RIF pain…an unusual
suspect
HS.








84 year old gentleman
7/52 history of right iliac fossa pain
‘Tightness’ at RIF
Constant
Non radiating
Worse on hip flexion and movement
No fevers/night sweats/rigors
No nausea/vomiting/altered bowel habit
History
Past Medical History
 NIDDM
 MI – ’98
 Right inguinal hernia repair
 Vit B12 deficiency
Medications
 Metformin
 Aspirin
 Atorvastatin
 Pantoprazole

History



Social History
– Non smoker
– No C2H5OH
Family History
– NIDDM
Systems review
– NAD
Examination







BP 118/66, PR 90, Temp 36.5, Sats 96% on RA
Abdomen soft
Tender at RIF
Guarding on deep palpation at RIF
No distension
Bowel sounds present and normal
DRE- NAD
Investigations
Radiology
Bloods







Hb
WBC
Neut
ESR
CRP
U&E
LFTs
12.7
7.17
4.93
35
6
normal
normal


PFA
– density projected
over Right renal
pelvis (7X5mm),
?renal calculus.
Bowel within normal
limits.
CXR
– NAD
Intra-operative





Laparoscopy
Laparoscopic mobilisation of ceacum
Findings:
– hard appendiceal mass
Converted to laparotomy
Right hemicolectomy
Histology


Diffuse large B cell lymphoma, appendix, germinal
centre type
Margins and lymph nodes free.
Post operative course





Wound infection
Oncology review
CT Thorax, abdomen, pelvis
Discharged on POD 17 with po Antibiotics
Follow up
– 1/12 in our OPD
– 3/12 in oncology OPD
Appendiceal Tumours
Background

Gastrointestinal tract
– is the most frequently involved extranodal site of Non
Hodgkins lymphoma (30-45%).
– 4-20% of all Non Hodgkins lymphoma.

Incidence of primary lymphomas of appendix
– estimated as 0.015% of all gastrointestinal lymphomas.

1% of all appendectomy specimens contain a
neoplasm.
Presentation







Acute appendicitis
Weight loss
Anorexia
Palpable lower quadrant mass
Obstruction/constipation
Nausea/vomiting
Diagnosis- histological
Investigation






History
– similar to appendicitis.
Examination
– tender RIF +/- mass
Bloods
– Normal/Raised inflammatory markers
Radiology (pre op)
– CXR/PFA – perforation/obstruction
– CT ABDOMEN – mass
Histology
Radiology (post op)
– CT TAP - mets
Management


Early detection + high suspicion –
essential.
Surgery
– Appendectomy
– +/- Right hemicolectomy
– +/- lymph node dissection
Types

Divided into 2 major groups
– Carcinoid

occurs at tip of appendix.
– Non-carcinoid
originate at the epithelial lining of appendix.
 Produce a thick gelatinous material known as
mucin.

Carcinoid
Most common form (>50% cases)
F>M
Occur in 4th decade of life.
Symptoms
similar to appendicitis.
Carcinoid syndrome – flushing, SOB, diarrhea,
Right sided heart valve disease.
Tx- appendectomy + Right hemicolectomy +
lymph node dissection.
85% 5-year survival rate.
B cell lymphoma



non-Hodgkin's B-cell lymphoma
usually present in second to third
decade of life.
Symptoms
– Like appendicitis

Treatment
– Appendectomy + Right hemicolectomy
Adenocarcinoma








F=M
Occurs 6th decade of life
Rarer but more aggressive type.
Occur in the epithelial lining of the appendix – obstructive symptoms.
Symptoms
– Abdominal pain, constipation, N+V.
Treatment
– Appendectomy + right hemicolectomy.
Prognosis – poorer than carcinoid.
5 yr survival.
– Duke’s A – 94
– Duke’s B – 83%
– Duke’s C – 44%
Pseudomyxoma peritonei
(PMP)



Presence of acellular mucin within abdominal cavity.
Usually has metastased at time of presentation.
Spread
– direct
– rarely through bloodstream or lymphatics.

Sypmtoms
–
–
–
–

Bowel obstruction
Increase in abdominal size
Pelvic discomfort
Ovarian masses
Treatment
– debulking surgery.
Summary




Appendicitis should be the top of your
differential for anyone with RIF pain.
Appendiceal cancer is a rare (and usually an
incidental) finding
Should be suspected in any elderly person
presenting with appendicitis like symptoms
and signs
Histology of ALL patients post
appendectomy should be checked








http://www.ajronline.org/cgi/content/full/178/5/1123 (histology pictures)
http://www.ijpmonline.org/article.asp?issn=03774929;year=2008;volume=51;issue=3;spage=392;epage=394;aulast=Radha
(indian case)
http://www.mdanderson.org/patient-and-cancer-information/cancerinformation/cancer-types/appendix-cancer/index.html
www.medscape.com/viewarticle/431119_3 (normal CT appendix)
http://www.dmvsurgerycenter.com/Portals/0/gensurg.gif (surgery pic)
www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=cmed.section.24834 (info on
adenocarcinoma)
http://www.aboutcancer.com/appendix_cancer.htm
(graph)
http://www.thedoctorsdoctor.com/diseases/
appendix_adenoca.htm - Appendiceal tumors:
retrospective clinicopathologic analysis of appendiceal tumors from
7,970 appendectomies. Connor SJ, Hanna GB, Frizelle FA