|Year : 2016 | Volume
| Issue : 2 | Page : 70-72
Clinicopathologic findings in elderly patients with appendix mass
BB Kombo, JE Raphael
Department of Surgery, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria
|Date of Submission||22-May-2015|
|Date of Acceptance||26-Jun-2016|
|Date of Web Publication||30-Aug-2016|
B B Kombo
Department of Surgery, Niger Delta University Teaching Hospital, Wilberforce Island, Bayelsa State
Source of Support: None, Conflict of Interest: None
Background: An appendix mass is a complication of acute appendicitis with an adherent covering of bowel and omentum enclosing a pocket of pus. A carcinoma may masquerade as an appendix mass in the middle-aged and elderly patients. The clinical findings may not be specific, hence the need for a high index of suspicion when managing the elderly with a suspected appendix mass.
Aim: The aim of this study was to highlight the clinicopathological findings in elderly patients with appendix mass.
Methods: This is a retrospective study of patients aged 60 and older diagnosed with appendix masses and managed surgically. The study was carried out from January 2002 to December 2005. The hospital records of all patients within the study period were obtained and analyzed. A literature review was done using the PubMed search engine. Data analysis was done using SPSS software version 17.
Results: Fifty-eight patients presented with appendix masses and were operated upon during the period with a female:male ratio of 1.5:1. The modal age range was 60-69 years. Most of the patients presented within 5 days of the onset of symptoms. Abdominal pain (89.7%) was the most common symptom. Constitutional symptoms (any of fever, malaise, and anorexia) (27.5%), weight loss (15.5%), and constipation (12.5%) were the other symptoms observed. Acutely inflamed appendix was the most common pathological finding (39.7%). Perforated appendix (17.3%), adenocarcinoma of cecum (15.5%), ameboma (8.6%), benign appendix tumor (5.2%), ascaris-perforated cecum (5.2%), endometriosis (3.4%), and pedunculated fibroid (1.7%) were the other pathological findings.
Conclusion: The appendix mass in the elderly should be treated by surgical exploration as soon as the patient is fit because tumors may masquerade in the mass.
Keywords: Appendicitis, appendix mass, appendix tumor, cecal tumor
|How to cite this article:|
Kombo B B, Raphael J E. Clinicopathologic findings in elderly patients with appendix mass. Port Harcourt Med J 2016;10:70-2
|How to cite this URL:|
Kombo B B, Raphael J E. Clinicopathologic findings in elderly patients with appendix mass. Port Harcourt Med J [serial online] 2016 [cited 2021 May 13];10:70-2. Available from: https://www.phmj.org/text.asp?2016/10/2/70/189457
| Introduction|| |
The appendix is the most frequently operated organ by the surgeons. ,, It was described as "worm of the intestine" by the Egyptians. It is absent in lower animals and was omitted by Aristotle and Galen in their dissection of animals. The first description was probably by Celsius during the dissection of criminals executed by Caesar. Philipe Verheyen coined the term appendix vermiformis in 1710. 
The function of the appendix is unclear. The walls of the appendix contain mucus-secreting goblet cells and lymphoid tissue that develop during the 14 th and 15 th weeks of gestation. In the fetus and up to the third decade of life, it has immunological function. The lymphoid tissues subsequently start to atrophy and disappear at 60 years of age. 
Acute appendicitis in its uncomplicated classic form is easily diagnosed and treated. The incidence decreases with age. Majority of the acute appendicitis (90%) affects children and young adults with a peak incidence between 10 and 30 years. This is suggested to be a consequence of the atrophy of lymphoid structures of the appendix with age. , The diagnosis is often clinical. The benefits of imaging modalities have been equivocal. , The risk of perforation in the elderly population is high, up to 70% in some reports. , The morbidity and mortality in the elderly remain significant at 28-60% and 10%, respectively. ,,
An appendix mass, on the other hand, is the end result of a walled-off appendicitis or perforation. ,, We present our experience in the management of patients aged 60 years and older with appendix mass. The aim of this paper is to present the clinical and pathologic findings in patients, 60 years and above who were diagnosed with appendix mass and had surgical interventions.
| Patients and Methods|| |
This is a retrospective study carried out from January 2002 to December 2005 at the Department of Surgery, University of Port Harcourt Teaching Hospital. The hospital records of patients including case notes, theater records, and pathology reports of patients aged 60 years and older who were diagnosed with appendix masses and managed surgically were obtained. The history, presentation, diagnosis, intraoperative findings, and pathological findings were also retrieved and analyzed. Literature review was done using PubMed search, and data analysis was done with SPSS version 17.
| Results|| |
Fifty-eight patients presented with appendix masses and were operated upon during the period with a female:male ratio of 1.5:1. The modal age range was 60-69 years [Table 1].
Most of the patients presented within 5 days of the onset of symptom. Abdominal pain (89.7%) was the most common symptom while constipation (12.5%) was the least common [Table 2].
Acutely inflamed appendix was the most common pathological finding (39.7%). Perforated appendix (17.3%), adenocarcinoma of cecum (15.5%), ameboma (8.6%), benign appendix tumor (5.2%), ascaris-perforated cecum (5.2%), endometriosis (3.4%), and pedunculated fibroid (1.7%) were the other pathological findings [Table 3].
|Table 3: Pathological findings in patients aged 60 years and above with appendix mass|
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| Discussion|| |
An appendix mass is an inflamed appendix with adherent covering of omentum and small bowel, occasionally enclosing a pocket of pus. The history is similar to appendicitis with a longer duration of onset.  This is a complication that has been observed in 2-6% of the patients with acute appendicitis.  In our study, the modal age of the patients with appendix mass was 60-69 years. This is not unexpected because the appendix, like all lymphoid structures, undergoes atrophy with age. This finding is thought to explain the reduced frequency of diseases of the appendix with age. 
The frequency of appendix abscess was observed to be higher in females in our study (60.3%) The reason for the observation is not clear. It may not be unrelated to the predisposition to pelvic inflammatory disease from retrograde infection via the fallopian tubes. Abdominal pain was the most common symptom in 89.7% of the patients. Only 27.5% of the patients had fever in association with anorexia and vomiting. These findings may be related to the reduced expression of mediators of inflammation at the extremes of age. ,
Most of the patients (56.9%) presented within 5 days of the onset of the symptom. Majority of this group have acutely inflamed or perforated appendix alone as the primary pathology. Those with other co-existing pathologies such as uterine fibroid had a more indolent presentation. There is a paucity of literature characterizing the clinical presentation of appendicitis and appendix masses in the elderly.
Clinical examination reveals a mass in the right iliac fossa in all cases. These were confirmed with ultrasound scan (USS). While USS can detect an appendix mass, the sensitivity is low in diagnosing associated pathologies with a significant interobserver variation. , None of our patients had computerized tomography or bowel contrast studies. While other differential diagnosis of appendix masses was entertained, a definitive diagnosis was not made until after surgery. Acute appendicitis and perforation were the most common pathologies observed in our study. Inflammation led to neutrophil infiltration and abscess formation between the bowel loops. Attempts by omentum, and loop of the bowel to wall off the inflammatory process, result in the formation of an appendix mass.  Adenocarcinoma of the cecum was found in 15.5% of the patients. This is not unexpected as the incidence of colonic tumors increases generally with age. ,
Advances in science have not significantly changed the management of patients with appendix mass. There is still controversy over the best form of treatment , between nonoperative treatment, early or delayed surgical exploration. ,, An alternative in those with a well-defined abscess at presentation is ultrasound or computed tomography (CT)-guided drainage. CT-guided drainage has become a successful way of deferring operation in those who are not fit for surgery. , In the elderly patients, however, caution needs to be entertained because of the broad range of differential diagnosis. This is especially important in the females where gynecological conditions frequently create additional camouflage. The management trend in the elderly is toward surgical exploration, and this is our practice.
Intraoperative procedures that were carried out varied from drainage of appendix abscess, appendicectomy to right hemi-colectomy and other appropriate treatments. The diversity of possible intraoperative differentials emphasizes the need for multi-disciplinary management in some cases. Barium enema and colonoscopy are increasingly being added in the evaluation of older patients with appendix mass to exclude colonic tumor. The postoperative hospital stay largely depended on the pathology. Patients who presented late from the onset of symptoms tend to have longer hospital stay. This may be due to the early use of antibiotics in those of inflammatory aetiology, the most common cause of appendix mass in this study. Though some have suggested that there is no benefit of antimicrobial use in patients with wall off appendix mass. ,
| Conclusion|| |
The appendix mass in the elderly should be treated by surgical exploration as soon as the patient is fit because tumors may masquerade in the mass.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Herrington JL Jr. The vermiform appendix: Its surgical history. Contemp Surg 1991;39:36-44.
Kyriazis AA, Esterly JR. Development of lymphoid tissues in the human embryo and early fetus. Arch Pathol 1970;90:348-53.
Nitecki S, Assalia A, Schein M. Contemporary management of the appendiceal mass. Br J Surg 1993;80:18-20.
Hogan MJ. Appendiceal abscess drainage. Tech Vasc Interv Radiol 2003;6:205-14.
Brown CV, Abrishami M, Muller M, Velmahos GC. Appendiceal abscess: Immediate operation or percutaneous drainage? Am Surg 2003;69:829-32.
Friedell ML, Perez-Izquierdo M. Is there a role for interval appendectomy in the management of acute appendicitis? Am Surg 2000;66:1158-62.
Tekin A, Kurtoglu HC, Can I, Oztan S. Routine interval appendectomy is unnecessary after conservative treatment of appendiceal mass. Colorectal Dis 2008;10:465-8.
Corfield L. Interval appendicectomy after appendiceal mass or abscess in adults: What is "best practice"? Surg Today 2007;37:1-4.
Eryilmaz R, Sahin M, Savas MR. Is interval appendectomy necessary after conservative treatment of appendiceal masses? Ulus Travma Acil Cerrahi Derg 2004;10:185-8.
Adalla SA. Appendiceal mass: Interval appendicectomy should not be the rule. Br J Clin Pract 1996;50:168-9.
Okafor PI, Orakwe JC, Chianakwana GU. Management of appendiceal masses in a peripheral hospital in Nigeria: Review of thirty cases. World J Surg 2003;27:800-3.
Bagi P, Dueholm S. Nonoperative management of the ultrasonically evaluated appendiceal mass. Surgery 1987;101:602-5.
Samuel M, Hosie G, Holmes K. Prospective evaluation of nonsurgical versus surgical management of appendiceal mass. J Pediatr Surg 2002;37:882-6.
Fitzmaurice GJ, McWilliams B, Hurreiz H, Epanomeritakis E. Antibiotics versus appendectomy in the management of acute appendicitis: A review of the current evidence. Can J Surg 2011;54:307-14.
Kaminski A, Liu IL, Applebaum H, Lee SL, Haigh PI. Routine interval appendectomy is not justified after initial nonoperative treatment of acute appendicitis. Arch Surg 2005;140:897-901.
[Table 1], [Table 2], [Table 3]