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Objectives: The appendix, although considered a vestigial organ, is of considerable clinical importance because acute appendicitis is a common medical problem. There are also other disease processes involving the appendix. The appendix is among the first specimens that the pathologist (and surgeon) cuts one's teeth on. Thus, there may be a tendency to underestimate the clinically and prognostically significant appendiceal pathologies., Methods: We provide a vade mecum of the pathologic features of a wide range of nonneoplastic appendiceal pathologies, with an emphasis on developing a practical approach to grossing, microscopy, and reporting-all with clinical and therapeutic implications. Much of this is based on literature on MEDLINE with reference to years 2008 to 2023, as well as on personal experiences and interpretations., Results: The appendix can harbor a myriad of nonneoplastic pathologies, including infections, inflammations of varying etiologies (including interval appendectomy), endometriosis, diverticulosis, and so on. Chronic appendicitis, Crohn disease, and clinical audit are recurring themes while COVID-19 is a new entity., Conclusions: Most importantly, all pathologists should appreciate that the appendix is not as "routine" a specimen as one would want to believe., (© The Author(s) 2024. Published by Oxford University Press on behalf of American Society for Clinical Pathology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Introduction: Mucocoele of the appendix occurs in 0.2-0.7% of people in the world without any well-defined clinical symptoms. It occurs when there is an accumulation of mucous in the lumen of the appendix., Case Presentation: We present three cases: a 48-year-old male admitted to the emergency room with a one-day history of right iliac fossa pain. Abdominal examination was suggestive of acute appendicitis. The initial abdominal computerised tomography scan was reported as being unremarkable. At surgery, a firm tumour of the appendix was found, and a limited right hemicolectomy was done. Histopathology confirmed a mucocoele of the appendix with borderline mucinous histology.The second case is a 63-year-old man who presented with a one-year history of abdominal distension and weight loss. Previous abdominal ultrasound was suggestive of liver cirrhosis with significant ascitic fluid. Abdominal magnetic resonance imaging found an appendix mucocoele with infiltration of the omentum and scalloping of the liver surface suggestive of pseudomyxoma peritonei. A percutaneous biopsy of the omental mass confirmed metastatic mucinous adenocarcinoma of the appendix.The third case is a 68-year-old man who, during an annual medical check-up, had an incidental finding of a cystic right iliac fossa mass on ultrasound, confirmed on abdominopelvic computerised tomography scan to be an appendix mucocele. He had laparoscopic appendicectomy. The histopathological diagnosis confirmed a mucinous cystadenoma of the appendix., Conclusion: Preoperative diagnosis of appendiceal mucocoele is difficult and commonly discovered intraoperatively. The prognosis is good for the histologically benign type, but it is poor when malignant or peritoneal lesions are present., Funding: None declared., Competing Interests: Conflict of interest: None declared, (Copyright © The Author(s).)

Endoscopic finding of invaginated appendiceal stump mimicking polyp is very rare. We present a case of patient with appendiceal stump mimicking cecal polyp covered with dysplastic mucosa which makes it even more rare. Polypoid lesions involving the appendiceal area represent a specific diagnostic-therapeutic dilemma. In these situations simple colonoscopic polypectomy poses increased risk for perforation. In our case biopsy of the polypoid cecal lesion revealed dysplastic mucosa. Due to the non-lifting sign and increased risk of perforation from simple polypectomy, polyp was removed by cecal wedge resection using combined endoscopic laparoscopic approach. Histopathology of the specimen confirmed medium dysplastic epithelium covering lymphoid follicles specific for appendix. In our case, decision on the need to remove the polyp, based on biopsy histology, was quite clear; however, the question is what should we have done if the biopsy finding was negative? In such a situation, conservative approach with endoscopic follow-up of the polyp and regular biopsy specimen analysis, or a more active approach of polyp removal should be considered. This issue can be discussed, however, we do believe that decision on approaching such patients should be made individually, based on the patient's age, comorbidities, general condition and operative risk.

According to the literature, serrated lesions and polyps of the appendix are extremely rare in children or teenagers. Herein, we present the pathologic and molecular features of a sessile serrated lesion (SSL) that was incidentally found in the appendix of a teenage girl. Our findings not only illustrate that appendiceal SSL may occur in young patients such as teenagers but also confirm further that BRAF V600E mutation may be found in a subset of these neoplastic lesions.

Background: Tetratrichomonas gallinarum is parasitic protozoa with a wide host range. However, its lethal infection is rare reported., Case Presentation: Here, we described the first lethal cases of T. gallinarum infection in black swans in China. Five black swans died within a week in succession without obvious symptoms except mild diarrhea. At necropsy, severe lesions were observed in caeca with thickened caecal walls and hemorrhages in the mucosa. A large number of moving trophozoites were found in the contents of the cecum by microscopic examination. The livers were enlarged with multiple bleeding spots on the surface. Histopathology of the livers showed mononuclear cell infiltration and moderate hyperplasia of fibrous tissue. The histopathology of the cecum showed that the villi of the cecum were edematous. Finally, the presence of T. gallinarum was determined by specific PCR andin-situ hybridization assay. Additionally, common pathogens that can cause similar symptoms were excluded., Conclusions: The death of the black swan was caused by T. gallinarum, suggesting that the parasite might be a new threat to the Cygnus birds.

Mucocele of the appendix is the accumulation of mucoid material in the appendiceal lumen. Although the terminology is imprecise, as it does not differentiate between the benign and malignant nature of the condition, preoperative recognition is imperative as spillage of the mucus during surgical handling can result in grave complications like pseudomyxoma peritonei. Mucocele developing in a stump of the appendix, i.e., a remnant of appendiceal tissue after surgical removal of an inflamed organ, is an extremely uncommon phenomenon, as not many cases are reported in the literature. In this review, all cases reported in English literature are discussed., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2021 Syed Muhammad Ali et al.)

Objectives: To determine the prevalence of appendiceal histopathology in patients with confirmed endometriosis following minimally invasive surgery (MIS) for endometriosis. To determine whether pre-operative symptoms, age, intra-operative appendiceal appearance, or endometrioma laterality were associated with appendix histopathology in patients with suspected endometriosis., Methods: One hundred thirty-five patients ages 16-52 with suspected endometriosis undergoing MIS for endometriosis with concomitant appendectomy at two metropolitan academic hospitals from January 1, 2012 to June 30, 2017 were included in this retrospective chart-review study. Medical records were reviewed for pre-operative symptoms, age, intraoperative appendix appearance, appendix histopathology, histopathologically-confirmed endometriosis, and endometriomas., Results: In patients with confirmed endometriosis, the prevalence of all appendiceal histopathology was 25%, which included appendiceal endometriosis (18%), appendiceal tumors (2%), and inflammation (5%). Dyspareunia was the only pre-operative symptom significantly associated with appendiceal histopathology (p = 0.04). The presence of a right endometrioma was associated with appendiceal histopathology (p = 0.009). Additionally, appendiceal histopathology was not significantly associated with age nor intra-operative appendiceal characteristics., Conclusion: This manuscript adds to the limited pool of studies regarding appendiceal histopathology and appendiceal tumors in patients with suspected and confirmed endometriosis. On the basis of the high rate of histopathological appendices found in this population; the lack of association with possible diagnostic factors such as age, most pre-operative symptoms, and intra-operative appendiceal characteristics; and the relatively low risks of concomitant appendectomy, we suggest that surgeons consider concomitant appendectomies at the time of MIS for endometriosis., (© 2021 by SLS, Society of Laparoscopic & Robotic Surgeons.)

Introduction: The differential diagnosis of caecal mass is broad and the inclusion of appendiceal pathologies is an important element., Case Report: We report a 37-year-old woman with recurrent right iliac fossa pain. Computed tomography scan revealed a caecal mass suggesting complete inversion or intussusception of the appendix, which was confirmed by pathologic microscopic examination. This case report discusses appendiceal intussusception with emphasis on diagnosis and treatment options., Discussion: Appendiceal intussusception is a rare entity and the complete type typically presents as a polypoid lesion located at the appendiceal orifice in the caecum. It is imperative to include this entity in the differential diagnosis of caecal mass, especially during colonoscopy, as the removal of this polypoid lesion can result in a devastating caecal perforation or haemorrhage.

Introduction: Appendicitis is the most common surgical emergency. Most commonly it is a result of luminal occlusion that leads to ischaemia and eventually to perforation with resultant localised or diffuse peritonitis. Unusual causes have been documented including viral infections, parasites, tuberculosis and neoplasms. These conditions are important to recognise, as they may need additional specific management. This study endeavours to identify the incidence and type of unusual histopathology of appendicitis., Method: A retrospective review of histopathological reports of appendix specimens obtained during appendectomies done between January 2012 and December 2014 in the three academic hospitals of Johannesburg - Chris Hani Baragwanath Academic Hospital (CHBAH), Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), and Helen Joseph Hospital (HJH). All specimens were examined by pathologists of the National Health Laboratory Services (NHLS)., Results: A total of 2 408 histopathology results were obtained from the NHLS. 164 specimens were excluded because they were part of colonic resection for unrelated conditions. Of the 2 244 specimens included, 8.1% were normal, 52.7% showed acute appendicitis and 30.1% showed complicated appendicitis. Unusual pathology comprised 5.3% (119/2 244). The median age of all patients was 25.6 years (0-88yrs) and the gender distribution was 61.9% males and 38.1% females. The most common unusual causes were parasites (37%), mainly schistosomiasis (24.3%), followed by neoplasm (20%) and fibrous obliteration (14.2%)., Conclusion: All appendectomy specimens must be submitted to the pathologist for histological diagnosis. It is important that the result be checked before the patient is discharged as further specific treatment may be indicated., (Copyright© Authors.)

Myxoglobulosis is a particular, rare, form of appendicular mucocele, characterized by the presence of numerous, occasionally calcified, globules that are grouped together like grapes, and look like pearls or fish eggs, in the appendicular lumen. The diagnosis of myxoglobulosis is most often fortuitous, but sometimes, can be made in the face of acute appendicitis or another setting of abdominal pain. Imaging (sonography or computerized tomography (CT)) is highly suggestive when it shows a cystic, encapsulated, oblong, well-delineated mass, containing (heterogeneous, liquid, and viscous) mucus with calcified globules. In contrast to acute appendicitis, the wall of the appendix is thin (<6mm) and there is no peri-appendicular inflammation. Long-term complications are similar to other appendicular mucoceles, including invagination, bleeding, perforation, peritonitis and peritoneal pseudomyxoma., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

The aim of this study was to investigate the relationship between the appendiceal diameter (AD) and age, sex, height, and body weight in children and to verify how does the normal AD grows in childhood. We evaluated the AD of patients younger than 16 years of age who underwent laparoscopic surgery at our hospital. We statistically examined the relationship between the AD and the age, sex, height, and weight. A final cohort of 188 patients participated in the study. The median AD for the sample population was 5 mm (range, 3.2-8.1). There was no significant difference in the AD between males and females in the multivariate analysis (P = 0.500). There was a positive correlation between the age and the AD (R = 0.396, P < 0.001). The AD had a significant positive correlation with the height and weight (P < 0.001, P < 0.001, respectively). The reference curve with regard to the AD can be useful in clinical situations, although it should be kept in mind that the range of individual differences in AD is large, and the growth degree by age is not uniform during childhood.

Post-inflammatory mucosal hyperplasia and appendiceal diverticulosis simulate mucinous neoplasms, causing diagnostic confusion. Distinction between neoplasia and its mimics is particularly important since many authorities now consider all appendiceal mucinous neoplasms to be potentially malignant. The purpose of this study was to identify clinicopathologic and molecular features that may distinguish appendiceal mucinous neoplasms from non-neoplastic mimics. We retrospectively identified 92 mucinous lesions confined to the right lower quadrant, including 55 non-neoplastic examples of mucosal hyperplasia and/or diverticulosis and 37 low-grade neoplasms. Presenting symptoms, radiographic findings, appendiceal diameter, appearances of the lamina propria, non-neoplastic crypts, and epithelium, as well as mural changes were recorded. Twenty non-neoplastic lesions were subjected to KRAS mutational testing. Non-neoplastic appendices were smaller (p < 0.05) and more likely to present with symptoms of appendicitis (p < 0.05) than neoplasms. While post-inflammatory mucosal hyperplasia and diverticula often showed goblet cell-rich epithelium, extruded mucin pools, and patchy mural alterations with fibrosis, they always contained non-neoplastic crypts lined by mixed epithelial cell types and separated by lamina propria with predominantly preserved wall architecture. On the other hand, mucinous neoplasms lacked normal crypts (p < 0.05) and showed decreased lamina propria (p < 0.05) with diffusely thickened muscularis mucosae and lymphoid atrophy. Six (30%) non-neoplastic lesions contained KRAS mutations, particularly those containing goblet cell-rich hyperplastic epithelium. We conclude that distinction between neoplastic and non-neoplastic mucinous appendiceal lesions requires recognition of key morphologic features; KRAS mutational testing is an unreliable biomarker that cannot be used to assess biologic risk or confirm a diagnosis of neoplasia.

Background/aims: To determine the histopathological features of incidental appendectomy specimens obtained from living liver donors (LLDs) Materials and Methods: Between September 2005 and November 2018, 1910 LLDs underwent living donor hepatectomy at our institute. Incidental appendectomy together with living donor hepatectomy (LDH) was performed in 170 LLDs. The decision for incidental appendectomy was made by experienced gastrointestinal surgeons. Histopathological features of the appendectomy specimens were analyzed by two pathologists, and the following parameters were retrospectively evaluated: age, sex, appendix length (mm), appendix width (mm), presence of appendicitis, and unusual histopathological findings., Results: Histopathological findings from 97 male and 73 female LLDs aged between 18 and 64 (median: 30) years were retrospectively examined. The length of the appendix vermiformis ranged from 25 to 120 (median: 70) mm, whereas its width ranged from 4 to 13 (median: 6) mm. The following histopathological findings were observed: normal appendix vermiformis (n=137), fibrous obliteration (n=13), acute appendicitis (n=5), enterobius vermicularis (n=4), lymphoid hyperplasia (n=4), low-grade appendiceal mucinous neoplasm (n=2), mucinous cystadenoma (n=1), grade 1 neuroendocrine tumor (n=1), hyperplastic polyp (n=1), enterobius vermicularis with fibrous obliteration (n=1), and acute appendicitis with eosinophilic infiltration (n=1)., Conclusion: This study showed that a careful inspection of the abdominal cavity was useful, and appendectomy should be performed when required. In addition, even if the macroscopic appearance of the appendectomy specimens is normal, histopathological evaluations facilitate an early diagnosis of numerous unusual appendiceal diseases.

Appendiceal endometriosis, endosalpingiosis, and decidual lesions have received little attention in the pathology literature, meaning their clinicopathologic features remain unclear. We identified 72 cases of appendiceal gynecologic proliferations with available slides. Clinical presentation was recorded when available, and histologic findings were correlated with clinical data. Cases included conventional endometriosis (51), endosalpingiosis (14), and decidual lesions (7). The patients with endosalpingiosis were significantly older (median 45 years) than those with endometriosis (median 34 years, P = .0085) or decidual lesions (median 31 years, P = .0088). Most endometriosis patients presented with known/suspected endometriosis (20/51, 39%), while acute appendicitis was the most common presentation for patients with endosalpingiosis (5/14, 36%) or a decidual lesion (5/7, 71%). Few patients presenting with appendicitis were ever diagnosed with extra-appendiceal disease. All 51 endometriosis cases showed both glands and stroma, and 18 (35%) had hemosiderin. One case progressed to endometrioid adenocarcinoma. Endosalpingiosis was an incidental finding in all cases, confined to the serosa in 4 and extending intramurally in 10. Four of the 7 patients with a decidual lesion were pregnant, and 2 others were taking oral contraceptives. The cases included florid decidualized endometriosis (5) and deciduosis (2). Two cases spread transmurally and effectively obliterated the appendix. Conventional appendiceal endometriosis can have several clinical presentations. Patients with it who present with acute appendicitis rarely develop it elsewhere. Appendiceal endosalpingiosis is rare and effectively incidental. Decidualized endometriosis may overtake the entire appendix., (Copyright © 2019 Elsevier Inc. All rights reserved.)

IgG4-related disease is a recent entity that has been described in a wide variety of organ systems. A 46-year-old female presented with acute appendicitis accompanied by a mass-forming lesion, raising a concern for neoplasm, and therefore, hemicolectomy was performed. The lesion revealed a dense lymphoplasmacytic infiltrate accompanied by storiform fibrosis and obliterative phlebitis. The IgG4/IgG plasma cell ratio was >50%, and the number of IgG4-positive plasma cells was >100/high-power field. In order to assess the IgG4/IgG plasma cell ratio, MUM1 was employed instead of IgG to successfully estimate the plasma cell concentration. There was also a concomitant hyperplasia of S100-positive cell, which could represent dendritic or Schwannian origin and possibly play a pathophysiologic role. The hyperplasia was significant by itself that it may mimic a mass-forming lesion. This newly described entity of the past decade deserves increased recognition due to clinical implication and surgical morbidity. This is the first case of IgG4-related disease in the appendix to our knowledge that fully satisfied all the pathological diagnostic criteria. We would like to also highlight our innovative approach of evaluating the IgG4/IgG plasma cell.

Starting from a typical case, we try to highlight the main critical elements, both in the diagnostic algorithm and in the therapeutic one. We hereby present a 54-year old patient, known with hepatic steatosis and renal microlithiasis, which undergoes an ultrasonography in ambulatory, on the background of unsystematised abdominal discomfort; the ultrasound reveals the presence of a tumoral mass in the right iliac fossa., (Celsius.)

Aim: In the presence of large bowel obstruction, the choice of treatment is determined by the patient's general status, the tumour characteristics and the perceived risk of caecal perforation. This study was designed to evaluate the predictive factors of impending caecal perforation, and also investigated the use of caecal volumetry., Method: From January 2011 to June 2016, patients with obstructive distal colon cancer undergoing emergency laparotomy, for whom a pretreatment CT scan was available, were included in this retrospective, case-control, two-centre study. Two patient groups were defined: patients with and without impending caecal perforation. The primary end-point of the study was a determination of predictive factors for caecal perforation., Results: A total of 72 patients (45 men, 62.5%) were included. Univariate analysis revealed that the presence of pericaecal fluid (P < 0.0001), caecal pneumatosis (P < 0.0001), mean maximum caecal diameter (P = 0.001), mean caecal diameter at the ileocaecal junction (P = 0.0001) and mean caecal volume (P = 0.001) were associated with caecal perforation. Receiver operating characteristic curve analysis revealed that a caecal volume greater than 400 cm 3 (P < 0.0001), a maximum caecal diameter > 9 cm (P = 0.002) and a caecal diameter at the ileocaecal junction > 7.5 cm (P = 0.001) were associated with impending caecal perforation. In multivariate analysis, only caecal volume > 400 cm 3 (P = 0.001) was correlated with the risk of impending caecal perforation., Conclusion: Caecal volumetry is an easy and useful tool to predict impending caecal perforation in patients with large bowel obstruction., (Colorectal Disease © 2018 The Association of Coloproctology of Great Britain and Ireland.)

Aims: Propofol can be applied as an anesthetic or sedative agent for septic patients. Our previous studies showed that propofol ameliorated inflammation- and nitrosative stress-induced cellular insults. This study further evaluated effects of propofol on cecal ligation and puncture (CLP)-induced septic insults to rats and its possible mechanisms., Main Methods: Wistar rats were administered with CLP and effects of propofol on CLP-induced liver dysfunction and rat death were evaluated. Levels of hepatic or systemic nitrogen oxides (NOx) and interleukin (IL)-6 were quantified. Sequentially, inducible nitric oxide synthase (iNOS) and IL-6 gene expressions, toll-like receptor 4 (TLR4) protein levels, and nuclear factor (NF)-κB translocation were determined., Key Findings: Subjecting rats to CLP led to body weight loss, liver weight gain, and death. Administration of propofol lessened CLP-induced augmentations of serum and hepatic nitrosative stress and IL-6 levels. Additionally, propofol suppressed CLP-induced enhancements in levels of hepatic iNOS protein. Furthermore, the CLP-induced iNOS and IL-6 mRNA expressions in the liver were inhibited following propofol administration. Sequentially, subjecting rats to CLP enhanced hepatic TLR4 protein levels and NF-κB translocation to nuclei, but propofol inhibited these augmentations., Significance: Consequently, exposure to propofol protected against CLP-induced liver dysfunction and increased the survival rates of the animals. This study shows that propofol can protect rats against septic insults through suppression of systemic and hepatic nitrosative and inflammatory stress due to inhibition of TLR4/NF-κB-mediated iNOS and IL-6 mRNA and protein expressions., (Copyright © 2018 Elsevier Inc. All rights reserved.)

We present a case of ileocecal endometriosis as a cause of infrequent ileocolic intussusception in an adult patient. It is reviewed as published by the authors Sanchez Cifuentes, A et al. 2016, emphasizing the rarity of the location of endometriosis, and its association as a cause of intussusception.

Background: Cecal volvulus is a rare clinical entity with an average incidence of 2.8-7.1 per million people per year, accounting for 1-2% of all large bowel obstructions. Cecal bascule is the rarest type of cecal volvulus, accounting for 5-20% of all cases. Although several case reports have been published, there is no consensus regarding its diagnosis and treatment. The aim of this study was to review the literature on cecal bascule in order to summarize the etiopathogenesis, clinical features, diagnosis, and treatment options., Methods: The PubMed, MEDLINE, and Scopus databases were systematically searched by two independent authors. Cecal bascule was defined as anterior displacement of the distended cecum on the ascending colon without any torsion. The etiopathogenesis, clinical features, diagnosis, and treatment options were analyzed., Results: Nineteen previously published papers reporting on 26 patients were included. The mean age of patients from previously reported cases was 55.1 ± 19.2 years, and 54% of all patients were males. Presenting symptoms included abdominal pain in 16 (61%), distension in 22 (84%), and vomiting in eight patients (30%). The mean time to diagnosis was 3.6 ± 2.6 days. The extent of surgery varied from cecopexy to right colectomy. There was no postoperative mortality. Cecal bascule recurred one 1 year after index surgery in one patient., Conclusions: Cecal bascule is a rare clinical entity, which is mostly encountered in patients with peritoneal adhesions, mobile cecum, bowel dysfunction, and cecal displacement. In patients with recurrent or persistent abdominal pain and distension, cecal bascule should be considered. The majority of these patients require surgical management.

Aim: We investigated the effects of atorvastatin and N-acetyl cysteine in decreasing ischemia-reperfusion damage after detorsion of a volvulus of the cecum and ascending colon., Methods: Wistar albino rats (250-300 g) were divided into four groups. A cecal-ascending colon volvulus was created by the intestinal clockwise 720° rotation. At the end of one hour, the bowel was detorsioned. Group I (n = 7) was the sham (laparotomy) group, Group II (n = 7) the control (no treatment, volvulus or detorsion), Group III (n = 7) (N-acetyl cysteine administered ) , and Group IV (n = 7) (atorvastatin administered ) group. Blood samples were collected from each group via peripheral veins and centrifuged one hour after detorsion. The parameters of ischemia including malondialdehyde, glutathione peroxidase, catalase, and superoxide dismutase were then observed in the serous fluid., Results: Malondialdehyde and superoxide dismutase increased in the control group, whereas they were reduced in the Group III and Group IV (p = 0.005; p = 0.008, respectively). The glutathione peroxidase levels revealed no significant differences (p > 0.05), whereas the catalase levels of the group III was higher than in each of the other three groups (p < 0.001). Histopathological evaluation detected reduced lesioning of the organ in the groups which were given atorvastatin and N-acetyl cysteine., Conclusion: Atorvastatin and of N-acetyl cysteine have a similar preventive effect in experimental ischemia-reperfusion injury (Tab. 8, Fig. 6, Ref. 24).

Objectives: The aim of the study was to evaluate clinical, endoscopic, radiologic, and histopathological features helpful in differentiating Crohn disease (CD) from intestinal tuberculosis (ITB) in children., Methods: Patients diagnosed to have CD or ITB based on standard recommended criteria were enrolled. Children with inflammatory bowel disease unclassified or suspected ITB or CD with incomplete work-up or lost to follow-up were excluded. The clinical and laboratory (radiology, endoscopy, and histology) details of children were analyzed., Results: Twenty cases of ITB (14 [3-17] years) and 23 of CD (11 [1-17] years) were enrolled. Presentation with chronic diarrhea (82% vs 40%; P = 0.006) and blood in stool (74% vs 10%; P = 0.001) favored CD, whereas subacute intestinal obstruction (20% vs 0%; P = 0.04) and ascites (30% vs 0%; P = 0.005) favored ITB. Presence of deep ulcers (61% vs 30%; P = 0.04), longitudinal ulcers (48% vs 15%; P = 0.02), involvement of multiple colonic segments (70% vs 35%; P = 0.02), left-sided colon (87% vs 40%; P = 0.003), extraintestinal manifestations (21.7% vs 0%; P = 0.02), and higher platelet count (3.9 vs 2.6 × 10/mm; P = 0.02) favored CD. Isolated ileocecal involvement (40% vs 8.7%; P = 0.03) was a feature of ITB. TB bacilli were demonstrated in 40% ITB cases (colon-6, ascites-1, abdominal lymph node-1). On multivariate analysis, presence of blood in stool (odds ratio: 37.5 [confidence interval: 3.85-365.72], P = 0.002) and left-sided colonic involvement (odds ratio: 16.2 [confidence interval: 1.63-161.98], P = 0.02) were independent predictors of CD., Conclusions: Microbiologic confirmation of tuberculosis is possible in 40% ITB cases. Presence of blood in stool and left-sided colonic involvement are the most important features favoring CD.

Objective: To determine whether deep-infiltrating endometriosis (DE) carries an increased risk of appendiceal endometriosis (AppE) as compared with superficial endometriosis or no endometriosis., Methods: In a retrospective study, data were obtained by chart review of an internal database for women who underwent coincidental appendectomy during benign gynecologic surgery between July 2009 and February 2014 at a tertiary referral center in the USA. Univariate, bivariate, and regression analyses were performed. The primary exposure was surgically documented endometriosis (DE, superficial, or no endometriosis). The primary outcome was AppE., Results: Endometriosis was diagnosed for 151 (38.2%) of 395 women; 82 (54.3%) had DE. The prevalence of AppE was 13.2% (52/395) overall; 8 (11.6%) of 69 women with superficial endometriosis and 32 (39.0%) of 82 with DE were affected. Frequency of AppE was increased among women with DE, abnormal appendix appearance, and surgical indication (all P<0.001). Women with DE had a 5.9-fold (95% confidence interval [CI] 2.9-11.9) higher risk of AppE compared with women without endometriosis, controlling for appendiceal appearance and surgical indication, and a 2.7-fold (95% CI 1.2-6.2) higher risk of AppE compared with those with superficial endometriosis., Conclusion: Women with DE have increased risk of AppE. Coincidental appendectomy should form part of complete endometriosis excision for these patients., (© 2017 International Federation of Gynecology and Obstetrics.)

Ehlers-Danlos syndrome, hypermobility type (EDS-HT) is unexpectedly common and is associated with a high rate of gastrointestinal manifestations. We herein report the first documented case of mobile cecum associated with EDS-HT. A 21-year-old woman with repeated right lower abdominal pain was initially diagnosed with EDS-HT. Abdominal examinations performed in the supine position, such as CT and ultrasonography, showed no gross abnormalities. In contrast, oral barium gastrointestinal transit X-ray images obtained with changes in the patient's body position revealed position-dependent cecal volvulus with mobile cecum. She was finally discharged with a dramatic resolution of her symptoms after laparoscopic cecopexy for mobile cecum.

Appendicular diverticulosis is a rare condition. It is important to know its insidious form of presentation for its early diagnosis and treatment, thus diminishing morbimortality. In case of incidental findings, an appendicectomy will be performed to prevent complications and the development of malignancy.

Introduction: Neurogenic appendicopathy is not a very well-known disease., Objective: To analyze the experience in the management of neurogenic appendicopathy in a tertiary hospital, assessing its clinical presentation, histological staging, the treatment carried out and its clinical evolution., Method: The study population included patients with histopathological criteria for neurogenic appendicopathy who did not present with MEN 2B syndrome, neurofibromatosis type I or Cowden syndrome. An analysis was carried out of tissue samples taken from a simple appendectomy after a diagnosis of neurogenic appendicopathy between 2000 and 2013, inclusive. The histopathological criteria were neurogenic hyperplasia with S-100 protein positivity and neuron-specific enolase in the immunohistochemical analysis., Results: Of the 4,969 samples from the appendectomies analyzed, 0.16% (n = 8) met histopathological criteria of neurogenic appendicopathy. The age at presentation was 27.8 ± 12 years. Four patients were male and four were female. All patients started with abdominal pain in the right iliac fossa (RIF), and were operated on due to a diagnosis of acute appendix, with a simple appendectomy being performed. In four cases, another associated disease accounted for the pain in the RIF. With regard to histopathological type, submucosal neurogenic hyperplasia was present in five patients and fibrous obliteration in three patients. No statistically significant differences were found between the histological types. After surgery, during a mean follow up of 73.2 ± 28 months (15-105), all the patients remained asymptomatic., Conclusion: Neurogenic appendicopathy is an uncommon entity that can evolve as abdominal pain which is similar to acute appendix. Simple appendectomy is curative.

Background: The early prediction of gangrenous/perforated appendicitis is of great importance for the surgical planning, further treatments, and predicting the course of disease. Ischemia-modified albumin (IMA) was previously reported as a biomarker of various ischemia-based diseases. Our aim is to determine the predictive value of serum IMA in the severity of acute appendicitis., Methods: Sixty-two patients who underwent urgent appendectomy were included in the study. Plasma level of IMA was measured after diagnosis and before treatment. All patients were classified as noncomplicated (acute) appendicitis and complicated (gangrenous/perforated) appendicitis according to histopathological findings, and comparisons were made between the groups., Results: The data of 62 patients with a mean age of 30.1 years were statistically evaluated. The pathological diagnoses were acute appendicitis in 33 (53.2%), and gangrenous/perforated appendicitis in 29 (46.8%) patients. There were significant differences in computed tomography (CT) findings (P = .031) and IMA (P = .012) levels between the groups. A strong positive correlation between IMA levels and CT findings was also found (Spearman ρ = +0.688, P = .003)., Conclusions: The IMA can be considered as a novel and useful marker to distinguish gangrenous/perforated appendicitis from noncomplicated appendicitis. The correlation of IMA with CT findings also enhances the predictive value of IMA., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Endometriosis of the appendix can be an incidental finding or a cause of appendicitis, intussusception, perforation or retention mucocele. Intestinal metaplasia of appendiceal endometriosis may occur, which can lead to a misdiagnosis of low-grade appendiceal mucinous neoplasm. On a retrospective search of the pathology database from 2001 to 2015, we identified 78 appendiceal endometriosis cases and intestinal metaplasia was present in 10/78 (13%) cases. In most of the cases (90%), the foci of intestinal metaplasia were mainly localized close to the mucosa. Intestinal and endometrial hybrid glands were present in 9/10 (90%) cases. These cases were often associated with marked appendiceal distortion, luminal obliteration and mass formation, causing concern for a mucinous neoplasm clinically and pathologically. Our findings indicate that intestinal metaplasia in appendiceal endometriosis is not an uncommon phenomenon, which can be mistaken for a mucinous neoplasm. Endometriosis should be kept in mind when a diagnosis of appendiceal mucinous neoplasm is made, especially in a young woman with a clinical history of endometriosis., (Copyright © 2016 Elsevier GmbH. All rights reserved.)

Purpose: To evaluate whether deep pelvic endometriosis or endometriomas diagnosed at pelvic MRI are associated with extrapelvic bowel endometriosis (EPBE) (ileal, appendicular, or cecal involvement) in order to suggest criteria for performing an additional imaging examination dedicated to the assessment of EPBE., Methods: Ninety-six patients operated on for deep pelvic endometriosis were retrospectively included. They were classified in two groups according to the presence of surgically and histologically proven EPBE. According to pelvic endometriotic lesions described on the preoperative pelvic MRI, a logistic regression analysis was performed to evaluate a possible association between EPBE and pelvic endometriosis., Results: Eleven patients had EPBE (5 appendicular, 2 cecal, and 4 ileocecal lesions) at surgery. In adjusted models, involvement of the right ureter, rectosigmoid, and sigmoid localizations were statistically associated with EPBE with adjusted OR of 9.13 (95% CI 1.98-42.19), 5.8 (95% CI 1.12-30.07), and 6.74 (95% CI 1.23-36.77), respectively., Conclusions: Further imaging evaluation to assess ileal, appendicular, or cecal endometriosis should be proposed in case of sigmoid or rectosigmoid endometriosis diagnosed at pelvic MRI. A right ureteral lesion diagnosed preoperatively should be considered carefully as its association with EPBE is not described so far.

Background: Crohn's disease (CD) is frequently complicated by intestinal strictures, which are commonly treated by endoscopic balloon dilation (EBD). However, available data on this area of treatment is limited. The aim of this study was to depict the heterogeneity of endoscopic management of CD-associated strictures among international CD specialists to identify common treatment standards., Methods: IBD experts of the International Organization for the Study of Inflammatory Bowel Disease (IOIBD), the European Crohn's and Colitis Organization (ECCO), and from the Prospective Value In IBD trials (PROVIT) completed a web-based questionnaire to evaluate their endoscopic experience, practice setting, and number of EBDs performed annually. Additionally, two case scenarios and technical practice parameters were investigated., Results: A total of 126 subjects from 15 countries completed the survey. The maximal length of dilated stricture was 4.5 ± 1.7 cm. The most commonly used maximal balloon size was graded as 15-18 mm. While 87.2 % of the participants favored EBD for anastomotic strictures, only 58.6 % did so in the case of naïve strictures. Only 35.7 % of physicians dilated actively inflamed strictures. Interventional endoscopists were more likely to dilate only clinically symptomatic strictures (p = 0.046). Surgeons favored surgical treatment of de novo ileocecal strictures compared to gastroenterologists (p = 0.026), reported a shorter stricture length being amendable by EBD (p = 0.045), and more frequently used concomitant therapies (p = 0.001). Operator experience increased the likelihood of EBD use in actively inflamed strictures (p = 0.002), maximum length of stricture, and maximum balloon size (p = 0.001)., Conclusions: EBD is a widely used treatment approach for stricturing CD. Individual approaches differ significantly based on background of the operator, experience level, and practice setting.

A de Garengeot hernia is defined as an incarcerated femoral hernia containing the vermiform appendix. We describe the case of a patient with a type 4 appendiceal diverticulum within a de Garengeot hernia and delineate valuable learning points. A 76-year-old woman presented with a 2-week history of a non-reducible painless femoral mass. Outpatient ultrasonography demonstrated a 36mm × 20mm smooth walled, multiloculated, partially cystic lesion anterior to the right inguinal ligament in keeping with an incarcerated femoral hernia. Intraoperatively, the appendix was found to be incarcerated in the sac of the femoral hernia and appendicectomy was performed. Histopathology demonstrated no evidence of inflammation in the appendix. However, an incidental appendiceal diverticulum was identified. It is widely recognised that a de Garengeot hernia may present with concomitant appendicitis, secondary to raised intraluminal pressure in the incarcerated appendix. Appendiceal diverticulosis is also believed to develop in response to raised pressure in the appendix and may therefore develop secondary to incarceration in a de Garengeot hernia. To our knowledge, only one such case has been described in the literature. A de Garengeot hernia is a rare entity, which poses significant diagnostic challenges. A high index of clinical suspicion is necessary as these hernias are at particularly high risk of perforation and so prompt surgical management is paramount.

Introduction Malrotation of the midgut and appendiceal mucocoele are both extremely rare pathological conditions in adults. To our knowledge, there are only two reported cases in the English literature with a combination of both conditions. Case History A 65-year-old man presented with a 10-day history of upper abdominal pain associated with abdominal bloating and weight loss. He was otherwise fit and healthy with no significant past medical history. On examination, his abdomen was soft with tenderness and palpable fullness over the left upper quadrant. The initial blood test, chest x-ray and abdominal x-ray demonstrated no significant abnormality. Computed tomography showed a 17cm x 8cm x 6cm elongated cystic mass with possible malrotation of the intestines. Histopathology showed a low grade mucinous tumour of the appendix. At 12 months following surgery, there was no evidence of recurrence or postoperative complications and the patient was discharged from the care of the colorectal team. Conclusions We report a patient with a combination of two rare conditions. This case illustrates how a combination of pathologies can present a challenge to the unwary general surgeon.

Inflammatory myofibroblastic tumor (IMT) is a rare soft-tissue neoplasm of unknown etiology. It mimics, clinically and radiologically, malignant tumors. Histologically, this tumor is composed of differentiated myofibroblastic spindle cells accompanied by an inflammatory infiltrate, with numerous plasma cells and/or lymphocytes. Initially described in the lung, numerous extrapulmonary sites of this tumor have been found but appendiceal IMT is rare, especially in adult women. In this study, we aimed to examine the literature as well as to describe a case of a 42-year-old woman that we operated on that presented as an appendiceal mass that obstructed the lumen of the appendix and caused acute appendicitis. Upon histopathological examination, the lesion was identified as an IMT. Awareness of this type of tumor in the differential diagnosis of appendiceal masses, avoids overtreatment, and highlights the need of long-term follow-up regarding the tendency for local recurrence and small risk of distant metastasis.