A Rare Simultaneous Occurrence of Appendiceal Diverticulitis and Peptic
Ulcer that Leads to Abdominal Peritonitis Symptoms
Authors: Maziar Moayerifar1.MD, Hossein Torabi.
MD2, Kasra Shirini. MD3*, Yalda
Ashoorian.MD 4
Department of General Surgery, Poursina Medical and Educational
Center, Guilan University of Medical Sciences, Rasht, Guilan, Iran
Email: dr_maziar_m@yahoo.com
Department of General Surgery, Poursina Medical and Educational
Center, Guilan University of Medical Sciences, Rasht, Guilan, Iran
Email: dr.torabi1367@yahoo.com
Department of General Surgery, Iran University of Medical Science,
Tehran, Iran, Email: kasrashirini21@gmail.com
Department of Pathology and Laboratory Medicine, Rasht, Guilan
University of Medical Science, Rasht, Iran, Email:
Y.ashoorian@gmail.com
Corresponding Author:
Kasra Shirini, MD, Iran University of Medical Science, Tehran, Iran
Email:
Kasrashirini21@gmail.com
Telephone number: 00989112481500
P.O Box: 14665-354
Acknowledgment: None
Figures: 6 Tables: 0
Abstract Word Count: 94
Main article Word Count: 1440
Disclosure of conflicts of interest: The authors certify that there is
no conflict of interest with any financial organization regarding the
material discussed in the manuscript. The patient has consented to the
submission of the case report for submission to the journal.
Funding: The authors report no involvement in the research by the
sponsor that could have influenced the outcome of this work.
Authors’ contributions: All authors contributed equally to the
manuscript and read and approved the final version of the manuscript.
Patient’s contest: Written informed consent was obtained from the
patient to publish this report in accordance with the journal’s patient
consent policy.
Abstract:
Appendiceal diverticulitis is an infrequent disease that can mimic other
diseases’ symptoms or cause different symptoms because of its various
complications. However, one of the most frequent complications of this
disease is a perforation that can lead to other serious problems such as
peritonitis. This complication can threaten a patient’s health
condition. In this article, a male patient presented with abdominal pain
and was admitted to the surgical ward with suspicion of a perforated
peptic ulcer. However, more investigation showed a simultaneous
occurrence of peptic ulcer and perforated appendiceal diverticulitis
that cause peritonitis symptoms.
Keywords: appendiceal diverticula, appendiceal diverticulitis,
peritonitis, peptic ulcer, laparotomy
Introduction:
The first person who described Appendiceal diverticulitis was Kelynack,
a pathologist in the 19th century. He described it as ”a greatly
distended appendix, totally shut off from the cecum, having two distinct
diverticular processes directed between the folds of the mesentery” and
classified it into congenital and acquired
types [1,2].
It is a rare condition with a prevalence incidence of 0.014% to 1.9
% [2-4].
Studies showed that despite the similarities between appendiceal
diverticulitis and acute appendicitis, the prevalence of perforation in
appendiceal diverticulitis is three to four times higher which increases
the risk of abdominal peritonitis. Also, it can be synchronous neoplasms
such as carcinoids and mucinous adenomas and adenocarcinomas, or it can
mimic other diseases’ symptoms. So the preoperative diagnosis of this
disease is challenging and
essential [2,5].
As regards this issue, a patient with generalized abdominal peritonitis
symptoms, without any specific appendicitis symptoms, presented in this
article and finally discovered appendiceal diverticulitis as the main
reason but mimicking abdominal peritonitis due to perforated peptic
ulcer.
Case presentation:
A 35-year-old patient presented to the surgical department of Poursina
Hospital Medical Center, Rasht, Iran, in October 2021, with no history
of underlying diseases and with complained of abdominal pain started
five days ago with a predominance of the left lower quadrant of the
abdomen and hypogastric area and two times vomiting, a day before
hospitalization. The patient claimed that the abdominal pain had been
vague and generalized and started five months ago for the first time. It
was persistent but improved with the use of painkillers. The pain was
worsened with feeding and relatively relieved by lying supine, and it
had nothing to do with defecation and gas passing. The patient was a
drug abuser. He also mentioned occasional constipation from the
beginning of the pain in the past five years ago. Moderate but
progressive generalized tenderness was detected during physical
examination but guarding, and rebound tenderness were not detected. He
had a low-grade fever, estimated at 38.1 Celsius, but other vital signs
were normal. Therefore, due to the patient’s symptoms, he was admitted
to the surgical ward with suspicion of general peritonitis due to the
perforated peptic ulcer. He was asked to do an upright chest X-ray and
supine abdominal X-ray. The upright chest X-ray pictures were
unrevealing, as shown in Figure 1. As shown in Figure 2, dilated,
gas-filled bowel loops in the supine abdominal X-ray could signify
mechanical or ileus obstruction. Furthermore, the Rigler sign can be
seen in the abdominal X-ray that was a sign of pneumoperitoneum, leading
the surgical team to reinforce the suspicion of perforation. He was also
asked to do an endoscopic procedure, and the results showed erosive
gastropathy and duodenal ulcer, and the patient was prescribed high-dose
proton pump inhibitors (PPI). After that, he was asked to do abdominal
sonography. The result revealed a blind loop in the right lower quadrant
(RLQ) of the abdominal cavity with standard size in the base and
proximal parts. Still, it increased the diameter in the Tip that it was
approximately seven millimeters. It was non-compressive and with slight
fat haziness around it. These findings led to suspicion of appendicitis.
Due to the inconsistency of the clinical findings during the physical
examination with the ultrasonography findings and due to the suspicion
of perforated or complicated appendicitis, he was advised to do
abdominal computed tomography (CT) scan with intravenous and oral
contrast for more investigations. The CT-scan imaging confirmed a
mass-like lesion in the RLQ of the abdominal cavity that could represent
appendicitis and tissue wall, thickening in the AP region. Still, unlike
usual appendicitis, the IV contrast fluid filled the appendix, as shown
in Figure 3. The blood test analyzed presented a standard range of
lactate dehydrogenase (LDH) = 309 (usually should be under 460 in
adults) and leukocytosis (white blood cells [WBC] = 11200 g/dL with
a neutrophilia ratio of 73%) and Amylase = 54 U/Lit (normally should be
under 95). Unfortunately, generalized abdominal tenderness intensified
during hospitalization, and hypogastric rebound tenderness was found as
a new sign.
Therefore, the patient underwent laparotomy with suspicion of general
peritonitis due to the perforated peptic ulcer or perforated
appendicitis. A midline incision was performed. On the external side of
the duodenum wall, the stiff tissue was touched at the same site as an
ulcer reported by endoscopy but no perforation was detected. Also, a
mass-like lesion was seen in the right lower quadrant area of the
abdomen cavity with lots of adhesions to its around tissues. It was
discreetly removed from the surrounding tissues, and a diverticular
appendix appeared, as can be seen in Figure 4. The tissue was sent for
more pathological investigations. After providing the necessary
hemostasis, the abdominal cavity was closed. He had a good recovery, and
the vital signs were stable after surgery. The patient was transferred
to the ICU ward and transferred to the surgical ward after one day and
discharged after four days with good general condition and stable vital
signs. Ciprofloxacin and Metronidazole treatment was started for him and
continued for seven days. There was no complication in the three-month
follow-up. The pathological reporting showed herniation of mucosa and
submucosa and muscular layer through the wall of appendix and confirmed
the diagnosis of the appendix with multiple diverticulosis and
appendiceal diverticulitis, as can be seen in Figures 5 and 6.
Discussion:
Different cases of appendiceal diverticula with different symptoms and
complications have been reported, including patients of various ages and
with different health
conditions [2,6,7].
This disease is classified into two groups based on the number of layers
herniating through the appendix wall. Acquired or pseudodiverticula form
and congenital or true form, which means all three appendiceal layers
herniate through a normal wall
histologically [2,4,8].
The congenital type is rare and accounts for 3% of all diagnosed
appendix diverticulosis
cases [9-11].
Appendiceal diverticulitis risk factors are male gender, age over 30,
cystic fibrosis, and Hirschsprung
disease [12].
Appendiceal diverticulitis is not only a rare condition that can mimic
other diseases’ symptoms, and most of all, it is confused with acute
appendicitis, but also it can be synchronous with other serious diseases
such as carcinoid
tumors [2,5].
One of the most complications of appendiceal diverticulitis is
perforation, with an incidence prevalence of
66% [13].
Other complications could be chronic pain and acute
inflammation [14].
Due to these reasons, it is crucial to diagnose this problem
preoperatively. Using imaging methods such as ultrasonography and
CT-scan can be very useful to diagnose appendiceal diverticulitis, while
CT-scan is better and has 80 % sensitivity and 100 % specificity.
Still, both methods are highly dependent on radiologists’
experiences [10,13].
On the other hand, the diagnosis of appendiceal diverticulitis may not
be possible due to the small size or involvement of inflammatory
mass [12].
So, the definitive diagnosis way is a postoperative pathology
report [15].
The definitive treatment way to eradicate symptomatic appendiceal
diverticulitis is an appendectomy, and choosing the appropriate surgical
method between laparotomy or laparoscopy depends on the patient’s
condition and surgical team
decision [15] Choosing
the appropriate surgical method is crucial to perform a safe way to
avoid rupture that it can lead to peritoneal seeding and peritonitis
consequently [5].
In this article, the male patient presented with abdominal pain and
generalized abdominal tenderness with suspicion of perforated peptic
ulcer. After medical investigation, such as physical examination, blood
test analysis, ultrasonography, and endoscopy procedure, the patient was
diagnosed with a non-perforated duodenum ulcer and appendicitis. These
diagnoses justified the patient’s symptoms as the simultaneous
occurrence of peptic ulcer and appendicitis can cause generalized
abdominal pain and generalized abdominal tenderness. However, as a
rebound tenderness suddenly appeared in the physical examination and the
patent’s abdominal tenderness progressed from moderate to severe, the
surgical team decided to choose the laparotomy method instead of the
laparoscopy one due to suspicion of general peritonitis and the
patient’s condition.
Conclusion:
This article is about a 35-year-old male presenting with generalized
abdominal pain with a predominance of the left lower quadrant of the
abdomen and hypogastric area mimicking perforated peptic ulcer but found
to have abdominal peritonitis due to appendiceal diverticulitis. It is
crucial to diagnose and treat this disease preoperatively as some
studies showed that appendiceal diverticulitis could be asymptomatic
until getting infected or accidentally during a medical investigation or
can mimic other diseases’ symptoms or occur simultaneously with other
serious diseases. So, using different imaging methods such as
ultrasonography and CT-scan could be beneficial, but physical
examination findings should be considered too. However, the definitive
way to diagnose the disease is postoperative pathological
investigation.
Therefore, appendiceal diverticulitis should be regarded as an important
differential diagnosis in patients with abdominal pain.
Disclosure of conflicts of interest: The authors certify that there is
no conflict of interest with any financial organization regarding the
material discussed in the manuscript. The patient has consented to the
submission of the case report for submission to the journal.
Funding: The authors report no involvement in the research by the
sponsor that could have influenced the outcome of this work.
Authors’ contributions: All authors contributed equally to the
manuscript and read and approved the final version of the manuscript.
References:
- Albeeshi MZ, Alwanyan AA, Salim AA, Albabtain
IT: Appendiceal
diverticulitis presenting as acute appendicitis diagnosed
postoperatively. J Surg Case Rep. 2019,
11:1-3. 10.1093/jscr/rjz332
- Abdulmomen AA, Zalzahrani AS, Al Mulla LA, Alaqeel
FO: Acute perforated
appendicitis associated with appendiceal diverticulitis in a young
man: a case report with literature review. Am J Case Rep. 2022,
23:e934838-1 -
7. 10.12659/AJCR.934838
- Williams JM, Adamo DA, Olson
MC: Acute
appendiceal diverticulitis: a case report. Radiol Case Rep. 2021,
24:1072-1074. 10.1016/j.radcr.2021.02.034
- Altieri ML, Piozzi GN, Salvatori P, Mirra M, Piccolo G, Olivari
N: Appendiceal
diverticulitis, a rare relevant pathology: presentation of a case
report and review of the literature. Int J Surg Case Rep. 2017,
33:31-34. 10.1016/j.ijscr.2017.02.027
- Khan SL, Siddeswarappa M, Khan
MF: A case
report describing diverticulosis of the appendix presenting as acute
appendicitis. Int J Surg Case Rep. 2016,
29:155-157. 10.1016/j.ijscr.2016.10.074
- Souferi B, Sheppard K, Onayemi AO, Davis
JM: Incidental
findings of appendiceal diverticulitis presenting as acute
appendicitis. The American Surgeon.
2021, 10.1177/00031348211065125
- Krzak AM, Townson A, Malam Y, Mathews
J: Diverticulitis
complicated by colovenous fistula formation and pylephlebitis.
Journal of Surgical Case Reports. 2022,
2022:1-3. 10.1093/jscr/rjab591
- Dupre MP, Jadavji I, Matshes E, Urbanski
SJ: Diverticular
disease of the vermiform appendix: a diagnostic clue to underlying
appendiceal neoplasm. Hum Pathol. 2008,
39:1823-18266. 10.1016/j.humpath.2008.06.001
- Abdullgaffar
B: Diverticulosis
and diverticulitis of the appendix. Int J Surg Pathol. 2009,
17:231-237. 10.1177/1066896909332728
- Majeski
J: Diverticulum
of the vermiform appendix is associated with chronic abdominal pain.
Am J of Surg. 2003,
186:129-131. 10.1016/S0002-9610(03)00187-9
- Konen O, Edelstein E, Osadchi A, Shapiro M, Rathaus
V: Sonographic appearance
of an appendiceal diverticulum. J Clin Ultrasound. 2002,
30:45-47. 10.1002/jcu.10023
- Chia ML, Chan SWY, Shelat
VG: Diverticular Disease
of the Appendix Is Associated with Complicated Appendicitis. GE Port
J Gastroenterol. 2021,
28:236-242. 10.1159/000511822
- Zubieta-O’Farrill G, Guerra-Mora JR, Gudiño-Chávez A,
Gonzalez-Alvarado C, Cornejo-López GB, Villanueva-Sáenz
E: Appendiceal
diverticulum associated with chronic appendicitis. Int J Surg Case
Rep. 2014,
5:961-963. 10.1016/j.ijscr.2014.10.066
- Medlicott SAC, Urbanski
SJ: Acquired
Diverticulosis of the Vermiform Appendix: A Disease of Multiple
Etiologies: A Retrospective Analysis and Review of the Literature.
International Journal of Surgical Pathology. 1998,
6:23-27. 10.1177/106689699800600106
- Fiordaliso M, De Marco AF, Constantini
R: A case of
type 2 appendiceal diverticulum perforated and a review of the
literature. Int J of Sur Case Rep. 2020,
77:450-453. 10.1016/j.ijscr.2020.10.114
Figures Description:
Figure1: Upright Chest X-ray
Figure2: Supine abdominal X-ray, red arrows show gas filled bowel loops,
the green arrow points to Rigler sign
Figure3: Abdominal CT-scan, the green arrow shows appendix filled by IV
contrast fluid
Figure4: Appendix after appendectomy
Figure5: Microscopic view of diverticular appendix tissue
Figure6: Microscopic view of diverticular appendix tissue