The Journal of Emergency Medicine, Vol. 28, No. 1, pp.

41 43, 2005
Copyright 2005 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/05 $see front matter

doi:10.1016/j.jemermed.2004.07.007

Clinical
Communications

ACUTE APPENDICITIS OF THE APPENDICEAL STUMP

Miriam T. Aschkenasy,

MD, MPH*

and Frank J. Rybicki,

MD, PhD

*Department of Emergency Medicine, Boston Medical Center, Boston, Massachusetts and Department of Radiology, Brigham and
Womens Hospital and Harvard Medical School, Boston, Massachusetts
Reprint Address: Miriam T. Aschkenasy, MD, Department of Emergency Medicine, Boston Medical Center, One Boston Medical Center
Place, Dowling One South, Boston, MA 02118

e AbstractWe report a case of a 27-year-old man, status

post open appendectomy as an infant, in whom the diagnosis of acute appendicitis of the appendiceal stump was made
by computed tomography (CT). A coronal reformatted CT
image demonstrated both the inflamed appendix and a
normal terminal ileum. Although rare, stump appendicitis
may present with signs and symptoms typical of acute
appendicitis in patients status post appendectomy and
should be considered in the differential diagnosis. 2005
Elsevier Inc.

CASE REPORT
A 27-year-old man presented to the Emergency Department with a chief complaint of 9 h of right lower quadrant pain that woke him from sleep at 2 AM. The patient
described the pain as sharp and deep and stated that the
pain was intensifying. He admitted to nausea but denied
vomiting, fever, chills, change in bowel habits, or sick
contacts. He reported a similar episode 1 year prior that
spontaneously resolved over 3 weeks. The patients occupation includes delivering automobile parts and he
claimed that the pain could have been related to strenuous lifting.
The past medical history was non-contributory. The
patient was status post open appendectomy as an infant
with no other surgical history or history of hernia. The
patient did not know exactly how old he was when he
had his appendectomy. He believed that it was performed
in Puerto Rico but could provide no other details of his
prior surgery. He took no medications and had no drug
allergies.
Initial physical examination revealed a temperature of
36.1C (97.0F), heart rate of 67 beats/min, respiratory
rate of 18 breaths/min, and blood pressure of 131/82 mm
Hg. He was awake, alert and in no apparent distress lying
comfortably on the stretcher. Examination of the abdomen and genitourinary system demonstrated exquisite
tenderness with palpation over McBurneys point. There
was no rebound or guarding, no abdominal distention, no

e Keywordsappendicitis; recurrence; appendectomy;

appendiceal abscess; computed tomography; abscess;
stumpitis

INTRODUCTION
Acute appendicitis of an appendiceal stump, or stump
appendicitis, is a rare complication after appendectomy.
Although usually an early complication, delays in presentation can occur up to 50 years later (1). Stump
appendicitis has been associated with the length of the
stump and the utilization of laparoscopic surgery, but a
clear etiology has not been identified (15). Although the
signs and symptoms do not differ from acute appendicitis, the diagnosis is often not considered because of the
past surgical history. We report a case of a man with
stump appendicitis who presented 27 years after an open
appendectomy as an infant.

RECEIVED: 20 June 2003; FINAL

ACCEPTED: 8 July 2004

SUBMISSION RECEIVED:

10 June 2004;
41

42

M. T. Aschkenasy and F. J. Rybicki

DISCUSSION

Figure 1. Coronal reformatted image from CT scan of the

abdomen and pelvis after administration of oral and intravenous contrast material. The inflammation surrounding the
dilatated (2.2 cm width) appendiceal stump (straight arrow)
is well depicted in the coronal plane. Lateral to the stump is
thickening of the peritoneal reflection. Also seen is a normal
terminal ileum (curved arrow). Imaging also excludes free
intraperitoneal air and abscess formation.

organomegaly or masses palpated, and slightly decreased

bowel sounds. There was no evidence of urethral discharge, scrotal swelling or hernia. There was no pain
with palpation of the testes.
The urinalysis was normal and the white blood cell
count was 20.1 1000/mm3. Computed tomography (CT)
scan of the abdomen and pelvis was diagnostic of stump
appendicitis (Figure 1). The CT scan demonstrated
thickening at the base of the cecum with a 7-mm appendicolith, with inflammation of an appendiceal stump
seen, measuring up to 2.2 cm, which appears edematous
with surrounding stranding. No free air or abscess is
identified.
The patient was taken to the operating room and the
CT diagnosis was confirmed. According to the operative
report: The appendiceal stump was identified and felt to
be acutely inflamed and the base of the appendix appeared normal. The base of the appendix and the rim of
the cecum were then removed. The patient did well
post-operatively and was discharged home the next day.

Abdominal pain is a common chief complaint for patients evaluated in emergency departments, with an estimated 6.8 million cases annually (6). Acute appendicitis is the most common diagnosis leading to emergency
abdominal surgery in the United States (7). Although a
surgical history of appendectomy substantially decreases
the risk of appendicitis, stump appendicitis is a rare but
recognized cause of right lower quadrant pain.
Since the first reported case in 1945, acute inflammation of the appendiceal stump has been documented with
a delay between appendectomy and presentation extending from 2 weeks to over 50 years (1,8 11). Of the eight
cases reviewed, four occurred 10 to 34 years after initial
appendectomy and four occurred within 2 years of prior
appendectomy, with two prior documented laparoscopic
appendectomies (2,3,5,9,10,1315). It has been proposed
that a long appendiceal stump is a risk factor for stump
appendicitis. Moreover, the increased utilization of laparoscopic surgery in acute appendicitis has been implicated, most probably due to an inability to amputate the
appendix close to the cecal base (2,9). There are not
enough cases of stump appendicitis to determine an
incidence and the lack of data makes it difficult to draw
any conclusions regarding etiology. To date, no relationship between laparoscopic appendectomy and stump appendicitis has been demonstrated (1,12).
Patients with abdominal pain can be challenging. A
patient status post appendectomy who presents with
signs and symptoms suggestive of acute appendicitis
should be considered for stump appendicitis, especially if
there is no other reasonable explanation for the pain. As
with appendicitis, the course of action depends on the
level of suspicion and the clinical presentation of the
patient. If there is a high clinical suspicion, a CT scan of
the abdomen with contrast will help to evaluate the
appendiceal stump.
In conclusion, stump appendicitis is a rare but important consideration in patients who are status post appendectomy and present with symptoms of acute appendicitis. In particular, in patients for whom acute appendicitis
is strongly suspected, the history of prior appendectomy
should not entirely exclude the diagnosis. In these patients, CT scan of the abdomen and pelvis can not only
assist in the pre-operative diagnosis, but can also exclude
other etiologies of right lower quadrant pain.

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