[JNUS]

Appendectomy is one of the most commonly performed Emr. surgeries. Stump appendicitis is an uncommon complication of the procedure that develops with acute inflammation of the residual appendix in a patient who has had a prior appendectomy. The complication typically occurs in patients in whom the appendix was not completely removed in the initial procedure. In 36 reports of this rare condition, the disease occurred anywhere from 2 months up to 50 years after the initial appendectomy, with 1 year being the median interval.1 The clinical presentation is similar to initial appendicitis, with right lower quadrant pain, anorexia, vomiting, and fever. Right lower quadrant tenderness, often accompanied by a positive psoas sign, obturator sign, or Rovsing sign, may be noted on the physical exam. The WBC count is usually elevated, with the mean being 14.9 x 109/L.1 Stump appendicitis is not usually considered as the etiology for right lower quadrant pain in patients with a prior history of appendectomy; as a result, a delay in treatment may occur, which may explain why the rate of perforation for stump appendicitis approaches 70%.

Some reports have suggested that the laparoscopic appendectomy technique is associated with an increased incidence of stump appendicitis, because it may be easier to incorrectly identify the appendiceal base; however, the most recent comprehensive review of the literature on stump appendicitis by Liang et al reveals that only 34% of stump appendicitis cases follow laparoscopic appendectomy, and 66% of cases follow open resection.1 Irrespective of the technique, not adequately identifying the base of the appendix and failing to amputate the entire appendix can lead to stump appendicitis. Methods for identifying the base of the appendix that decrease the likelihood of leaving residual appendiceal tissue include tracing the taenia coli of the cecum to the appendix or dissecting and ligating the recurrent branch of the appendiceal artery, which marks the true base of the appendix.1

A CT scan with oral and intravenous (IV) contrast can diagnose stump appendicitis. The findings may include pericecal inflammatory changes, abscess formation, fluid in the right paracolic gutter, or cecal wall thickening. A cecal arrowhead sign, indicating inflammation at the base of the appendix, may be visualized. A specific diagnosis can be made if inflammatory changes surround the visualized stump, as in this case. When the diagnosis is made, the patient should proceed to the operating room for a complete appendectomy.

Clinicians and radiologists should consider the diagnosis of stump appendicitis when examining patients who are status post-appendectomy and present with appendicitis-like symptoms consistent with an acute infectious etiology in the right lower quadrant. A CT scan of the abdomen should be considered, to allow for earlier diagnosis of this uncommon complication, as well as to avoid the relatively higher rate of perforation and increased morbidity associated with a late diagnosis. The patient in this case was taken to the operating room and had an uneventful completion of her appendectomy with removal of the remaining, infected stump.