ELECTRONIC IMAGE OF THE MONTH Appendiceal Mucocele: A Diagnosis To Keep in Mind When Encountering a Retrovesical Lesion Q7
Nicole M. Grigg-Gutierrez,* Priscilla Magno,‡ and Doris H. Toro*
Q1
*Department of Gastroenterology, ‡Department of Endoscopy, Veterans Affairs Caribbean Healthcare System, San Juan, Puerto Rico
web 4C/FPO
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52
Q3 Q4
Q5
43-year-old Hispanic man with irritable bowel syndrome presented for evaluation of newonset colicky abdominal pain, a 20-pound weight loss, and worsening of alternating episodes of diarrhea and constipation. The abdominal examination was essentially normal. Stool examination and serologic tests for celiac disease were negative. A colonoscopy identified 2 small tubular adenomas that were removed by snare polypectomy. An abdominal and pelvic computerized tomography scan showed a 5.6 7.6 5.8 cm multiloculated mass in the retrovesical pouch with wall enhancement, peripheral calcifications, and internal septations (Figure A). Endoscopic ultrasound–guided fine-needle aspiration confirmed findings of a complex retrovesical mass that was not associated with the rectal or bladder wall (Figure B). Aspirate showed benign ductal epithelial cells with reactive atypia and mucoid material. Repeated abdominal computerized tomography scans showed a connection of the retrovesical mass to a thickened appendix tip wall, which was suggestive of an appendiceal mucocele (Figure C). The patient underwent an exploratory laparotomy, right hemicolectomy, and sigmoidectomy. The pathology report confirmed a ruptured mucocele secondary to mucinous cystadenoma of the appendix, and a confined pseudomyxoma in the sigmoid colon (Figure D). A mucocele of the appendix is a rare condition characterized by cystic dilation of the appendiceal lumen owing to obstruction and subsequent accumulation of mucus from an epithelial villous cystadenoma.1,2 The majority of mucoceles are retrocecal in origin; however,
A
location can vary according to the position and length of the appendix, which may include subcecal, anterior, or posterior ileocecal regions. The incidence is reported to be between 0.2% and 0.3%, with the highest rate of occurrence in females and patients older than 50 years of age.1 The most common symptoms include abdominal pain, changes in bowel habits, and weight loss.3 Diagnosis is performed by imaging studies showing an encapsulated cystic lesion with calcifications (seen in 50% of cases), or by colonoscopy showing a pathognomonic erythematous soft mass with central crater and mucus discharge.3 Treatment for a mucocele of the appendix includes conventional appendectomy and/or a right hemicolectomy (if bowel invasion occurs), which avoids iatrogenic rupture and pseudomyxoma peritonei. This case shows the importance of including an appendiceal mucocele in the broad differential diagnosis of a calcified retrovesical mass. Upon a literature review, there were only 2 case reports of a retrovesical mucocele4,5; both cases resulted in a diagnostic challenge. The uncharacteristic location of this mucocele, which initially masked the diagnosis, can be explained by the appendix being located at the ileocecal region or medial aspect of the cecum, favoring the growth of the distal portion of the mucocele toward a retrovesical position. A high level of suspicion and perseverance is required when evaluating intra-abdominal masses.
References 1.
Karakaya K, Barut F, Emre AU, et al. Appendiceal mucocele: case reports and review of current literature. World J Gastroenterol 2008;14:2280–2283.
Clinical Gastroenterology and Hepatology 2015;-:-–SCO 5.2.0 DTD YJCGH54097_proof 9 January 2015 6:30 pm ce DVC
Q6
53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104
ELECTRONIC IMAGE OF THE MONTH, continued 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160
2.
Rampone B, Roviello F, Marelli D, et al. Giant appendiceal mucocele: report of a case and brief review. World J Gastroenterol 2005;11:4761–4763.
3.
Goyal A, Goyal S, Bagree R, et al. Giant mucocele of the appendix as pelvic mass: a rare presentation. Indian J Surg 2009; 72(Suppl 1):347–348.
4.
Pereira Arias JG, Ibarluzea González JG, Gutiérrez Díez JM, et al. Unusual retrovesical cystic lesion: appendiceal mucocele. Arch Esp Urol 2002;55:560–564.
5.
Akhtar M, Basu S, Montogomery H, et al. Bladder outflow obstruction: an unusual presentation of mucocele of the appendix. Internet J Urol 2013;4:2.
Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2014.12.006
e2 SCO 5.2.0 DTD YJCGH54097_proof 9 January 2015 6:30 pm ce DVC
Q2
161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216
Nicole M. Grigg-Gutierrez,* Priscilla Magno,‡ and Doris H. Toro*
Q1
*Department of Gastroenterology, ‡Department of Endoscopy, Veterans Affairs Caribbean Healthcare System, San Juan, Puerto Rico
web 4C/FPO
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52
Q3 Q4
Q5
43-year-old Hispanic man with irritable bowel syndrome presented for evaluation of newonset colicky abdominal pain, a 20-pound weight loss, and worsening of alternating episodes of diarrhea and constipation. The abdominal examination was essentially normal. Stool examination and serologic tests for celiac disease were negative. A colonoscopy identified 2 small tubular adenomas that were removed by snare polypectomy. An abdominal and pelvic computerized tomography scan showed a 5.6 7.6 5.8 cm multiloculated mass in the retrovesical pouch with wall enhancement, peripheral calcifications, and internal septations (Figure A). Endoscopic ultrasound–guided fine-needle aspiration confirmed findings of a complex retrovesical mass that was not associated with the rectal or bladder wall (Figure B). Aspirate showed benign ductal epithelial cells with reactive atypia and mucoid material. Repeated abdominal computerized tomography scans showed a connection of the retrovesical mass to a thickened appendix tip wall, which was suggestive of an appendiceal mucocele (Figure C). The patient underwent an exploratory laparotomy, right hemicolectomy, and sigmoidectomy. The pathology report confirmed a ruptured mucocele secondary to mucinous cystadenoma of the appendix, and a confined pseudomyxoma in the sigmoid colon (Figure D). A mucocele of the appendix is a rare condition characterized by cystic dilation of the appendiceal lumen owing to obstruction and subsequent accumulation of mucus from an epithelial villous cystadenoma.1,2 The majority of mucoceles are retrocecal in origin; however,
A
location can vary according to the position and length of the appendix, which may include subcecal, anterior, or posterior ileocecal regions. The incidence is reported to be between 0.2% and 0.3%, with the highest rate of occurrence in females and patients older than 50 years of age.1 The most common symptoms include abdominal pain, changes in bowel habits, and weight loss.3 Diagnosis is performed by imaging studies showing an encapsulated cystic lesion with calcifications (seen in 50% of cases), or by colonoscopy showing a pathognomonic erythematous soft mass with central crater and mucus discharge.3 Treatment for a mucocele of the appendix includes conventional appendectomy and/or a right hemicolectomy (if bowel invasion occurs), which avoids iatrogenic rupture and pseudomyxoma peritonei. This case shows the importance of including an appendiceal mucocele in the broad differential diagnosis of a calcified retrovesical mass. Upon a literature review, there were only 2 case reports of a retrovesical mucocele4,5; both cases resulted in a diagnostic challenge. The uncharacteristic location of this mucocele, which initially masked the diagnosis, can be explained by the appendix being located at the ileocecal region or medial aspect of the cecum, favoring the growth of the distal portion of the mucocele toward a retrovesical position. A high level of suspicion and perseverance is required when evaluating intra-abdominal masses.
References 1.
Karakaya K, Barut F, Emre AU, et al. Appendiceal mucocele: case reports and review of current literature. World J Gastroenterol 2008;14:2280–2283.
Clinical Gastroenterology and Hepatology 2015;-:-–SCO 5.2.0 DTD YJCGH54097_proof 9 January 2015 6:30 pm ce DVC
Q6
53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104
ELECTRONIC IMAGE OF THE MONTH, continued 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160
2.
Rampone B, Roviello F, Marelli D, et al. Giant appendiceal mucocele: report of a case and brief review. World J Gastroenterol 2005;11:4761–4763.
3.
Goyal A, Goyal S, Bagree R, et al. Giant mucocele of the appendix as pelvic mass: a rare presentation. Indian J Surg 2009; 72(Suppl 1):347–348.
4.
Pereira Arias JG, Ibarluzea González JG, Gutiérrez Díez JM, et al. Unusual retrovesical cystic lesion: appendiceal mucocele. Arch Esp Urol 2002;55:560–564.
5.
Akhtar M, Basu S, Montogomery H, et al. Bladder outflow obstruction: an unusual presentation of mucocele of the appendix. Internet J Urol 2013;4:2.
Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2014.12.006
e2 SCO 5.2.0 DTD YJCGH54097_proof 9 January 2015 6:30 pm ce DVC
Q2
161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216
