A Rare Case of Acute Abdomen Due to Rupture Appendiceal Mucocele

Case Report

A Rare Case of Acute Abdomen Due to Rupture Appendiceal Mucocele

Corresponding author:Dr. Hong-Ming Chao, Division of General Surgery, Department of Surgery, Taoyuan Armed Forces General Hospital, Taiwan No. 168, Zhongxing Road, Longtan Dist, Taoyuan City, Taiwan.
Phone: 886-3-4799595; E-mail: jordan721102@gmail.com
Abstract

Colon perforation initially presents as peritonitis but can rapidly progress to septic shock, which has a high mortality rate. Here, we report on a 85-year-old female with a history of hypertension and type II diabetes mellitus. The patient presented to the emergency department after suffering from abdominal pain and dysuria for one day. Her vital signs were normal; however, a blood test revealed elevated levels of band form neutrophils. A physical examination further revealed diffuse abdominal tenderness and muscle guarding. Hollow organ perforation was highly suspected. An investigation with abdominal computer tomography revealed a rupture cystic lesion over right lower abdomen and we suspect rupture appendiceal mucocele. The patient underwent diagnostic laparoscope. During the surgical process, a rupture cystic lesion over the cecumwas noted, which can be indicative of rupture appendiceal mucocele. We thus conducted laparoscopic right hemicolectomy and end-ileostomy. The final pathological report identified cecal diverticulitis and adenocarcinoma with perforation and peritonitis.

Keywords:Colon Perforation; Pneumoperitoneum; Appendiceal Mucocele

Introduction

Colon perforation is characterized by a high mortality rate because the condition can easily progress to peritonitis with septic shock. Appendiceal mucocele are rare and are found about 0.3 % in appendectomy [1]. In this report, we describe one clinical case of appendiceal mucocele with perforation and peritonitis. We further discuss the clinical manifestations, radiological findings, and management of surgery.

Case Report

A 85-year-old female presented to the emergency department after suffering from abdominal pain for 1 day and dysurina for 1 day. The patient had a past history of hypertension and type II diabetes mellitus. His blood pressure was 135/92 mmHg; his pulse was 88 beats per minute; and his body temperature was 36.5℃. A blood test conducted at the time of admission further showed that the patient had a white blood cell count of 10250, a hemoglobin count of 8.8, a band form neutrophil level of 6%, and an acute kidney injury with a creatinine level of 2.15.

Abdomen physical examination revealed abdominal guarding, tenderness, and rigidity of the abdomen. Under the impression of surgical abdomen, abdomen computer tomography was performed, and rupture appendiceal mucocele was found. After the patient communicated with his family, we arranged diagnostic laparoscope to be performed. During the surgical procedure, malignant appendiceal mucocele was suspected. We thus performed laparoscopic right hemicolectomy and end-ileostomy. The patient was transferred to an intensive care unit following surgery. After his condition stabilized, the patient was discharged and followed up by the hospital out-patient department.

Discussion

Appendiceal Mucocele is uncommon. Rupture Appendiceal Mucocele could result in acute peritonitis and septic shock. Early and correct diagnosis of hollow organ perforation is very important.

Clinical manifestations of colon perforation include abdomen tenderness, abdomen muscle guarding, or shock. A chest X-ray may reveal the presence of free air over the sub phrenic region, and abdomen computer tomography may indicate that free air and fluid has collected in the peritoneal cavity.

Hinchey’s classification can be used to assess peritoneal contamination intraoperatively. This classification system divides diverticulitis into four stages. Stage I is chartered by a periodic or mesenteric abscess; stage II is characterized by a walled-off pelvic abscess; stage III is characterized by generalized purulent peritonitis; and stage IV is characterized by generalized fecal peritonitis [2].

An important step in treating colon perforation is to remove the source of infection, as feculent peritonitis leads to a high mortality rate [3]. Therefore, emergent surgery with resection of the involved colon is an equally important part of treatment.

Appendiceal Mucocele can be classified into the following types:

1.mucosal hyperplasia (histologically similar to hyperplastic colon polyp). 2.simple or retention cysts due to obstruction (ex: fecalith).3. mucinous cystadenomas (morphologically reminiscent of adenomatous colon polyps or villous adenomas) 4. mucinous cystadenocarcinomas (glandular invasion into the stroma) [4,5].

Retention cysts, cystadenomas, or mucosal hyperplasia should be performed by standard appendectomy. But complicated Mucocele with involvement of the terminal ileum or cecum, mucinous cystadenocarcinomas shoulder be considered first. Therefore, right hemicolectomy shoulder be performed for complicated Mucocele [6].

Colon perforation due to Appendiceal Mucocele is rare. Therefore, surgical resection of the involved colon should extend to tumor free margins. For the patient reported here, surgery with segmental resection of the cecum, ascending colon and terminal ileum. Even in the trouble case. laparoscopic surgery is safe and feasible due to the progress in laparoscopic equipments and techniqyes.

Figure 1. Rupture Appendiceal Mucocele over right lower abdomen

Figure 2. Surgery specimens(Appendiceal Mucocele, cecum, ascending colon and

References

  1. Aho AJ, Heinonen R, Laurén P. Benign and malignant mucocele of the appendix. Histological types and prognosis. Acta Chir Scand. 1973, 139(4): 392-400.
  2. Hinchey EJ, Schaal PG, Richards GK. Treatment of perforated diverticular disease of the colon. Adv Surg. 1978, 12: 85-109.
  3. Sarin S, Boulos PB. Long-term outcome of patients presenting with acute complications of diverticular disease.Ann R Coll Surg Engl. 1994, 76(2):117-120.
  4. Higa E, Rosai J, Pizzimbono CA, Wise L. Mucosal hyperplasia, mucinous cystadenoma, and mucinous cystadenocarcinoma of the appendix. A re-evaluation of appendiceal “mucocele”. Cancer. 1973, 32(6): 1525-1541.
  5. Landen S, Bertrand C, Maddern GJ, et al. Appendiceal mucoceles and pseudomyxoma peritonei. Surg Gynecol Obstet. 1992, 175(5): 401-404.
  6. Park KJ, Choi HJ, Kim SH. Laparoscopic approach to mucocele of appendiceal mucinous cystadenoma: feasibility and short-term outcomes in 24 consecutive cases. Surg Endosc. 2015, 29(11): 3179-3183.

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