GMJ POSTER PROCEEDINGS

GULF MEDICAL JOURNAL

UNUSUAL PRESENTATION OF RECURRENT APPENDICITIS –

A RARE CASE REPORT AND LITERATURE REVIEW
Yassin Malallah Tahir1, Mrudula Sudhakaran1*, Princy Ann Philip1, Ranya El-Amin1
1Department of Surgery, Thumbay Hospital, Ajman, UAE
*Presenting Author

ABSTRACT
Introduction: Chronic or recurrent appendicitis is a clinical entity in which a patient has chronic
pain originating from the appendix and inflammation may or may not accompany it. This condition
is categorized into chronic or recurrent appendicitis and appendiceal colic pain.
Case Presentation: A 46-year old male presented with complaints of intermittent abdominal pain
for six months. Tenderness in the right iliac fossa on deep palpation was present. Ultrasonography
showed an inflamed appendix with numerous adhesions and a large fecolith. He underwent
laparoscopic appendectomy. The specimen was 6 cm in length and 3 cm in diameter; an appendix
with a 3 cm diameter is rare. The histopathologic examination was consistent with recurrent
appendicitis with lymphoid hyperplasia.
Conclusion: Chronic appendicitis is a clinical entity distinct from acute appendicitis in clinical
presentation as well as histopathological appearances. Chronic appendicitis is diagnosed if a patient
has had symptoms for more than four weeks, histopathological examination findings from specimen
are typical, and the patient shows clinical improvement after the surgical removal of the appendix.
Ultrasonogram, barium enema, and computerized tomography can help in diagnosis. In our case, the
inflamed appendix had one of the largest diameters ever reported.
Keywords: Chronic/recurrent appendicitis, largest diameter, 3 cm diameter, dilated lumen
Citation: Tahir YM, Sudhakaran M, Philip PA, El-Amin R. Unusual presentation of recurrent
appendicitis – a rare case report and literature review. Gulf Medical Journal. 2016;5(S2):S39–S42.

INTRODUCTION higher lumen pressure, followed by the

Reginald Fitz was the first person to describe
acute appendicitis in detail in 1889. Thereafter,
our knowledge of appendicitis has significantly
evolved.
In acute appendicitis, the main factor
initiating the inflammatory sequence is luminal
obstruction, which can occur due to fecoliths,
lymphoid hyperplasia, seeds of vegetables and
fruits, intestinal worms, viral infections
(particularly in children), and, in rare instances,
cancer (mostly in elderly population).
Once obstruction occurs, mucus secretion
and inflammatory exudates increase, leading to
Correspondence: Dr. Yassin Malallah Tahir
(FRCS), Department of Surgery, Thumbay
Hospital, Ajman, UAE. Email:
taherdryasien@yahoo.com
obstruction of lymphatic drainage. Bacterial
invasion of the submucosa also occurs.
Resolution can occur at this stage
spontaneously or after antibiotic therapy.
Some patients with such features can
continue to have low-grade abdominal pain for
several weeks and can develop a clinical entity
termed chronic appendicitis1–4.
Others can present with recurrent episodes
of abdominal pain after a symptomless period
of weeks or months. This condition is a distinct
clinical entity called recurrent appendicitis1, 4, 5.
The severity of inflammation increases with
the level of obstruction. The luminal capacity of
a normal appendix is only 0.1 ml. As the
distension continues after the multiplication of
bacteria, it can result in reflex nausea and
vomiting. The inflammation of serosa will cause

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YASSIN MALALLAH TAHIR, ET AL GMJ. ASM 2016;5(S2):S39–S42

pain in the abdomen to shift from the uneventful and the patient was discharged on
periumbilical region to the right iliac fossa. A the second postoperative day.
progressive invasion of bacteria can lead to the Histopathology Report
infarction and perforation of the appendix. This
The gross and microscopic examinations are
sequence of events causes acute symptomatic
consistent with the diagnosis of recurrent
presentation and this is the most common
appendicitis with lymphoid hyperplasia.
presentation of appendicitis, known as acute
Figure 1. Histopathology report
appendicitis. This is usually managed by
emergency appendectomy.
Chronic or recurrent appendicitis is also
eventually managed with appendectomy and the
diagnosis is made retrospectively after the
histopathological evaluation of the specimen
and symptomatic relief after appendectomy1, 3–6.

CASE REPORT
A 46-year old male with no known
comorbidities presented to the internal
medicine physician with recurrent lower Figure 2. Laparoscopic photo: arrows – distended
abdominal pain (three episodes in the last six appendix
months). On examination, a left iliac fossa mass
was noticed, and the patient was advised to
undergo colonoscopic evaluation. Colonoscopy
showed external pressure on the descending
colon. Moreover, umbilical herniation was
present. Ultrasonography revealed a right iliac
fossa mass and suggested a CT scan evaluation
for the diagnosis. The CT scan showed a
markedly distended appendix with a maximum
diameter of 24 mm and a large rounded
calcified shadow within measuring 20 × 18 mm,
suggestive of a calcified appendicolith. Subtle
haziness in the surrounding fat planes was
Figure 3. Laparoscopic photo (large arrows: distended
observed. A reactionary abdominal lymph node
end of appendix; small arrows: base of appendix)
enlargement was noted. A surgical consultation
of the case was done for further management.
All routine blood investigations were
normal.
The patient underwent laparoscopic
appendectomy under general anesthesia. Per-
operative findings include an inflamed and a
bloated appendix, round at the tip and 30 mm
in diameter. There were numerous hard
adhesions between the mesoappendix and the
left mesocolon as well as hard adhesions
between the tip of the appendix and the
mesocolon. The postoperative period was

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40 www.gulfmedicaljournal.com
UNUSUAL PRESENTATION OF RECURRENT
APPENDICITIS
Figure 4. Laparoscopic photo (large arrows: appendix
inside endobag; small arrows: endobag)
DISCUSSION
Acute appendicitis is a common cause of
emergency operations. The appendiceal lumen
becomes obstructed and, therefore, the
appendix distends and becomes inflamed. In
some cases, this over-distended wall can
perforate and the inflammation can spread
through the peritoneum. In other cases, there is
formation of phlegm on which adhesions are
held among the peripheral tissue6, 7.
Acute appendicitis usually presents within
48 hours of periumbilical pain localized to the
right iliac fossa. This will be accompanied by
fever, nausea, vomiting, abdominal guarding,
and rebound tenderness. The complete blood
count will increase, with neutrophils being
predominant. The diagnosis is usually based on
clinical history, examination, laboratory
investigations, and imaging modalities (such as
ultrasonogram and CT scan of abdomen) 6–11.
Typically, acute appendicitis is managed
with the surgical removal of the inflamed
appendix through laparotomy or laparoscopy.
In some cases, patients experience one or
several episodes of acute appendicitis lasting 1–
2 days, which subsides by itself; this is termed
as recurrent appendicitis1, 4–6. Chronic
appendicitis presents as continuous, less intense
abdominal pain, which may last weeks or
months or even years1–4.
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GMJ. ASM 2016;5(S2):S39–S42
The exact etiology is unknown, but it is
believed that recurrent appendicitis results from
the transient obstruction of the lumen, while
chronic appendicitis occurs due to the
continuous partial obstruction of the lumen3, 6, 7.
The causes of obstruction in the lumen include
fecolith, lymphoid hyperplasia, tumors, foreign
bodies, luminal secretions, and appendiceal
folding6, 7.
Pathological examination usually reveals
chronic inflammation with aggravation and
infiltration of lymphocytic and eosinophilic
accumulation, granulomatous reaction, fibrosis,
and, sometimes, foreign body giant cell
reaction6, 7. The patients with carcinoma have
pathological changes consistent with carcinoma.
Imaging modalities used to diagnose
chronic or recurrent appendicitis include: 1)
barium enema, which can reveal
partial/nonfilling of lumen; 2) ultrasonography,
which can show a dilated, noncompressible
appendix more than 6 mm in diameter with or
without associated fecolith or abscess
formation; and 3) CT scan, which can reveal a
dilated appendix with periappendiceal fat
stranding, appendiceal wall thickening and
surrounding edema, calcified appendoliths,
abscess, phlegmon, and inguinal
lymphadenopathy 9–12. The accuracy of a CT
scan in diagnosing appendicitis is 93–98%6, 7.
In our case, the patient had three episodes
of moderate abdominal pain over six months.
His routine blood reports were normal.
Colonoscopy showed external pressure. The CT
scan revealed a markedly enlarged appendix
with an appendicolith inside and reactionary
lymphnode enlargement6–8, 13. His
histopathology reports were consistent with a
diagnosis of recurrent appendicitis with
lymphoid hyperplasia14. The diameter of the
appendix was 3 cm; an inflamed appendix with
a diameter more than 2.5 cm is rare9, 10–12.
CONCLUSION
Based on the literature review, our case is an
example of recurrent appendicitis with an
appendiceal diameter of 3 cm, a rare
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YASSIN MALALLAH TAHIR, ET AL
presentation9–12. The condition was managed
with laparoscopic appendectomy. The
postoperative period was uneventful. A follow-
up revealed the patient was relieved of his
symptoms.
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