INTRAMURAL APPENDICITIS: A RARE ANATOMICAL LOCATION (CASE REPORT AND LITERATURE REVIEW)

INTRAMURAL APPENDICITIS: A RARE ANATOMICAL LOCATION (CASE REPORT AND LITERATURE REVIEW) DOI: https://doi.org/10.25040/ntsh2026.01.01Keywords: vermiform appendix, anatomical variations of appendix location, intramural appendicitis, endometriosisAbstract Acute appendicitis remains one of the most common urgent surgical diseases of the abdominal cavity. Atypical variants of vermiform appendix localization significantly complicate clinical diagnosis and may lead to diagnostic errors and inappropriate surgical intervention. Case report. A 33-year-old female patient was admitted to the emergency surgery department with complaints of right iliac pain lasting two days, abdominal bloating, nausea, and low-grade fever. Comorbid condition: chronic gastritis. In February 2025, she underwent laparoscopic myomectomy for multiple uterine fibroids. The abdomen was moderately tender in the right iliac region; peritoneal signs were equivocal. Complete blood count showed mild leukocytosis (9.80 × 10⁹/L) without a left shift. Diagnostic laparoscopy revealed that the vermiform appendix was not visualized; however, deformation of the cecal dome and a small amount of clear effusion in the right iliac region were observed. Conversion to open surgery was performed. The cecal dome was of normal color without adhesions. A dense elastic mass measuring 3 × 3 × 4 cm was palpated within its wall. After opening the serosal layer over the indurated area, the appendix was identified within the submucosal layer of the cecal dome. It lacked a serosal covering and had a dark cherry color. Histopathological examination revealed appendiceal endometriosis with signs of inflammation. The postoperative course was uneventful. Downloads References 1. GBD 2021 Appendicitis Collaborator Group. Trends and levels of the global, regional, and national burden of appendicitis between 1990 and 2021: findings from the Global Burden of Disease Study 2021. Lancet Gastroenterol Hepatol. 2024 Sep;9(9):825-858. https://doi.org/10.1016/S2468-1253(24)00157-2 2. Munasinghe BM, Karunatileke CT, Hewawasam GGC, Hewavitharane CG, Kuruppu K. A peculiar appendix: a case report. Int J Surg Case Rep. 2022 Oct;99:107726. https://doi.org/10.1016/j.ijscr.2022.107726 3. Constantin M, Petrescu L, Matanie C, Vrancianu CO, Niculescu AG, Andronic O, et al. The vermiform appendix and its pathologies. Cancers (Basel). 2023 Jul 29;15(15):3872. https://doi.org/10.3390/cancers15153872 4. Kacprzyk A, Droś J, Stefura T, Krzysztofik M, Jasińska K, Pędziwiatr M, et al. Variations and morphometric features of the vermiform appendix: a systematic review and meta-analysis of 114,080 subjects with clinical implications. Clin Anat. 2020 Jan;33(1):85-98. https://doi.org/10.1002/ca.23474 5. McGladdery WF. The intramural appendix. Cent Afr J Med. 1972;18(3):54-55 6. Abramson DJ. Vermiform appendix located within the cecal wall: anomalies and bizarre locations. Dis Colon Rectum. 1983 Jun;26(6):386-389. https://doi.org/10.1007/BF02553380 7. Rosenthal MD, Sarosi GS. Appendicitis (Ch. 120). In: Feldman M, Friedman LS, Brandt LJ, et al, eds. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease. 11th Ed. Elsevier; 2021:1983-1992 8. Chauhan S, Anand S. Intracecal appendix: an extremely rare anatomical variation. A case report and review of literature. Surg Radiol Anat. 2018 Jan;40(1):111-114. https://doi.org/10.1007/s00276-017-1890-3 9. Sakellariadis A, Sofou F, Chrysikos D, Sampsakos-Mariolis T, Schizas D, Troupis T, et al. Anatomical variations of the vermiform appendix. Acta Med Acad. 2024 Dec 20;53(3):335-342. https://doi.org/10.5644/ama2006-124.461 10. Cañizares Quisiguiña SI, Guamán Maldonado LV, Hidalgo Jaramillo IM, Borja Herrera TP, Carrión Guzmán CLÁ, et al. Incidental neuroendocrine tumor of a complete subserosal appendix: an unusual presentation of a rare anatomical variation. A case report and review of literature. BMC Surg. 2021;21:421. https://doi.org/10.1186/s12893-021-01429-3 11. von Rokitansky C. Ueber Uterusdrusen-Neubildung in Uterus and Ovarialsarcomen (Uterine gland proliferation in uterine and ovarian sarcomas). Zeitschrift Gesellschaft fur Aerzte zu Wien 1860;37:577-581. Available at https://iiif.wellcomecollection.org/pdf/b22326558. Accessed June 1, 2026 12. Allahqoli L, Mazidimoradi A, Momenimovahed Z, Günther V, Ackermann J, Salehiniya H, et al. Appendiceal endometriosis: a comprehensive review of the literature. Diagnostics (Basel). 2023 Jun 1;13(11):1827. https://doi.org/10.3390/diagnostics13111827