{"paper_id":"eebe3b8f-9bb7-4438-833f-ed63dfee0dea","body_text":"General surgery\nLetter to the Editor\nCorresponding author:\nBartu Badak\nDepartment of Surgery\nEskisehir Osmangazi \nUniversity\n26000 Eskisehir, Turkey\nPhone: +90 506672530 3\nE-mail: drbartu@gmail.com\nDepartment of Surgery, Eskisehir Osmangazi University, Eskisehir, Turkey\nSubmitted: 5 February 2018\nAccepted: 22 March 2018\nArch Med Sci Civil Dis 2018; 3: e70–e72\nDOI: https://doi.org/10.5114/amscd.2018.77325\nCopyright © 2018 Termedia & Banach \nAppendiceal endometriosis: an unusual cause of acute \nappendicitis\nBartu Badak\nAppendectomy is the most commonly performed abdominal surgical \nprocedure worldwide [1]. Appendectomy specimens undergoing histo-\npathological examination show various pathologies that cause acute ap-\npendicitis. On the other hand, endometriosis is defined as the presence \nof functioning endometrial tissue outside the uterine cavity. It affects \nnearly 5–50% of reproductive-age women and may cause abdominal \npain and infertility in 50% of these patients [2]. Endometriosis is most \ncommonly seen in gynecologic organs and the pelvic peritoneum. How-\never, endometriosis of the appendix causing acute appendicitis is a very \nrare condition. In this study we describe such a case.\nA 42-year-old female patient was admitted to our hospital with a one-\nday history of abdominal pain and vomiting. Her medical history was nor-\nmal. Physical examination revealed right lower quadrant tenderness. In \nlaboratory tests the white blood cell count was 10 200/mm³. On abdomi-\nnal ultrasound, appendix tissue could not be visualized clearly due to the \npatient’s abdominal fat tissue. To reveal the etiology abdominal com-\nputed tomography (CT) was performed. Computed tomography showed \na bowel segment 12 mm in diameter at the right lower abdominal quad-\nrant (Figures 1 A, B). A diagnosis of acute appendicitis was made clini-\ncally and the patient underwent laparoscopic appendectomy (Figure 2).  \nThe histopathological examination showed appendiceal endometriosis \n7 days after the operation (Figure 3). The patient’s postoperative course \nwas uneventful. \nAppendectomy is the most commonly performed abdominal surgery \nworldwide [1]. The most common symptoms of acute appendicitis are \nabdominal pain, vomiting and rectal bleeding [3]. Gastrointestinal en-\ndometriosis represents nearly 3–37% of all endometriosis cases, but \nappendiceal endometriosis involves about 3% of gastrointestinal endo-\nmetriosis and nearly 1% of all endometriosis cases [4]. Obstruction of \nthe appendiceal lumen seems to be the responsible pathology that caus-\nes appendiceal infection [4]. The treatment of acute appendicitis is to \nperform an appendectomy procedure. Some institutions, including ours, \nsend an appendectomy specimen for histopathological examination. The \nmost common results in these examinations include appendiceal inflam-\nmation, mucinous neoplasms, adenocarcinomas, tuberculosis, Enterobius \nvermicularis, polyps and diverticulitis [5].\nThe term endometriosis means the presence of functioning endo-\nmetrial glands and stroma outside the uterine cavity. External endo-\nmetriosis is generally found in genital organs and pelvic peritoneum. \nEndometriosis may also involve the gastrointestinal system, omentum, \n\nAppendiceal endometriosis: an unusual cause of acute appendicitis\nArch Med Sci Civil Dis 2018 e71\nsurgical scars and mesentery, but it is rarely found \nin distant organs such as kidneys, lungs, or skin. \nThe most common areas are the ovaries (65%), \nuterine ligaments (30–60%), cul-de-sac (20–30%), \ngastrointestinal tract (3–37%), ureters (1–2%), \nbladder and scar tissue [6]. Similarly to acute ap-\npendicitis, the most common symptoms of endo-\nmetriosis are pelvic pain and vomiting. In our pa-\ntient the symptoms on admission to hospital were \nabdominal pain and vomiting. \nAppendiceal endometriosis is a  very rare pa-\nthology and was first described in 1860 by Von \nRokitansky [7]. Ultrasonography and computed \ntomography can be performed to confirm this rela-\ntionship with appendix and endometriosis tissues, \nbut no gold standard radiological method can be \nused for this diagnosis [8]. Laboratory parameters \nsuch as leukocytes and C-reactive protein can be \ndetermined, but like radiological methods there is \nno gold standard or specific parameter for diagno-\nsis. The treatment includes surgery primarily [9]. In \nour case we performed abdominal ultrasonogra-\nphy and tomography to confirm the diagnosis of \nacute appendicitis due to the patient’s right lower \nquadrant pain before surgery. After confirming ap-\npendiceal inflammation in computed tomography \nwe performed laparoscopic appendectomy. In ex-\nploration endometriosis was not suspected on the \nmacroscopic appearance, but the histopathological \nexamination of the appendix specimen confirmed \nappendiceal endometriosis.\nIn conclusion, although appendiceal endome-\ntriosis is a  rare entity, it should be considered \nin female reproductive patients with right lower \nquadrant pain and vomiting. Surgery is still the \nprimary treatment method of appendiceal endo-\nmetriosis.\nConflict of interest\nThe author declares no conflict of interest.\nFigure 1. Preoperative abdominal tomography\nA B\nFigure 2. Appendectomy specimen Figure 3. Histopathological examination\n\nBartu Badak\ne72 Arch Med Sci Civil Dis 2018\nReferences\n1. Addiss DG, Shaffer N, Fowler BS, Tauxe RV . The epidemi-\nology of appendicitis and appendectomy in the United \nStates. Am J Epidemiol 1990; 132: 910-25.\n2. Akbulut S, Dursun P , Kocbiyik A, Harman A, Sevmis S. \nAppendiceal endometriosis presenting as perforated \nappendicitis: report of a case and review of the litera-\nture. Arch Gynecol Obstet 2009; 280: 495-7.\n3. Chaar C, Wexelman B, Zuckerman K, Longo W. Intussep-\ntion of the appendix: comprehensive review of the liter-\nature. Am J Surg 2009; 198: 122-8.\n4. Akbulut S, Tas M, Sogutcu N, et al. Unusual histopatho-\nlogical findings in appendectomy specimens: a  retro-\nspective analysis and literature review. World J Gastro-\nenterol 2011; 17: 1961-70.\n5. Igawa HH, Ohura T, Sugihara T, Hosokawa M, Kawamu-\nra K, Kaneko Y. Umblical endometriosis. Ann Plast Surg \n1992; 29: 266-8.\n6. Gon S, Barui GN, Majumbar B, Baig SJ. Endometriosis of \nthe appendix: a diagnostic dilemma. Indian J Surg 2010; \n72: 315.\n7. Khoo JJ, Ismail MS, Tiu CC. Endometriosis of the appen-\ndix presenting as acute appendicitis. Singapore Med J \n2004; 45: 435-6.\n8. Bazot M, Darai E, Houraniet R, et al. Deep pelvic endo-\nmetriosis: MR imaging for diagnosis and prediction of \nextension of disease. Radiology 2004; 232: 379-89.\n9. Douglas C, Rotimi O. Extragenital endometriosis: a clini-\ncopathological review of a  Glasgow hospital experience \nwith case illustrations. J Obstet Gynaecol 2004; 24: 804-8.","source_license":"CC0","license_restricted":false}