{"paper_id":"bb16eaa7-22d2-47db-9040-3340dd2e4266","body_text":"246 Copyright © 2021 The Korean Society of Emergency Medicine\nStrangulated appendiceal \nintussusception caused by isolated \nendometriosis\nSeokyoun Lee1, Junhee Lee2, Keunyoung Kim3\n1 Department of Surgery, Wonkwang University Sanbon Hospital, Wonkwang University School of Medicine, \nGunpo, Korea\n2 Department of Emergency Medicine, Wonkwang University Sanbon Hospital, Wonkwang University School \nof Medicine, Gunpo, Korea\n3 Department of Surgery, Wonkwang University Hospital, Wonkwang University School of Medicine, Iksan, \nKorea\nClin Exp Emerg Med 2021;8(3):246-248\nhttps://doi.org/10.15441/ceem.20.026\neISSN: 2383-4625\nImage\nReceived: 16 March 2020\nRevised: 18 May 2020\nAccepted: 16 June 2020\nCorrespondence to: Seokyoun Lee\nDepartment of Surgery, Wonkwang \nUniversity Sanbon Hospital, Wonkwang \nUniversity School of Medicine, 321 \nSanbon-ro, Gunpo 15865, Korea\nE-mail: necuri@wku.ac.kr\nORCID \nhttps://orcid.org/0000-0001-7245-8449\nLee S, Lee J, Kim K. Strangulated \nappendiceal intussusception caused by \nisolated endometriosis. Clin Exp Emerg Med \n2021;8(3):246-248. https://doi.\norg/10.15441/ceem.20.026\nThis is an Open Access article distributed \nunder the terms of the Creative Commons \nAttribution Non-Commercial License (https://\ncreativecommons.org/licenses/by-nc/4.0/).\nWhat is already known\nAppendiceal endometriosis can present strangulated intussusception.\nWhat is new in the current study\nAppendiceal intussusception secondary to endometriosis should be considered \nin the differential diagnosis when female patients of reproductive age present \nwith clinical symptoms of acute appendicitis.\nA 33-year-old female was admitted to our emergency department for right lower quadrant ab-\ndominal pain, which was not associated with her menstrual cycle, and nausea, which had per-\nsisted for 3 days. She denied any prior history of abdominal pain, dysmenorrhea, menorrhagia, or \ndyspareunia. The patient had no family history of endometriosis. Abdominal computed tomogra-\nphy revealed appendiceal intussusception (AI) and invagination of the periappendiceal fat into \nthe cecum (Fig. 1). She underwent laparoscopic partial cecectomy with the presumed diagnosis \nof AI (Fig. 2). The ovaries and fallopian tubes were normal, with no endometrial spot. The invert-\ned appendix was completely necrotic (Fig. 3). Final surgical pathology was positive for gangre-\nnous intussusception of the appendix, with endometrial deposits (Fig. 4). \nAdult colonic intussusception is caused by either malignant tumors (64%–87% cases) or be-\nnign tumors (29%–33%). The most common causes are adenocarcinomas and lymphomas among \nmalignant tumors and lipomas, leiomyomas, adenomatous polyps, and endometriosis among be-\nnign tumors.1 AI is extremely rare, with reported rates of 0.01% in patients who undergo appen-\ndectomy.2 AI secondary to endometriosis is also extremely rare, with less than 30 cases reported. \nHowever, those cases involved endometriosis on other organs and the appendix. Only three cases \ninvolving isolated appendiceal endometriosis are reported in the literatures.3 Patients with AI can \nrange from being asymptomatic to presenting symptoms mimicking acute appendicitis.4 Preop-\nerative diagnosis is difficult owing to its rarity. Although endometriosis is reported to be the lead \npoint of AI, there are limited descriptions on imaging findings. Computed tomography findings \ninclude an enlarged appendix with an inverted appendiceal tip or a tumor protruding into the \n\n\n247Clin Exp Emerg Med 2021;8(3):246-248\nSeokyoun Lee, et al.\ncecum.5 This case highlights that isolated endometriosis without \ninvolvement of reproductive organs can present as a strangulated \nAI. AI secondary to endometriosis should be considered in the dif-\nferential diagnosis when female patients of childbearing age \npresent with clinical symptoms of acute appendicitis and radio-\nlogic findings of intussusception, even before obtaining a patho-\nlogical result. \nCONFLICT OF INTEREST\nNo potential conflict of interest relevant to this article was re-\nported.\nACKNOWLEDGMENTS\nThis paper was supported by Wonkwang University in 2020.\n \nREFERENCES\n1. Lee SY, Park WC, Lee JK, Kang DB, Kim Y, Yun KJ. Laparoscopic \ntreatment of adult sigmoidorectal intussusception caused by \na mucinous adenocarcinoma of the sigmoid colon: a case re-\nport. J Korean Soc Coloproctol 2011;27:44-9.\n2. Collins DC. 71,000 Human appendix specimens. a final report, \nsummarizing forty years’ study. Am J Proctol 1963;14:265-81.\nFig. 1. The abdominal computed tomography. (A) Axial view and (B) \ncoronal view. These images show a low-density tubular structure (5×1.6 \ncm in diameter) in the cecum near the appendiceal orifice, and focal in-\nvagination of the peri-appendiceal fat to the cecum (white arrow). \nA B\nFig. 3. Surgical specimen. Appearance of the specimen resected by lap-\naroscopic partial cecectomy. The inverted appendix (70×15 mm in size) \nis completely necrotic at the appendiceal orifice (inside the aspect of \nthe cecum denoted by a white arrow).\nFig. 4. High-power view of endometriosis within the appendix. Endome-\ntrial glands and stroma within the muscular layer, around the appendicu-\nlar mucosa (hematoxylin and eosin, × 200).\nFig. 2. Surgical findings. During laparoscopic exploration, the appendix \nwas not macroscopically visible in the right iliac fossa, but it was locat-\ned in the cecum (white arrow), which showed no possibility for reduc-\ntion (black arrow). Terminal ileum denoted by asterisk.\n\n248 www.ceemjournal.org \nStrangulated appendiceal intussusception\n3. Manoharan B, Haider AS, Samira AM, Bharathan B, Parra-\nBlanco A. Isolated appendiceal endometriosis resulting in in-\ntussusception. Oxf Med Case Reports 2018;10:349-52.\n4. Salehzadeh A, Scala A, Simson JN. Appendiceal intussuscep-\ntion mistaken for a polyp at colonoscopy: case report and re-\nview of literature. Ann R Coll Surg Engl 2010;92:W46-8.\n5. Hanly AM, Ryan EM, McNamara DA. Appendiceal intussuscep-\ntion and endometriosis mimicking colorectal cancer. Colorectal \nDis 2011;13:225-6.","source_license":"CC0","license_restricted":false}