AUCTORES
Globalize your Research
case report
*Corresponding Author: Nonso Mbah, Chukwuemeka Odumegwu Ojukwu University Teaching Hospital (COOUTH), PMB 5022, Awka. Anambra State, Nigeria.
Citation: Nonso Mbah., (2024), Appendiceal Mucocele: Delayed Presentation, Treatment and Literature Review, J, Surgical Case Reports and Images, 7(3); DOI:10.31579/2690-1897/188
Copyright: © 2024, Nonso Mbah. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 10 April 2024 | Accepted: 18 April 2024 | Published: 26 April 2024
Keywords: mucocele; delayed presentation; appendix; missed diagnosis; uncommon
Appendiceal mucocele is a non-specific term for 4 different pathological conditions of the vermiform appendix in which there’s an abnormal accumulation of mucinous material within the distended appendix. It is an uncommon condition. Missed diagnosis still occurs pre-operatively despite the availability of valuable ancillary imaging facilities. Open meticulous surgical treatment which avoids rupture or spillage of the mucinous content offers the best chance of cure.
Carl von Rokitansky of Vienna, Austria was the first to describe mucocele of the appendix in 1842.1 Since then, 4 different pathological conditions have been recognized to present under this non-specific terminology.2 The common feature in all cases is the abnormal distension of the vermiform appendix due to large accumulation of mucin.
The specific disease states which present as appendiceal mucocele (AM), and their respective incidence (%), are notably:
Mucoceles which are less than 2cm in diameter are usually simple retention cysts while mucosal hyperplasia, mucinous cystadenoma and mucinous cystadenocarcinoma are most likely to be greater than 2cm.2 While AM due to simple retention cyst and mucosal hyperplasia are non-neoplastic, the other 2 are neoplasms. Mucinous cystadenoma is a benign neoplasm with a very good prognosis, occurs with the highest incidence, and has approximately 20% risk of spontaneous rupture. Mucinous cystadenocarcinoma is malignant with the possibility of spontaneous rupture in 6% of cases. It also has poor prognosis with high rate of metastasis to the lymph nodes and liver.3
Being a heterogenous entity, AM has variable clinical presentations. It may be asymptomatic, with the diagnosis made as an incidental finding during imaging studies, or laparoscopic investigation for other abdominal conditions.4 Symptomatic cases may attend with abdominal pain, nausea, poor appetite, vomiting, change in bowel habit, weight loss, abdominal distension, rectal bleed or the presence of a painful palpable mass in the abdomen.3,4 Hospital presentation may either be as an acute condition similar to acute appendicitis, or for chronic symptoms as was the case with our patient.
Sonographic features typically associated with AM are ≥15mm outer diameter of the vermiform appendix and the onion-skin appearance.5 A multidetector CT scanner is the preferred diagnostic imaging modality. Pathognomonic CT findings include a well-encapsulated, rounded or tubular cystic mass adjacent to the caecum, as well as the presence of wall calcifications in 50% of cases.6 Preoperative colonoscopy is also diagnostic of this condition if it shows the peculiar “volcano sign” which is due to the presence of a mount-like elevation of the appendix orifice with a central crater from which yellowish mucoid material exudes.7
A dreaded complication of AM is the rupture or spillage of the mucin-producing epithelial cells within the peritoneal cavity and the attendant risk of developing pseudomyxoma peritonei (PMP). When PMP develops in patients with AM other than those with mucinous cystadenocarcinoma, survival and prognosis are better. By contrast, the prognosis of PMP is worse when associated with the cystadenocarcinoma.8,9
Similarly, AM due to simple retention cyst, mucosal hyperplasia and the benign mucinous cystadenoma have excellent post-operative outcome, with 5-year survival rates of 91 – 100%. Conversely, mucinous cystadenocarcinoma, being the malignant form of AM, has poor prognosis after appendicectomy, with 5-year survival rate of 25%.10
Mrs O. C, 69 years old widow, Para 9, presented at a private health facility in July 2021 with 1- year history of painful abdominal mass lesion. The pain was biting in character with a mild to moderate severity score of 3-5/10. She had associated change in bowel habits characterized by upwards of 2 days of constipation. No associated vomiting or weight loss. The patient reported having a background history of high blood pressure and bilateral knee arthritis. Her regular tablet medications comprised of Amlodipine, Losartan, Hydrochlorothiazide, Digoxin, Clopidogrel, Atorvastatin, Paracetamol and Diclofenac. The past surgical history was unremarkable.
On physical examination, she was afebrile (Temp 36.6oC), BP was 106/84mmHg, PR 90/min. She was moderately obese with a BMI of 34.1 (weight 95kg, height 1.67m). Her abdomen was globally soft and contained a slightly tender, mobile intra-abdominal mass at the right iliac fossa. It was firm in consistency with vague margins. The digital rectal examination was normal.
The pre-operative haematological investigations were unremarkable.
Her abdomino-pelvic sonography reported a mixed solid and cystic right adnexal mass with no definite vascular features and was suggestive of ovarian cyst with intra-cystic haemorrhage.
Computerised tomography (CT) scan report documented a right lower abdominopelvic cystic mass, probably a mesenteric cyst.
The patient was worked up for elective exploratory laparotomy. Intra-operatively, there was an enlarged dumb-bell shaped mass lesion with a wide base at the position of the vermiform appendix at the ileo-caecal junction (fig. 1). There were no visibly enlarged mesenteric lymph nodes. The rest of the abdominal viscera, including the liver, were macroscopically healthy looking.
The tumour was delivered from the abdominal cavity, doubly ligated at the base and excised (figure. 2 and 3). The stump was buried and the laparotomy wound was closed by mass closure. She had 1 unit of blood transfusion intra-operatively. Her post-operative course was uneventful. She was discharged from the hospital on the 4th post-operative day after the restoration of regular bowel movements.
Figure 1: Intra-operative insitu Appendiceal Mucocele.
Figure 2: Ligated base of Appendix Mucocele
Figure 3: Intact resected dumb-bell shaped Appendiceal Mucocele.
The histology report documented a 15cm x 6cm x 6cm enlarged and cystic appendicectomy tissue which weighed 295g and was filled with mucinous material. It had mucinous epithelial lining associated with dense inflammation on the collagenous wall including inflammatory giant cells. No atypia was noted. Histological diagnosis was Mucinous cystadenoma with foreign body granuloma.
The patient has remained asymptomatic on follow-up 2 years after surgical treatment.
Appendix mucocele is a difficult condition to diagnose. Despite well established sonographic and CT features of AM, the pre-operative diagnosis was completely missed in our case due to the non-familiarity with this condition by the attending sonologists and radiologists. The incidence is 0.2% to 0.7% in all appendicectomy specimens.2 Its rarity necessitates a high index of clinical suspicion and familiarity with the imaging features if cases are not to be missed, both by the radiologists and the clinicians.
The heterogenous nature of AM makes the clinical presentation ambiguous. Cases presenting in emergency rooms as acute appendicitis had previously been reported, even in pregnancy.4,11 Conversely, due to the mildness of the symptoms in some patients, late presentation with symptoms lasting for months, as in the case presented here, abound.12,13 The presence of an abdominal lump could be obvious to both the patient and clinician. In such situations, the differential diagnoses in either gender include mesenteric cyst, intussususception, colonic tumour, and in females may also suggest ovarian cyst, tubal pregnancy, uterine fibroid or tubo-ovarian abscess. Cases of AM which are diagnosed pre-operatively may benefit from surveillance colonoscopy. This investigation facilitates the identification of synchronous and metachronous colonic tumours, which if present would influence the extent of the planned definitive surgical resection.5,6 Our patient didn’t receive colonoscopy, as her AM was discovered intra-operatively.
The intact mucocele does not pose a threat to the patient. Conversely, when it is perforated or ruptured either iatrogenically or due to delayed presentation, there is spillage of the mucin-producing epithelial cells into the peritoneal cavity. This complication is associated with a high probability of precipitating pseudomyxoma peritonei, a potentially
catastrophic condition for which treatment is problematic and long term results are unsatisfactory.8 It is for these reasons that the open surgical
approach is favoured by many surgeons over the laparoscopic technique, for the resection of AM.14 The advantages of the open operation include meticulous tactile tissue handling and the opportunity to directly inspect parts of the abdominal cavity where mucinous tumours are most common. The favourable outcome of our case was predicated not only on the benign mucinous cystadenoma histology of her AM, but also on the use of laparotomy for her treatment which ensured the mucocele was not ruptured iatrogenically. However, recent reports posit that the operation for AM can alternatively be performed laparoscopically, both safely and successfully, by adhering to safety rules which include the use of an endobag to remove the mucocele and ensuring the conduct of the procedure by a surgeon who is experienced in advanced laparoscopy.15
In conclusion, a high index of clinical suspicion and familiarity with the characteristic imaging features are required for the pre-operative diagnosis of appendiceal mucocele by both the radiologist and clinician. Meticulous surgical technique is mandatory during the resection of the lesion in order to avoid iatrogenic rupture and the precipitation of such catastrophic complication as pseudomyxoma peritonei.
None.
None.
This case report is exempt from ethical approval in our institution.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
