has a higher mortality rate, in comparison with
common appendicits, taking into account the higher risk of perforation and the potential
association with appendiceal neoplasms.
Objective: The present case report aims to illustrate the fact that preoperative simple
diagnosis of acute appendicitis according to the clinical signs and physical examination may
not

only

be

insufficient,

but

could

be

fatal

in

certain

circumstances,

like appendiceal diverticulitis, if surgical intervention is delayed.

Case Report: Here we present a female patient with a history of right lower abdominal
pain and fever of 3 days duration. She was diagnosed with acute appendicitis according to the
preoperative

physical,

laboratory,

and

imaging

examinations.

The appendiceal diverticulitis accompanying acute appendicitis was an intraoperative finding,

which was proven by histopathologic examination.
Conclusion: Preoperative diagnosing is a difficult process, the condition, frecquently,
representing an intaoperative surpise, for which the only therapeutical choice being
appendectomy, in order to prevent its serious complications.

Keywords: vermiform apendix, appendiceal diverticulitis, atypical appendicitis

Introduction
Diverticular disease of the appendix is a rare condition characterized by herniation or
outpouching of the appendiceal mucosa through the muscular wall, usually occuring between
the fourth and fifth decade of life.
The incidence of diverticula found in appendectomy specimens ranges from 0.004% to
2.1%, and from routine autopsies, 0.20% to 0.6%.

Place RJ, Simmang CL, Huber PJ.

Appendiceal diverticulitis. South Med J 2000;93:76-9.

As with all intestinal diverticula, appendiceal diverticula can be classified as congenital
or acquired. The congenital form, which is very rare, is a true diverticulum; the more prevalent
acquired form is a false diverticulum on the mesenteric border of the appendix.
We describe a case of a ......-year-old woman with appendiceal diverticulosis and a short
review of the literature regarding the subject.
Case report
A -year-old female patient presented in the Emergency Department of the Sfntul
Pantelimon Clinical Emergency Hospital in Bucharest with a history of abdominal pain,
vomiting and fever for 48 hours. The pain was located in the right iliac fossa, radiating
to the epigastrum, of a constricting type, continuous in nature, with no aggravating or
relieving factors, associated with 3-4 episodes of emesis, non-bilious in nature.
The clinical examination revealed tachycardia and no fever, tenderness in the right
iliac fossa, maximal at MCBurney's point, positive Lapinsky maneuver, rebound
tenderness, with no free fluid and normal bowel sounds. The other systems were normal.
Thus, a clinical diagnosis of acute appendicitis was made and the patient was taken
up for emergency appendectomy.
Intraoperatively, the appendix was inflamed, located retrocecal, with multiple
diverticuli, arising from the appendix along the anti-mesenteric border, ranging from
0.5x0,6cm to 0.5x0.8cm from the base to the tip.
Postoperative period was uneventful, with rapid recovery.
The histopathological report revealed: .....
A postoperative colonoscopic examination was made...........
The particularity of the case.....

Disscusion
Being extremely rare, there are only few studies regarding congenital or acquired
diverticular disease of the appendix, in the medical literature. Moreover, it is commonly
overlooked by clinicians, radiologists, and surgeons because of the limited symptoms, thus
leading to serious complications.
Congenital appendiceal diverticulosis was shown to have a prevalence of 0.014%, being
equally frequent in both sexes and commonly presenting as a single diverticulum. Acquired
DDA is, also, rare, being reported in 0.2% to 1.7% of all appendectomy specimens, with a
higher incidence in male patients. D. C. Collins, A study of 50,000 specimens of the human
vermiform appendix, Surgery, Gynecology & Obstetrics, vol. 101, no. 4, pp. 437445, 1955.
N. P. Blair, S. P. Bugis, L. J. Turner, and M. M. MacLeod, Review of the pathologic
diagnoses of 2,216 appendectomy specimens, American Journal of Surgery, vol. 165, no. 5,
pp. 618620, 1993.
P. Delikaris, P. S. Teglbjaerg, P. Fisker Sorensen, and I. Balslev, Diverticula of the
vermiform appendix. Alternatives of clinical presentation and significance, Diseases of the
Colon and Rectum, vol. 26, no. 6, pp. 374376, 1983
Having a nonspecific symptomatology, patients present, frecquently, in the Emergency
Departments for acute right lower quadrant abdominal pain, after a long and insidious
evolution, thus delaying the consultation and increasing the morbidity and mortality rates.
Despite being first described in 1893 by Kelynack, it is commonly considered by
surgeons and pathologists as a variant of true appendicitis. Phillips BJ, Perry CW. Appendiceal
diverticulitis. Mayo Clin Proc 1999;74:890-2 However, appendiceal diverticulitis represents a
distinct entity because of the much higher risk of perforation or malignization, and a prolonged
postoperative convalescence period needed.
Recent studies noticed an association between this condition and appendiceal
neoplasms, considering the diverticular disease of the appendix as a marker of regional
neoplasms, Lamps et al. discovering a 25% association with appendiceal mucinous neoplasms.
L. W. Lamps, G. F. Gray Jr., B. R. Dilday, and M. K. Washington, The coexistence of lowgrade mucinous neoplasms of the appendix and appendiceal diverticula: a possible role in the
pathogenesis of pseudomyxoma peritonei, Modern Pathology, vol. 13, no. 5, pp. 495501,
2000.

Dupre et al. revealed that 48% of appendectomy specimens with diverticulosis were
developing appendiceal neoplasms including well-differentiated neuroendocrine tumors
(carcinoid), mucinous adenoma, tubular adenoma, and adenocarcinoma. M. P. Dupre, I.
Jadavji, E. Matshes, and S. J. Urbanski, Diverticular disease of the vermiform appendix: a
diagnostic clue to underlying appendiceal neoplasm, Human Pathology, vol. 39, no. 12, pp.
18231826, 2008.
The pathogenesis of appendiceal diverticula is not completely elucidated, several
theories having been proposed. The mechanical principle suggests an increased intraluminal
pressure against a point of weakness, anatomically represented by the widened vascular cleft
in the muscular layer, secondary to obstruction or excessive contraction of a hypertrophied
muscular layer, resulting in the herniation of mucosa through the cleft.
Appendiceal diverticulitis has been classified into 4 subtypes.Type 1 occurs when a
normal-appearing appendix is found with an acutely inflamed diverticulum. Type 2 involves
an acutely inflamed diverticulum with surrounding appendicitis. Type 3 is conventional
appendicitis with an incidental uninvolved diverticulum. Type 4 is an incidental appendiceal
diverticulum with no evidence of appendicitis or diverticulitis. Phillips BJ, Perry CW.
Appendiceal diverticulitis. Mayo Clin Proc 1999;74:890-2
Acute diverticulitis of the appendix has been shown to be more than 4 times as likely as
acute appendicitis to perforate (occurring in 66% of cases), increasing mortality 30-fold
compared with simple appendicitis, highlighting the importance of the appendectomy when
appendiceal diverticar disease is found incidentally during surgery or upon barium enema.
Phillips BJ, Perry CW. Appendiceal diverticulitis. Mayo Clin Proc 1999;74:890-2
Image studies including abdominal computed tomography scan, ultrasonography, and
plain film may improve the preoperative diagnosis, but, although this is of interest, it should
not change the management, as the appendix must still be removed.
Conclusions
Appendicular diverticulosis and acute appendicitis are two different entities, though the
clinical presentation of appendicular diverticulitis overlaps that of acute appendicitis, carrying
higher chances of perforation.
Appendectomy is the treatment of choice, wether there is a silent clinical manifestation,
with no apparent complications in the near future, or the diagnosis is made incidentally.

Every surgeon should be aware of the possibility of diverticulitis of the appendix in the
operating room, even if this does not change the operative management.
As diverticular disease of the appendix can be found as solitary lesions, as multiple
lesions confined to the right colon, or as part of a generalized disease of the entire colon,
postoperative barium enema or colonoscopic examination may be useful.