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Home / Articles / Appendicitis Sans Appendix (Stump Appendicitis) 1985
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Appendicitis Sans Appendix (Stump Appendicitis) 1985

The caecum was closed in two layers.  No mortality or no faecal fistula noted in post operative period.  Histological analysis indicated; lymphoid hyperplasia of remnant of the appendix in 15 cases, one case had abscess of wall of the caecum & foreign body giant cell granuloma, in four cases granuloma of stump was present.  It is concluded that routine appendicectomy does not remove complete  lymphoid tissue of the appendix, which can cause grumbling to severe pain in the right iliac fossa.

 

 

 

KEY – WORDS

Post appendicectomy Pain, remnant of the appendix, local excision.

I N T R O D U C T I O N

The first appendicectomy was performed by Amyand in 1736.  Heister recognized the exact site of the primary inflammation in Peri-Para caecal region in 1755.  (1)  It was Fitz, Professor of medicine gave a lucid and logical description of clinical features, details of the pathological changes and he first used the term appendicitis.  Kronlein published first account of appendicectomy in 1886.  (2)  Mc Burney pioneered early diagnosis and surgical intervention and also devised muscle splitting incision by his name.  (3)  Murphy further popularized clinical early detection of the disease appendicitis by his popular triate of symptoms in 1889-1890.

In the developed and developing countries the appendicitis is the commonest condition for the laparatomy.  (4)  The causative factors are thought to be obstruction of lumen of the appendix due to faecolith impaction, lymphoid hyperplasia, and muscular in coordination or idiopathic. (5, 6, 7)

Intention for above historical detail is to ascertain that experience of last century has not helped in the improvement of the diagnosis of the appendicitis which solely depends on tenderness over Mc Burney’s point still.  (8-9) Increase in the total white cell count and/or in the polymorph is not mandatory (10-11).   The patients presenting for pain and tenderness over the Mc Burney's point after appendicectomy pose with difficult problem.  Every surgeon must have faced such problems.  The study of 82 cases of post appendicectomy pain is present in relation to etiology, treatment and follow-up.

 

 

 

 

 

 

 

 

 

 

 

 

 

MATERIAL AND METHOD

In the routine follow up 82 cases were detected, attending outdoor department frequently for pain in the right iliac fossa after appendicectomy in the period of 1982 – 1986, from 468 patients post appendecectomy.  The complimentary removal of the appendix associated with negative laprotomy, chronic duodenal ulcer; were excluded from the analysis. In the series 14 cases were from age group 10-20 (17%),  Four cases from age group of 40-50 (4.8%), one case from 50-60 age group (1.1%) and  63 cases out of 82 were between 20-40 age groups (78.7%)  (Table No.1).  Review of the histology record indicates 74 cases out of 82 were from group of lymphoid hyperplasia or acute inflammation of acute appendicitis (92.5%) & 8 cases were there from phlegmon or perforated appendicitis (7.5%)  (TableNo.2). All these cases had grumbling pain in the right iliac fossa and confirmed tenderness at the Mc Burney’s point as before prior to surgery. Routine investigations like CBS, Urine, & stool could reveal nothing particular.  The Barium studies showed no significant findings.

These 82 cases were treated with antibiotics, oral administration of ampicilline, metronidazol or cephalosporine had temporary relief in 64 patients.  Re exploration was advised in 18 cases in view of severity, continuity of pain and tenderness over Mc Burney’s point without any benefit with above treatment.  Two cases of these eighteen were not interested in repeat surgery.

Bowel was prepared with oral metranidazol and cephalosporine, followed by mechanical cleansing assuming Rt. Hemicolectomy may be required.  16 patients were explored by right mid paramedian incision.

Results

All cases had a nodular thickening present in wall of the caecum with inflammation in 3 cases and in 13 cases without inflammation.  Adhesions were present at the site of invagination of stump of the appendix in 5 cases, in one case few drops of pus collection was present in the thickened nodule, in  one case hypertrophic  granuloma was present.

The partial excision of the caecum was done around nodule and sutured in two layers, with 2/0 chronic catgut on eyeless needle and 60 number linen.  Peritoneal cavity drained for 48 hours.  Average stay in the hospital was for 10 days.  These patients were followed up from 6 months to 3 years have not presented with pain or tenderness. Histology examination of 16 specimen indicated hyperplasia of inflamed lymphoid tissue in the remnant of stump of the appendix.  In addition four of these cases had foreign body giant cell granuloma and two of them had granuloma without  foreign body giant cells. One case did show chronic abscess in the caecal wall.

 

 

 

 

C O N C L U S I O N

It brings to conclusion that post appendicectomy pain is due to remnant of the appendix in all cases.  (12) In few cases foreign body giant cell granuloma due to non-absorbable suture was used earlier.  Post appendicectomy pain was rarely present in the cases who suffered with phlegmons, gangrene or perforated appendicitis is due to sloughing of the lymphoid tissue. (Table No.2) It is commonest in the group of acute appendicitis and catarrhal inflammation of the appendix in 74 cases out of 290 (25.5%)  (Table No.1)

The lymphoid tissue of the appendix and tonsil had similar reaction to infection.  The lymphoid tissue is present in follicular and diffuse form situated in the sub mucosal plane.  Once it is infected gets repeated attacks till it is removed.  Phlegmon and quinsy destroy the lymphoid tissue and auto ablation of tissue is done.  It has Wharthin’s giant cell reaction to measles infection in both tonsils as well as appendiceal lymphoid tissue. (13-14). Even small portion remaining after surgical removal can cause chronic grumbling pain and indicates its complete removal. The stump appendicitis is itself incomplete removal of the lymphoid tissue of the appendix and can cause similar pain even after appendicectomy.

One hundred cases of longitudinal section of the stump appendicectomy specimen suggest the cut edges were not free from follicular lymphoid tissue; which support above view.  The post appendicectomy pain can pose with difficult problem should be treated with care.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

R E F E R E N C E S

 

  1. Surg. Gyneol, obstef. 152 : 424 – 1981.  Achary cope A history of the acute abdomen London Oxford University Press 1965.
  2. Fitz : RH Perforating inflammation of the vermiform appendix with special reference to its early diagnosis and treatment.Trans. Assoc Am Physicians  1 : 107 : 1886.
  3. Mc. Burney C Experience with early operative interference in cases of disease of the vermiform appendix.N.Y. Med. J. 50 : 676 1889.
  4. Piper R. Kager L,  The incidence of acute appendicitis and  appendicectomy. Acta Chir Scand 1982  148 : 45 -49.
  5. H-arton LWL.  Pathogenesis of acute appendicitis.B r. Med. J – 1977 – 3 1672 – 1673.Bowers WF. Appendicitis with especial.
  6. Reference to pathogenesis, bacteriology and healing. Arch. Surg. 1939 : 39 : 362 – 422.
  7. Burkitt – DP, Appendicitis.  The aetiology of the appendicitis. B r. J. Surgery 1971 : 58 : 695 – 699.
  8. Berry J. Malt RA, Appendicitis near its centenary.Ann. Surg. 1984 : 220 : 567 – 575.
  9. Edward FH, Daview RS; use of the baye sign algorithm in the computer assisted diagnosis of the appendicitis.
  10. J.P. Bolton, ER Craven, RJ croft etal.  An assessment of the value of the white cell count in the management of suspected acute appendicitis.B r. J. Surg. : 1975 : 62 : 906 – 908.

 

  1. Bower R.J. Bell MJ etal Diagnostic value of white cell count and neutrophil percentage in the evaluation of the abdominal pain in children.

 

  1. Francis D. The grumbling appendix.Br. Med. J. 2 : 936 : 1979.

 

  1. Tobe T. Inapparent virus infection as trigger of appendicitis. Lancet    1965 : 1 : 1343.

 

  1. Gorden H, Knignton H.T.  Appendicitis in measles. An. J. Path 19.  An J. Path 1941 : 17 : 165.

 

 

 

 

 

 

 

 

Table No. 1 Incidence in relation to Age & Sex

Age

Male ( 52 )

Females ( 30 )

1--10

 

 

11--20

11

3

21--30

18

14

31--40

20

11

41 --50

2

2

51 --60

1

0

Total

52

30

 

 

 

 

 

 

 

 

Table No 2     Review of Histology of 468 cases

Lymphoid Hyperplasia Catarrhal appendicitis

49

114

Localised acute

appendisitis

25

176

Phlegmon

 

2

42

Perforation

 

4

38

Gangrene

 

 

16

Record not available

 

2

82

 

 

82

468

 

 

 

 

 

 

 

 

 

Table No.3 Histology study of 16 cases

1.Lymphoid Hyperplasia with granuloma

15

2.Forein body granulation to non absorbable sture material used for invagination of  appendix stump

4

3.Granuloma of Non healed stupm

2

4.Ascess

 

1