|Year : 2013 | Volume
| Issue : 2 | Page : 103-105
Ayman A Al-Talib
Department of Obstetrics and Gynecology, University of Dammam, Saudi Arabia
|Date of Web Publication||25-Dec-2013|
Ayman A Al-Talib
Department of Obstetrics and Gynecology, King Fahd Hospital of the University, P. O. Box: 2208, Al-Khobar 39152
Source of Support: None, Conflict of Interest: None
Although appendiceal endometriosis is rare, appendix is the second most common site of intestinal endometriosis. Clinical diagnosis is difficult and histopathology is the only way to establish the diagnosis. We present a case of chronic pelvic pain secondary to appendiceal endometriosis and a review of the literature. There are no pathognomonic criteria to establish an accurate preoperative diagnosis. There is no specific radiologic test for diagnose. Laparoscopy provides detailed evaluation of the appendix but gross inspection of appendix alone is not enough to rule out the problem. The appendix may harbor endometriosis and could be a cause of chronic pelvic pain. When performing surgeries in a patient with chronic pelvic pain, surgeons should be aware of the possible contribution of the problem pelvic pain in patients with endometriosis. The appendix should be examined thoroughly during endometriosis-related operations. Appendectomy should be performed if the appendix looks abnormal.
تعنى هذه دراسة بحالة لسيدة في الواحد والثلاثين من العمر تعاني من الم متكرر في الجانب الأيمن من الحوض لعامين يزيد مع التبول والتبرز. وقد تم فحصها من قبل جراح المسالك البولية واستشاري الجهاز الهضمي وكانت نتيجة الفحص طبيعية. عند إجراء عملية المنظار وجد أن هناك غرس زائدي في بطانة الجزء الخلفي من الرحم. وأن الزائدة الدودية ملتحمة مع الجدار الأمامي للبطن. عند إجراء عمليات جراحية لألم الحوض المزمن على الجراحين توقع إسهام داء الزائدة البطاني في الألم للمرضى المصابين بداء بطانة الرحم.
Keywords: Appendectomy, appendiceal endometriosis, endometriosis, pelvic pain
|How to cite this article:|
Al-Talib AA. Appendiceal Endometriosis. Saudi J Med Med Sci 2013;1:103-5
| Introduction|| |
Although appendiceal endometriosis is rare, appendix is the second most common site of intestinal endometriosis. Clinical diagnosis is difficult and histopathology is the only way to establish the diagnosis.
| Case Report|| |
A 31-year-old woman nulliparous presented with recurrent cyclic right-sided pelvic pain for two years duration which was worse during defecation and urination. Her cycles were regular, no history of hematuria or hematochezia. She was previously investigated by a urologist and a gastroenterologist with negative findings. Abdominal and pelvic imaging including computerized tomography scan was within normal limits. At laparoscopy, we found endometriotic implants in the posterior cul de sac. The appendix was stretched and adhered to the anterior abdominal wall [Figure 1]. Excision of the endometriosis and appendectomy led to the resolution of her pain symptoms. Histopathological examination revealed endometriosis of the cul de sac and the appendix [Figure 2].
|Figure 2: Histopathological examination of the vermiform appendix|
(HE, original magnification ×40)
Click here to view
| Discussion|| |
Intestinal endometriosis is usually asymptomatic and found incidentally during surgery for other conditions. 
Although appendiceal endometriosis (AE) is rare, appendix is the second most common site of intestinal endometriosis.  Clinical diagnosis is difficult and histopathology is the only way to establish the diagnosis.
The incidence of endometriosis of the appendix varies from 0.8% to 20%. , Collins reported that the rate of AE was 0.05% in 50 000 cases of appendectomy.  There are no pathognomonic criteria to establish an accurate preoperative diagnosis of appendiceal endometriosis. 
AE is usually asymptomatic but may present with acute or chronic abdominal pain. Acute appendicitis as a manifestation of AE is extremely rare.  Massive lower intestinal bleeding  or intestinal intussusceptions' secondary to AE has been described. , In pregnancy, inflammatory changes associated with appendiceal endometriosis tend to be more prominent, and rare complications such as perforation and gangrenous inflammation can occur.  Another rare finding is the association between appendiceal endometriosis and obstructive mucocele. The mucous distension can cause secondary obstruction of the appendix. 
The natural history of AE is unclear, but endometriosis-related adhesions could cause obstruction and lead to acute or intermittent appendicitis. Small superficial endometriotic implants on the serosa under hormonal influence proliferate and infiltrate the appendix. Cyclic hemorrhage from these implants can lead to partial or complete obstruction of the lumen resulting in acute inflammation of the appendix. Chronic inflammation causes fibrosis, stricture formation, and adhesion to the neighboring pelvic structures.
There is no specific radiologic test to diagnose AE. Laparoscopy provides detailed evaluation of the appendix but gross inspection of appendix alone is not enough to rule out AE. In fact, 38% of grossly normal appearing appendix has histological evidence of endometriosis. 
Mittal et al. studied 16 cases of AE, 6 of them presented as acute appendicitis and 2 others had a ruptured appendix. Histopathological examinations revealed that the body of the appendix is involved in 56% of the cases and the tip of the appendix is involved in another 44%. The base of the appendix was involved in one case only. 
Endometriosis of the appendix usually involves the serosa or serosa and muscularis propria; the mucosa remains intact.  Another study reported that among 31 cases of AE, 13 (40%) involve the muscularis layer and 18 (60%) involve the serosa and muscularis layers.  Mital et al. found that among 16 AE specimens, muscular and seromuscular involvement occurred in two third of patients, while serosal involvement only in one third of the patients. In all patients, glands and stroma typical of endometriosis were found.  Rarely, the mucosa is involved by endometriosis where the patients may present with melena or rectal bleeding. 
The appendix may be involved and contributes to pelvic pain in women with endometriosis. Harris et al. studied 65 women with symptomatic endometriosis and right low abdominal quadrant pain pain; 52 (80%) underwent appendectomy as a part of surgery and abnormal looking appendix. Of these 52 excised appendices, 12 (31%) had histologically confirmed AE.  Berker et al. studied 231 patients who underwent appendectomy during laparoscopic treatment of endometriosis and chronic pelvic pain. One hundred and fifteen patients (22.1%) were found to have concomitant appendiceal pathology. 
Routine performance of appendectomy in patients with chronic pelvic pain was evaluated in several studies. , In one study, 106 patients underwent routine appendectomy during laparoscopic treatment of ovarian endometriosis. Gross abnormality was found in 3.3% of cases, and microscopic examination revealed endometriosis in 13.2% of cases.  Agarwala and Liu reported a routine appendectomy as the only procedure associated with improvement in 91% of women with pelvic pain. In their study, 48 of 317 appendices had visible pathology. AE was encountered in 14 cases (4.4%).  It appears that patients with abnormal looking appendix are likely to have AE compared to those with normal looking appendix.
Clinically, AE should be differentiated from catamenial appendicitis, where the patient experiences cycle-dependent symptoms such as right lower quadrant pain and anorexia, mimicking acute appendicitis. This condition is associated with histopathological finding of increased numbers of mast cells in the appendiceal muscularis. In those with pelvic endometriosis, it is speculated that cyclic production of peritoneal fluid prostaglandins or other vasoactive compounds by endometriotic lesions leads to appendiceal ischemia or reperfusion injury. Symptoms always resolve following appendectomy. 
The appendix may harbor endometriosis and could be a cause of chronic pelvic pain. When performing surgeries in a patient with chronic pelvic pain, surgeons should be aware of the possible contribution of AE to the pelvic pain in patients with endometriosis. The appendix should be examined thoroughly during endometriosis-related operations. Appendectomy should be performed if the appendix looks abnormal.
| References|| |
|1.||Al-Talib A, Tulandi T. Intestinal endometriosis. J Gynecol Surg 2010;7:61-2. |
|2.||Cameron I, Rogers S, Collins M, Reed M. Intestinal endometriosis: Presentation, investigation, and surgical management. Int J Colorectal Dis 1995;10:83-6. |
|3.||Nezhat C, Nezhat F. Incidental appendectomy during videolaseroscopy. Am J Obstet Gynecol 1991;165:559-64. |
|4.||Pittaway D. Appendectomy in the surgical treatment of endometriosis. Obstet Gynecol 1983;61:421-4. |
|5.||Collins DC. A study of 50000 specimens of the human vermiform appendix. Surg Gynecol Obstet 1955;101:437-41. |
|6.||Mittal V, Choudhury S, Cortez J. Endometriosis of the appendix presenting as acute appendicitis. Am J Surg 1981;142:519-21. |
|7.||Khoo J, Ismail M, Tiu C. Endometriosis of the appendix presenting as acute appendicitis. Singapore Med J 2004;45:435-6. |
|8.||Shome G, Nagaraju M, Munis A, Wiese D. Appendiceal endometriosis presenting as massive lower intestinal hemorrhage. Am J Gastroenterol 1995;90:1881-3. |
|9.||Sakaguchi N, Ito M, Sano K, Baba T, Koyama M, Hotchi M. Intussusception of the appendix: A report of three cases with different clinical and pathologic features. Pathol Int 2008;45:757-61. |
|10.||Mann W, Fromowitz F, Saychek T, Madariaga J, Chalas E. Endometriosis associated with appendiceal intussusception. A report of two cases. J Reprod Med 1984;29:625-9. |
|11.||Nakatani Y, Hara M, Misugi K, Korehisa H. Appendiceal endometriosis in pregnancy. Pathol Int 2008;37:1685-90. |
|12.||Driman D, Melega D, Vilos G, Plewes E. Mucocele of the Appendix Secondary to Endometriosis. Am J Clin Pathol 2000;113:860-4. |
|13.||Uohara J, Kovara T. Endometriosis of the appendix. Report of twelve cases and review of the literature. Am J Obstet Gynecol 1975;121:423-6. |
|14.||Panganiban W, Cornog J. Endometriosis of the intestines and vermiform appendix. Dis Colon Rectum 1972;15:253-60. |
|15.||Harris R, Foster W, Surrey M, Agarwal S. Appendiceal disease in women with endometriosis and right lower quadrant pain. J Am Assoc Gynecol Laparosc 2001;8:536-41. |
|16.||Berker B, Lashay N, Davarpanah R, Marziali M, Nezhat CH, Nezhat C. Laparoscopic appendectomy in patients with endometriosis. J Minim Invasive Gynecol 2005;12:206-9. |
|17.||Agarwala N, Liu CY. Laparoscopic appendectomy. J Am Assoc Gynecol Laparosc 2003;10:166-8. |
|18.||Harper A, Soules M. Appendectomy as a consideration in operations for endometriosis. Int J Gynecol Obstet 2002;79:53-4. |
|19.||Barrier BF, Frazier SR, Brennaman LM, Taylor JC, Ramshaw BJ. Catamenial appendicitis. Obstet Gynecol 2008;111:558-61. |
[Figure 1], [Figure 2]