Figure 1: Plain film of abdomen disclosing multiple intestinal airfluid levels.
Intussusception of the appendix vermiformis is an uncommon and an incidence rate of 0.01% has been reported in the literature[4,5]. Most of the cases in the literature are infants and children[6]. 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 vermiformis[7,8]. 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 nausea[3,9,10]. 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 preoperatively[11]. Barium enema examination and colonoscopy are contraindicated if there is the possibility of bowel perforation[11].
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 syndrome[12] and other cases were caused by endometriosis[4] and appendicitis[13]. 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 appendix[14-16]. The incidence of this lesion in the appendix is unknown[17]. 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 crypt[17]. SSA can mimic a hyperplastic polyp (HP) in the appendix but differs from HP by the lack of dysplastic changes in the crypt epithelium[17]. Bellizzi et al. demonstrated that SSA of the appendix was morphologically and immunophenotypically analogous to those seen in the colorectum[18]. However, they exhibited different rates of BRAF mutation and the lack of demonstrable resultant microsatellite instability[19].
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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