RIF pain…an unusual RIF pain…an unusual suspectsuspect

HS.HS.

84 year old gentleman 84 year old gentleman 7/52 history of right iliac fossa pain7/52 history of right iliac fossa pain ‘‘Tightness’ at RIFTightness’ at RIF ConstantConstant Non radiatingNon radiating Worse on hip flexion and movement Worse on hip flexion and movement No fevers/night sweats/rigorsNo fevers/night sweats/rigors No nausea/vomiting/altered bowel habitNo nausea/vomiting/altered bowel habit

HistoryHistory

Past Medical HistoryPast Medical History NIDDMNIDDM MI – ’98MI – ’98 Right inguinal hernia repairRight inguinal hernia repair Vit B12 deficiencyVit B12 deficiency

MedicationsMedications MetforminMetformin AspirinAspirin AtorvastatinAtorvastatin

PantoprazolePantoprazole

HistoryHistory

Social HistorySocial History– Non smokerNon smoker– No C2H5OHNo C2H5OH

Family HistoryFamily History– NIDDMNIDDM

Systems reviewSystems review– NADNAD

ExaminationExamination

BP 118/66, PR 90, Temp 36.5, Sats 96% on BP 118/66, PR 90, Temp 36.5, Sats 96% on RARA

Abdomen softAbdomen soft Tender at RIFTender at RIF Guarding on deep palpation at RIFGuarding on deep palpation at RIF No distension No distension Bowel sounds present and normalBowel sounds present and normal DRE- NADDRE- NAD

InvestigationsInvestigations

BloodsBloods

Hb Hb 12.712.7 WBC WBC 7.177.17 Neut Neut 4.934.93 ESR ESR 3535 CRP CRP 66 U&E U&E normal normal LFTs LFTs normalnormal

RadiologyRadiology

PFA PFA – density projected density projected

over Right renal over Right renal pelvis (7X5mm), ?pelvis (7X5mm), ?renal calculus. renal calculus. Bowel within Bowel within normal limits.normal limits.

CXR CXR – NADNAD

Intra-operativeIntra-operative

LaparoscopyLaparoscopy Laparoscopic mobilisation of ceacumLaparoscopic mobilisation of ceacum Findings:Findings:

– hard appendiceal masshard appendiceal mass Converted to laparotomyConverted to laparotomy Right hemicolectomyRight hemicolectomy

HistologyHistology

Diffuse large B cell lymphoma, appendix, Diffuse large B cell lymphoma, appendix, germinal centre typegerminal centre type

Margins and lymph nodes free.Margins and lymph nodes free.

Post operative coursePost operative course

Wound infectionWound infection Oncology reviewOncology review CT Thorax, abdomen, pelvisCT Thorax, abdomen, pelvis

Discharged on POD 17 with po Discharged on POD 17 with po AntibioticsAntibiotics

Follow up Follow up – 1/12 in our OPD1/12 in our OPD– 3/12 in oncology OPD 3/12 in oncology OPD

Appendiceal TumoursAppendiceal Tumours

BackgroundBackground

Gastrointestinal tract Gastrointestinal tract – is the most frequently involved extranodal site of is the most frequently involved extranodal site of

Non Hodgkins lymphoma (30-45%). Non Hodgkins lymphoma (30-45%). – 4-20% of all Non Hodgkins lymphoma.4-20% of all Non Hodgkins lymphoma.

Incidence of primary lymphomas of appendix Incidence of primary lymphomas of appendix – estimated as 0.015% of all gastrointestinal estimated as 0.015% of all gastrointestinal

lymphomas. lymphomas. 1% of all appendectomy specimens contain a 1% of all appendectomy specimens contain a

neoplasm. neoplasm.

PresentationPresentation

Acute appendicitisAcute appendicitis Weight loss Weight loss AnorexiaAnorexia Palpable lower quadrant massPalpable lower quadrant mass Obstruction/constipationObstruction/constipation Nausea/vomitingNausea/vomiting Diagnosis- histologicalDiagnosis- histological

InvestigationInvestigation

HistoryHistory– similar to appendicitis.similar to appendicitis.

Examination Examination – tender RIF +/- masstender RIF +/- mass

Bloods Bloods – Normal/Raised inflammatory markersNormal/Raised inflammatory markers

Radiology (pre op)Radiology (pre op)– CXR/PFA – perforation/obstructionCXR/PFA – perforation/obstruction– CT ABDOMEN – massCT ABDOMEN – mass

HistologyHistology Radiology (post op)Radiology (post op)

– CT TAP - metsCT TAP - mets

ManagementManagement

Early detection + high suspicion – Early detection + high suspicion – essential.essential.

Surgery Surgery – Appendectomy Appendectomy – +/- Right hemicolectomy +/- Right hemicolectomy – +/- lymph node dissection+/- lymph node dissection

TypesTypes

Divided into 2 major groupsDivided into 2 major groups– Carcinoid Carcinoid

occurs at tip of appendix.occurs at tip of appendix.

– Non-carcinoid Non-carcinoid originate at the epithelial lining of originate at the epithelial lining of

appendix.appendix. Produce a thick gelatinous material Produce a thick gelatinous material

known as mucin.known as mucin.

CarcinoidCarcinoid

Most common form (>50% cases)Most common form (>50% cases)F>MF>MOccur in 4Occur in 4thth decade of life. decade of life.Symptoms Symptoms

similar to appendicitis.similar to appendicitis.Carcinoid syndrome – flushing, SOB, Carcinoid syndrome – flushing, SOB,

diarrhea, Right sided heart valve diarrhea, Right sided heart valve disease.disease.

Tx- appendectomy + Right hemicolectomy + Tx- appendectomy + Right hemicolectomy + lymph node dissection.lymph node dissection.

85% 5-year survival rate.85% 5-year survival rate.

B cell lymphomaB cell lymphoma

non-Hodgkin's B-cell lymphoma non-Hodgkin's B-cell lymphoma usually present in second to third usually present in second to third

decade of life.decade of life. SymptomsSymptoms

– Like appendicitisLike appendicitis TreatmentTreatment

– Appendectomy + Right Appendectomy + Right hemicolectomyhemicolectomy

AdenocarcinomaAdenocarcinoma

F=MF=M Occurs 6Occurs 6thth decade of life decade of life Rarer but more aggressive type.Rarer but more aggressive type. Occur in the epithelial lining of the appendix – obstructive Occur in the epithelial lining of the appendix – obstructive

symptoms.symptoms. SymptomsSymptoms

– Abdominal pain, constipation, N+V.Abdominal pain, constipation, N+V. TreatmentTreatment

– Appendectomy + right hemicolectomy.Appendectomy + right hemicolectomy. Prognosis – poorer than carcinoid.Prognosis – poorer than carcinoid. 5 yr survival. 5 yr survival.

– Duke’s A – 94Duke’s A – 94– Duke’s B – 83%Duke’s B – 83%– Duke’s C – 44%Duke’s C – 44%

Pseudomyxoma Pseudomyxoma peritonei (PMP)peritonei (PMP) Presence of acellular mucin within abdominal cavity.Presence of acellular mucin within abdominal cavity. Usually has metastased at time of presentation.Usually has metastased at time of presentation. SpreadSpread

– directdirect– rarely through bloodstream or lymphatics.rarely through bloodstream or lymphatics.

SypmtomsSypmtoms– Bowel obstructionBowel obstruction– Increase in abdominal sizeIncrease in abdominal size– Pelvic discomfortPelvic discomfort– Ovarian masses Ovarian masses

TreatmentTreatment– debulking surgery.debulking surgery.

SummarySummary

Appendicitis should be the top of your Appendicitis should be the top of your differential for anyone with RIF pain.differential for anyone with RIF pain.

Appendiceal cancer is a rare (and Appendiceal cancer is a rare (and usually an incidental) findingusually an incidental) finding

Should be suspected in any elderly Should be suspected in any elderly person presenting with appendicitis person presenting with appendicitis like symptoms and signslike symptoms and signs

Histology of Histology of ALLALL patients post patients post appendectomy should be checkedappendectomy should be checked

http://www.ajronline.org/cgi/content/full/178/5/1123 (histology (histology pictures)pictures)

http://www.ijpmonline.org/article.asp?issn=0377-4929;year=2008;volume=51;issue=3;spage=392;epage=394;aulast=Radha (indian case) (indian case)

http://www.mdanderson.org/patient-and-cancer-information/cancer-http://www.mdanderson.org/patient-and-cancer-information/cancer-information/cancer-types/appendix-cancer/index.htmlinformation/cancer-types/appendix-cancer/index.html

www.medscape.com/viewarticle/431119_3 (normal CT appendix)www.medscape.com/viewarticle/431119_3 (normal CT appendix) http://www.dmvsurgerycenter.com/Portals/0/gensurg.gif (surgery pic)http://www.dmvsurgerycenter.com/Portals/0/gensurg.gif (surgery pic) www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=cmed.section.24834 (info on www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=cmed.section.24834 (info on

adenocarcinoma)adenocarcinoma) http://www.aboutcancer.com/http://www.aboutcancer.com/

appendix_cancer.htm (graph)appendix_cancer.htm (graph) http://www.thedoctorsdoctor.com/http://www.thedoctorsdoctor.com/

diseases/appendix_adenoca.htm - diseases/appendix_adenoca.htm - Appendiceal tumors: retrospective clinicopathologic analysis Appendiceal tumors: retrospective clinicopathologic analysis of appendiceal tumors from 7,970 appendectomies. Connor of appendiceal tumors from 7,970 appendectomies. Connor SJ, Hanna GB, Frizelle FASJ, Hanna GB, Frizelle FA