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DISCUSSION
A recent review article revealed 61 documented cases of stump appendicitis. Demographics of patients demonstrate mean age at presentation of 37 ± 2 years, with males comprising 62 percent
of patients. These patients presented predominantly with a chief complaint of abdominal pain (93 percent), with 77 percent of Mean time interval from initial appendectomy to presentation with stump appendicitis was 108 ± 20 months. Of the case reports reviewed that indicated type of initial appendectomy, 66 percent were open and 34 percent were performed laparoscopically.4 Demographically, the patient in the current case report presents similarly in age and chief complaint, compared to reviewed case reports; however, her time interval between initial appendectomy and presentation for stump appendicitis of approximately 14 months is well below the mean.
Conditions that could predispose toward occurrence of stump appendicitis include anatomic presentation and limitations encountered at initial appendectomy. Complete or partial retrocecal lying appendix could obscure visualization and lead
of stump appendicitis status post initial open appendectomy, laparoscopic appendectomy has been proposed as a risk factor for development of stump appendicitis.5 General technical limitations lack of tactile feedback and three-dimensional perspective have
of the appendiceal base and subsequent residual appendiceal stump.4 In the presented case, review of documentation from initial appendectomy revealed a retrocecal lying, nonperforated appendix. The operative note described visualization of both the cecum and, after blunt dissection, the appendix. The appendix was excised and removed after stapling at the base of the appendix, with no complications noted.
In the current patient case study, surgical resection of the appendiceal stump was deferred at the time of presentation, showed clinical improvement with percutaneous drain placement
was prioritized before planning for completion appendectomy, which is the treatment of choice for stump appendicitis. In the aforementioned literature review article, treatment among cases was predominantly open surgery for both nonperforated stump
appendicitis (85 percent) and perforated appendicitis (90 percent). Open surgery included open appendectomies and more extensive abdominal procedures including ileocecectomy, hemicolectomy, and cecectomy.4 Despite the documented predominance of open surgery for completion appendectomy, it has been proposed
that cases of stump appendicitis with delineated anatomy by CT
be treated with laparoscopic completion appendectomy.5
CONCLUSION
As illustrated by the patient presented in this case study,
stump appendicitis can offer a diagnostic dilemma in a patient presenting with right lower quadrant pain. Oftentimes, past surgical history of appendectomy precludes further workup of the appendix, or an appendiceal stump, as a source of symptoms and a nidus for infection, given the relative rarity of stump appendicitis. Accordingly, diagnosis of stump appendicitis
may be delayed while workup for other etiologies is conducted, with risk of possible clinical decline as the patient experiences incidence, evidence necessitates awareness of stump appendicitis as a clinical problem and etiology of abdominal pain, regardless of past surgical history.
CONTRIBUTING AUTHORS
■ ROLAND M. DIMAYA, DO is a second-year Emergency Medicine/Family Medicine Resident at Christiana Care Health System in Newark, Del.
■ NOVNEET SAHU, MD is a fifth-year Emergency Medicine/Family Medicine Resident at Christiana Care Health System in Newark, Del.
REFERENCES
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Buckius MT, McGrath B, Monk J, Grim R, Bell T, Ahuja V. Changing epidemiology of acute appendicitis in the United Sates: study period 1993-2008. J Surg Res. 2012;175:185-190.
National Center for Health Statistics. National Hospital Discharge Survey, 2010. Hyattsville, Maryland: Public Health Service. 2010.
Liang, MK, Lo HG, Marks JL. Stump appendicitis: a comprehensive review of literature. Am Sur. 2006;72:162-166.
Subramanian A. Liang MK. A 60-year literature review of stump appendicitis; the need for a critical view. Am J Sur. 2012;203:503-507.
Roberts KE, Starker LF, Duffy AJ, Bell RL, Bokhari J. Stump appendicitis: a surgeon’s dilemma. J Soc Laparoendoc Sur. 2011;15:373.
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Del Med J | September 2016 | Vol. 88 | No. 9
