When Appendicitis Recurs: Two Case Studies

Stump appendicitis is a rare complication that occurs when the residual appendix becomes inflamed after an appendectomy. It is estimated to occur in between 0.002% and 0.15% of cases, although it may be underreported due to diagnostic challenges. The condition involves inflammation of the remaining appendix tissue, often resulting from incomplete removal during the initial surgery.

Occasionally, a fecalith at the base can be the culprit. This complication is rarely considered initially by either physicians or patients, which can lead to delayed diagnosis and treatment. A team in London recently reported two cases that illustrate the specifics of this complication.

Two London Case Studies

The first case involved a 41-year-old man with a history of type 2 diabetes and hypercholesterolemia. He presented to the emergency department with generalized abdominal pain lasting 2 days; the pain worsened when he moved but was relieved with rest. The patient had undergone an appendectomy 2 years prior for perforated appendicitis, which was complicated by a postoperative abscess. Initially, he was diagnosed with biliary colic and treated with antibiotics and analgesics, but his symptoms worsened. A CT scan was performed, revealing inflammation of the appendiceal stump and cecum. He was subsequently operated on laparoscopically, but extensive adhesions necessitated an open procedure. A diagnosis of appendicitis in the residual stump was confirmed, and a complete resection was performed. The pathology revealed appendicitis in a remaining stump measuring 8 cm. Postoperative recovery was uneventful.

The second case involved an 18-year-old man who presented with abdominal pain radiating to the right iliac fossa, similar to the pain he experienced from appendicitis 2 months earlier. His initial appendectomy had been performed at a different hospital. Initial tests showed no signs of stump appendicitis, and he was diagnosed with mesenteric adenitis. However, his symptoms worsened and inflammatory markers increased, leading to another CT scan. This procedure confirmed inflammation in the appendiceal stump. A second surgery was performed, revealing an inflamed 3-cm stump with pus and partially resorbed sutures. The stump was removed, and the patient recovered.

Management Approach

These two cases highlight the nuances of stump appendicitis, which is often mistaken for conditions such as nephrolithiasis or chronic inflammatory bowel disease. Currently, diagnosis is aided by CT imaging, which shows a thickened and infiltrated residual stump beneath the cecum and occasionally cecal wall thickening, fatty tissue infiltration, or pericecal fluid collections.

From a technical standpoint, an appendiceal stump may be “left behind” because of a difficult dissection during the initial appendectomy, often due to significant inflammation or the retrocecal position of the appendix. In some cases, the surgery may have been performed hastily. In any event, the issue usually arises from improper identification of the appendix base, typically located at the convergence of the taenia coli on the cecal wall. The case of the 41-year-old man is a classic example, with an unusually long residual stump measuring 8 cm.

Therapeutic management lacks a clear consensus. Reoperation can be challenging, especially if difficulties were encountered during the initial surgery. Antibiotic therapy may be an option, but its efficacy remains unproven even in uncomplicated acute appendicitis. In cases involving complications, a visible fecalith on CT also supports the need for reoperation. If CT findings are unclear, pathology reports from the initial surgery may provide useful clues. If the removed appendix was unusually small, stump appendicitis is a plausible consideration.

Additionally, if symptoms persist or worsen, a repeat CT scan is advisable. Rare cases of double appendixes exist (the incidence is estimated at 0.004%), sometimes associated with cecal duplications. Other causes of “recurrent” appendicitis include inflammation of a cecal diverticulum or an epiploic appendix, which can be mistaken for the appendix, further underscoring the value of surgical documentation.

Although rare, stump appendicitis should be considered in any patient who experiences pain following an appendectomy, particularly in the right iliac fossa. CT imaging generally facilitates diagnosis, enabling timely management and reducing morbidity. If available, records from the initial surgery should be carefully reviewed.

This story was translatedfrom JIM using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.