Digestive Endoscopy 2014; 26: 603–609
Letters, Techniques and Images Submucosal tumor-like appendiceal intussusception as a result of fecalith A 73-year-old man was referred to Kitaibaraki Municipal General Hospital because of abdominal pain. Colonoscopy revealed a 20-mm submucosal tumor-like lesion in the cecum with a 3-mm central dimple-like appendiceal orifice (Fig. 1a,b). When pushed by biopsy forceps, the lesion was found to have a hard consistency. Contrast-enhanced computed tomography was done and a 23 × 20-mm mass in the cecum was found. The mass presented with internal heterogeneous mixed attenuation and there seemed to be calcification (Fig. 1c,d). Appendiceal intussusception as a result of fecalith was suspected; however, submucosal tumor such as leiomyoma or gastrointestinal stromal tumor could not be excluded. At the patient’s strong request, a laparoscopic operation was performed. After holding the appendix, the intussusception was easily removed, and laparoscopic appendectomy with partial cecal resection was carried out. The postoperative course was uneventful. The pathological diagnosis was fecalith in the appendix (Fig. 2a). Appendiceal intussusception is a rare condition with an incidence of 0.01% of surgically removed appendices.1 The mechanism of appendiceal intussusception is thought to be
Figure 2 (a) Macroscopic findings of the resected appendix, which contained the fecalith in the lumen. (b) Schematic figure of type III appendiceal intussusception. The invagination starts at the junction of the appendix and cecum.
abnormal peristalsis caused by local irritation, including irritation by a fecalith, foreign body, mucocele, endometriosis, or neoplasm.2 The classification of appendiceal intussusception is based on which part of the appendix is the intussusceptum and where the intussusception is located.3 Our case was classified as type III (Fig. 2b). In this type, biopsy or endoscopic resection may provoke preforation.2,4 Concerning the balance between surgical stress and the curative potential of resection in the case of malignancy, laparoscopic appendectomy with partial cecal resection is the best choice. We report an extremely rare case of submucosal tumorlike appendiceal intussusception as a result of a fecalith. Careful endoscopic examination identifying the appendiceal orifice is required in the case of cecal submucosal tumor. Authors declare no conflict of interests for this article. Yoshiyuki Meguro,1 Ayaki Koide1 and Takafumi Tabuchi2 1 Department of Surgery, Kitaibaraki Municipal General Hospital, Kitaibaraki and 2Fourth Department of Surgery, Tokyo Medical University, Ami, Japan doi: 10.1111/den.12297
REFERENCES
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Figure 1 (a) Colonoscopy showing 20-mm submucosal tumorlike lesion in the cecum. (b) There is a 3-mm central dimple-like appendiceal orifice at the top of the polypoid lesion. (c,d) Contrast-enhanced computed tomography showing a 23 × 20-mm mass in the cecum (arrows). The appendix is indicated by arrowheads. (c: coronal, d: sagittal.)
1 Collins DC. Seventy-one thousand human appendix specimens: A final report, summarizing forty years of study. Am. J. Proctol. 1963; 14: 265–81. 2 Lee CK, Lee SH, Park JY et al. Appendiceal intussusception due to a fecalith mimicking a submucosal tumor. Endoscopy 2009; 41 (Suppl 2): E25–6. 3 Chaar CI, Wexelman B, Zuckerman K et al. Intussusception of the appendix: Comprehensive review of the literature. Am. J. Surg. 2009; 198: 122–8. 4 Seddik H, Rabhi M. Two cases of appendiceal intussusception: A rare diagnostic pitfall in colonoscopy. Diagn. Ther. Endosc. Published online: 12 Apr 2011; DOI: 10.1155/2011/198984
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
603
Letters, Techniques and Images Submucosal tumor-like appendiceal intussusception as a result of fecalith A 73-year-old man was referred to Kitaibaraki Municipal General Hospital because of abdominal pain. Colonoscopy revealed a 20-mm submucosal tumor-like lesion in the cecum with a 3-mm central dimple-like appendiceal orifice (Fig. 1a,b). When pushed by biopsy forceps, the lesion was found to have a hard consistency. Contrast-enhanced computed tomography was done and a 23 × 20-mm mass in the cecum was found. The mass presented with internal heterogeneous mixed attenuation and there seemed to be calcification (Fig. 1c,d). Appendiceal intussusception as a result of fecalith was suspected; however, submucosal tumor such as leiomyoma or gastrointestinal stromal tumor could not be excluded. At the patient’s strong request, a laparoscopic operation was performed. After holding the appendix, the intussusception was easily removed, and laparoscopic appendectomy with partial cecal resection was carried out. The postoperative course was uneventful. The pathological diagnosis was fecalith in the appendix (Fig. 2a). Appendiceal intussusception is a rare condition with an incidence of 0.01% of surgically removed appendices.1 The mechanism of appendiceal intussusception is thought to be
Figure 2 (a) Macroscopic findings of the resected appendix, which contained the fecalith in the lumen. (b) Schematic figure of type III appendiceal intussusception. The invagination starts at the junction of the appendix and cecum.
abnormal peristalsis caused by local irritation, including irritation by a fecalith, foreign body, mucocele, endometriosis, or neoplasm.2 The classification of appendiceal intussusception is based on which part of the appendix is the intussusceptum and where the intussusception is located.3 Our case was classified as type III (Fig. 2b). In this type, biopsy or endoscopic resection may provoke preforation.2,4 Concerning the balance between surgical stress and the curative potential of resection in the case of malignancy, laparoscopic appendectomy with partial cecal resection is the best choice. We report an extremely rare case of submucosal tumorlike appendiceal intussusception as a result of a fecalith. Careful endoscopic examination identifying the appendiceal orifice is required in the case of cecal submucosal tumor. Authors declare no conflict of interests for this article. Yoshiyuki Meguro,1 Ayaki Koide1 and Takafumi Tabuchi2 1 Department of Surgery, Kitaibaraki Municipal General Hospital, Kitaibaraki and 2Fourth Department of Surgery, Tokyo Medical University, Ami, Japan doi: 10.1111/den.12297
REFERENCES
bs_bs_banner
Figure 1 (a) Colonoscopy showing 20-mm submucosal tumorlike lesion in the cecum. (b) There is a 3-mm central dimple-like appendiceal orifice at the top of the polypoid lesion. (c,d) Contrast-enhanced computed tomography showing a 23 × 20-mm mass in the cecum (arrows). The appendix is indicated by arrowheads. (c: coronal, d: sagittal.)
1 Collins DC. Seventy-one thousand human appendix specimens: A final report, summarizing forty years of study. Am. J. Proctol. 1963; 14: 265–81. 2 Lee CK, Lee SH, Park JY et al. Appendiceal intussusception due to a fecalith mimicking a submucosal tumor. Endoscopy 2009; 41 (Suppl 2): E25–6. 3 Chaar CI, Wexelman B, Zuckerman K et al. Intussusception of the appendix: Comprehensive review of the literature. Am. J. Surg. 2009; 198: 122–8. 4 Seddik H, Rabhi M. Two cases of appendiceal intussusception: A rare diagnostic pitfall in colonoscopy. Diagn. Ther. Endosc. Published online: 12 Apr 2011; DOI: 10.1155/2011/198984
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
603
