Caecal Appendiceal Intussusception Caused by Endometriosis: A Case Presentation of Laparoscopic Management

Appendiceal intussusception is an extremely rare condition ranging from partial invagination of the appendix to involvement of the entire colon. It may be due to intraluminal foreign bodies, lymphoid hyperplasia, polyps, neoplasia, or endometriosis. Endometriosis is an extremely rare cause of appendiceal intussusception. Patients usually present with symptoms of acute appendicitis. In the case presented here, appendiceal invagination was detected in laparoscopic exploration during surgery for suspected acute appendicitis and was treated laparoscopically.

Appendiceal intussusception is an extremely rare condition ranging from partial invagination of the appendix to involvement of the entire colon. Intussusception of the appendix may occur due to intraluminal foreign bodies or the formation of masses such as lymphoid hyperplasia, polyps, neoplasias, and endometriosis.1 Endometriosis is an extremely rare cause of appendiceal intussusception, with very few cases reported in the literature to date.2 Appendiceal endometriosis is known to cause not only acute and chronic symptoms of appendicitis,3 but also cyclic and chronic right lower quadrant pain,4 melena,5 and intestinal perforation.

The symptoms of endometriosis vary according to the organ it affects.6 Because it can occur in nearly every part of the gastrointestinal system, it has a broad spectrum of symptoms.7 Endometriosis of the appendix can manifest with a variety of symptoms. Patients can present with clinical signs of acute appendicitis,8 appendiceal intussusception,6 or chronic abdominal pain, nausea, and melena.9 Some patients may be asymptomatic.10 Although our patient’s history was unremarkable, she presented with sudden onset abdominal pain and clinical picture of acute appendicitis. Appendiceal intussusception may occur due to intraluminal foreign bodies or mass formations such as lymphoid hyperplasia, polyps, neoplasias, and endometriosis.1 Our patient was diagnosed postoperatively with endometriosis from pathology specimens. Appendiceal intussusception can be diagnosed on ultrasonography as a classic target sign.11 On computed tomography it typically appears as a mass within the cecum or as a target sign.2 In our case, ultrasound revealed intussusception of about 2 cm of the appendix into the cecum, and the patient was diagnosed with acute appendicitis associated with intussusception. Preoperative diagnosis of appendiceal endometriosis is difficult. It is diagnosed pathologically. Microscopy shows glandular tissue and endometrial stroma with hemorrhage.1 Our patient was also diagnosed by pathological examination in which typical endometrial tissue was observed in microscopy, and immunohistochemical examination revealed positive reactions for estrogen receptors and progesterone receptors in stroma and epithelial cells as well as positive CD10 reaction in stroma cells. According to some publications, appendectomy with cecal cuff resection is recommended for appendiceal intussusception. The appendix stump can undergo intussusception again or cause leaks after appendectomy; therefore, cecal cuff resection is proposed to ensure the appendix stump is removed.12 We also performed a cecal cuff linear resection when managing our patient due to the appendiceal intussusception.