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2012, Volume 28, Number 3, Page(s) 290-292
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DOI: 10.5146/tjpath.2012.01140 |
Intussusception of the Appendix Induced by Sessile Serrated Adenoma: A Case Report |
Ümran YILDIRIM1, İsmet ÖZAYDIN2, Havva ERDEM1, Ali Kemal UZUNLAR1 |
1Department of Pathology, Düzce University, Faculty of Medicine, DÜZCE, TURKEY
2Department of General Surgery, Düzce University, Faculty of Medicine, DÜZCE, TURKEY |
Keywords: Appendix, Intussusception, Serrated adenoma |
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Intussusception of the appendix vermiformis is a rare condition.
It occurs mainly in infants and children. Here, we report an
intussusception case that occurred in a 65-year-old male presenting
with repeated periumbilical pain, nausea, vomiting and febrile
sensation. The appendix was seen to be intussuscepted at laparoscopy.
The invaginated segment was reducted and simple appendicectomy
was carried out. Histopathologic examination revealed a sessile
serrated adenoma at the wall of the appendix, suggesting it as the
cause of the intussusception. |
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Intussusception primarily occurs in children, with only
about 5% of cases occurring in adults 1. Intussusception
of the appendix vermiformis in adults is a rare condition
caused by anatomical and pathological factors such as
tumors and is rarely diagnosed before surgery. Although
most appendiceal tumors are benign, tubular adenoma is an
unusual lesion 2. Here, we report a case with appendiceal
intussusception induced by sessile serrated adenoma (SSA)
and discuss the clinical features, classification, preoperative
diagnosis and therapy of this condition together with a
review of the literature. |
Top
Abstract
Introduction
Case Presentation
Disscussion
References
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A 65-year-old male was admitted with repeated
periumbilical pain, nausea, vomiting and febrile sensation.
His initial vital signs were blood pressure 102/68 mmHg,
pulse 102/min, respiration 18/min, and temperature
37.5 °C. Abdominal examination revealed a right lower
quadrant tenderness with voluntary guarding and mild
rebound tenderness. Pelvic examination and urinalysis were
normal with no evidence of haematuria or other findings
(such as infection). The WBC was 15.3x103/μL with 78% neutrophils and the C-reactive protein level was 87.2 mg/dl.
This presentation indicated acute appendicitis. Plain films
of the abdomen disclosed multiple intestinal air-fluid levels
(Figure 1). After appropriate fluid replacement, the patient
underwent emergency surgery. The appendix was seen to
be intussuscepted at surgery. The invaginated segment was
reducted and simple appendicectomy, rather than a right
hemicolectomy was carried out in the absence of any other
findings. Histopathologic examination revealed an SSA at
the wall of the appendix (Figure 2).
Click Here to Zoom |
Figure 1: Plain film of abdomen disclosing multiple intestinal airfluid
levels. |
Click Here to Zoom |
Figure 2: Microphotograph shows sessile serrated adenoma
involving the entire appendiceal circumference (H&E, x4). |
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Top
Abstract
Introduction
Case Presentation
Disscussion
References
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Intussusception was described firstly by Barbette of
Amsterdam in 1674 and further presented in a detailed
report in 1789 by John Hunter as “introssusception”.
Intussusception represents a rare form of bowel obstruction
in the adult 1. Several pathological conditions have
been reported as the leading point in intussusception,
and these include polyps, hamartomas, lipomas,
leiomyomas, neurofibromas, adenomas, inflammatory
polyps, tuberculosis, Meckel diverticulum, adhesions, and
heterotopic pancreas in children 1. Adult intussusception
represents 5% of all cases of intussusception and accounts for only 1%-5% of intestinal obstructions in adults 3. In
children, it is usually primary and benign, and pneumatic
or hydrostatic reduction of the intussusception is sufficient
to treat the condition in 80% of the patients. In contrast,
almost 90% of the cases of intussusception in adults are
secondary to a pathologic condition that serves as a lead
point, such as carcinomas, polyps, Meckel's diverticulum,
colonic diverticulum, strictures or benign neoplasms,
which are usually discovered intraoperatively 3.
Intussusception of the appendix vermiformis is an
uncommon and an incidence rate of 0.01% has been
reported in the literature4,5. Most of the cases in the
literature are infants and children6. Our case was an
adult male patient.
Some anatomical factors such as a fetal-type cecum
with a funnel-shaped, mobile appendix may also cause
intussusception of the appendix vermiformis7,8. The
clinical presentation in adult intussusception is often
chronic, and most patients present with nonspecific
symptoms that are suggestive of intestinal obstruction.
Abdominal pain is the most common symptom followed
by vomiting and nausea3,9,10. Our case was admitted as
acute appendicitis and intussusception of the appendix was
recognized during surgery.
Several imaging techniques such as plain abdominal X-rays,
contrast studies, barium enema examination, colonoscopy,
USG, and in recent years CT and MRI may help to precisely
identify the causative lesion preoperatively11. Barium
enema examination and colonoscopy are contraindicated if
there is the possibility of bowel perforation11.
There are a few cases appendiceal intussusception in the
literature. In one of them, the intussusception was caused
by appendiceal malignant polyp in a patient with Peutz-
Jeghers syndrome12 and other cases were caused by
endometriosis4 and appendicitis13. Our case is the
first appendiceal intussusception induced by SSA.
SSA is a recently described entity. It is more commonly
located in the right side of the colon and also can occur
in the appendix14-16. The incidence of this lesion in
the appendix is unknown17. SSA cases closely resemble
hyperplastic polyps morphologically but exhibit subtle
distinguishing architectural and cytologic features, such
as dilatation and serration of the basis of crypt, irregular
branching and asymmetric crypt17. SSA can mimic
a hyperplastic polyp (HP) in the appendix but differs
from HP by the lack of dysplastic changes in the crypt
epithelium17. Bellizzi et al. demonstrated that SSA of the
appendix was morphologically and immunophenotypically
analogous to those seen in the colorectum18. However,
they exhibited different rates of BRAF mutation and the
lack of demonstrable resultant microsatellite instability19.
In conclusion, intussusception of the vermiform appendix is
rare. Clinical signs, symptoms and radiological findings vary
among patients. Treatment of appendiceal intussusception
is mainly surgical. SSA is one of the probable diagnoses in
adults that should be considered in obstructive lesions of
the appendix causing intussusception. |
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Abstract
Introduction
Case Presentation
Discussion
References
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1) Marinis A, Yiallourou A, Samanides L, Dafnios N, Anastasopoulos G, Vassiliou I, Theodosopoulos T.: Intussusception of the bowel in adults: A review. World J Gastroenterol 2009, 15; 407-411, [ PubMed ]
2) Chen YC, Chiang JM: Appendiceal intussusception with adenocarcinoma
mimicking a cecal polyp. Gastrointest Endosc 2000, 52:130–131, [ PubMed ]
3) Azar T, Berger DL: Adult intussusception. Ann Surg 1997, 226: 134-138, PMID: 9296505
4) Ijaz S, Lidder S, Mohamid W, Carter M, Thompson H: Intussusception of the appendix secondary to endometriosis: a case report. J Med Case Rep 2008; 2:12, [ PubMed ]
5) Collins DC: 71,000 human appendix specimens. A final report, summarizing forty years’ study. Am J Proctol 1963, 14:265-281, [ PubMed ]
6) Forshall I: Intussusception of the vermiform appendix with a report of seven cases in children. Br J Surg 1953, 40:305-312, [ PubMed ]
7) Fink VH, Santos AL, Goldberg SL: Intussusception of the appendix: case reports and review of the literature. Am J Gastroenterol 1964, 42: 431-441, [ PubMed ]
8) Hill BJ, Schmidt KD, Economou SG: The ‘‘insideout’’ appendix. A review of the literature and report of two cases. Radiology 1970, 95:613-617, [ PubMed ]
9) Begos DG, Sandor A, Modlin IM: The diagnosis and management of adult intussusception. Am J Surg 1997, 173: 88-94, [ PubMed ]
10) Levine MS, Trenkner SW, Herlinger H, Mishkin JD, Reynolds JC: Coiled-spring sign of appendiceal intussusception. Radiology 1985, 155:41-44, [ PubMed ]
11) Yakan S, Calıskan C, Makay O, Deneclı AG, Korkut MA. Intussusception in adults: Clinical characteristics, diagnosis and operative strategies. World J Gastroenterol 2009, 15:1985-1989, [ PubMed ]
12) Miyahara M, Saito T, Etoh K, Shimoda K, Kitano S, Kobayashi M, Yokoyama S: Appendiceal intussusception due to an appendiceal malignant polyp--an association in a patient with Peutz-Jeghers syndrome: report of a case. Surg Today 1995, 25:834-837, [ PubMed ]
13) Ozuner G, Davidson P, Church J: Intussusception of the vermiform appendix: preoperative colonoscopic diagnosis of two cases and review of the literature. Int J Colorectal Dis 2000, 15:185–187, [ PubMed ]
14) Baker K, Zhang Y, Jin C, Jass JR: Proximal versus distal hyperplastic polyps of the colorectum: different lesions or a biological spectrum? J Clin Pathol. 2004, 57:1089-1093, [ PubMed ]
15) Higuchi T, Jass JR: My approach to serrated polyps of the colorectum. J Clin Pathol. 2004, 57:682-686, [ PubMed ]
16) Rubio CA: Serrated adenoma of the appendix. J Clin Pathol. 2004, 57:946-949, [ PubMed ]
17) Carr NJ, Emory TS, Sobin LH: Epithelial Neoplasms of the Appendix: In Odze RD, Goldblum JR (Eds): Surgical Pathology of the GI Tract, Liver, Biliary Tract and Pancreas. Philadelphia, Saunders, 2009, 639-653
18) Bellizzi AM, Rock J, Marsh WL, Frankel WL: Serrated lesions of the appendix: a morphologic and immunohistochemical appraisal. Am J Clin Pathol. 2010, 133:623-32, [ PubMed ]
19) Rubio CA: Serrated adenomas of the appendix. J Clin Pathol 2004, 57:946–949, [ PubMed ] |
Top
Abstract
Introduction
Case Presentation
Discussion
References
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