Case presentation of of appendiceal mucocele, and short description about the disease and findings in different imaging modalities.

2. Case Presentation
Dr Muhammad Umer Masud

3. Demographic Profile
Name: Rasheeda
Age: 68 years. F
Marital status: Married
Residence: Rawalakot
M.O.A : ER
D.O.A : 17-5-16

4. Presenting Complaints
Rasheeda Bibi, 68 yrs female presented to ER with
Pain in RIF – 4 days
Fever - 4 days
Associated with nausea and vomiting
 Pain in RHC – 10 days

5. History Of Present Illness
• Known hypertensive , diabetic .
• Known case of cholelithiasis.
• Pain in RIF. 4 days
• severe, continuous, radiating to back
• No aggravating factors.
• Pain in RHC – 10 days
• Fever, nausea and vomiting.

6. On Examination :
GIT: Distended abdomen
no visible pulsations, scar marks
Hernial orifices were intact.
Abdomen was soft
tenderness positive in RIF.
Rebound tenderness +ive.
Cough sign +ive
Obturator sign positive. Bowel sounds were audible
CVS: S1+ S2 + 0
CNS : GCS 15/15
Respiratory system: NVB

7. Labs:
Hb : 10.8 g/ dl
WBC : 6 x 10 *3/ ul
Platelets : 429 x 10 *3
RFTs:
Urea 32 mg/dl
Creatinine 0.8 mg /dl
Lipase : 34 u /l ( with in normal limits)

8. LFTS:
Bilirubin :0.7
ALP : 188 u
ALT:23u/l
S/E:
Na : 141 meq/L
K: 3.9 m Eq/ l

9. USG Abdomen Findings:
-Fatty hepatomegaly
-Cholelithiasis
-A blind ended cystic lesion in right iliac fossa with foci of
calcification.
-Patient could not hold urine so origin of lesion could not be
assessed.
CA 125 - normal limits.

11. CT scan :
elongated tubular blind ending hypodense area - right iliac fossa
- contiguous with base of cecum
- curvilinear mural calcification
most likely suggestive of appendiceal mucocele.
-Cholelithiasis

17. Per Op findings
. Mucocele of the appendix.
• Peritoneal biopsy was taken.
• Ileum separated from phlegmon.
• Appendix dissected.
• Base of the appendix was healthy.
• Both appendix and peritoneal biopsy (lymph nodes) were sent
for histopathology

19. Appendiceal mucocele:
- abnormal accumulation of mucus within the appendix.
- mucus causes obstruction of the appendiceal neck
- dilatation of the lumen.

20. Epidemiology
• 0.07-0.3%. Of all the appendectomied samples.
. middle aged individuals.

21. Etiology
1) Retention cyst = cystic dilatation of lumen - obstruction by
fecolith, foreign body, carcinoid, endometriois, adhesions,
volvulus.
2) Mucosal hyperplasia (25%)

22. 4)
Mucinous cystadenoma -hyperplasia with epithelial atypia (63%)
=mucin secreting tumor
5)
Mucinous cystadenocarcinoma with stromal invasion (12%)
6)
Cystic fibrosis.

23. Associated with:
Colonic adenocarcinoma
Mucin secreting tumor of the ovary.

24. Asymptomatic (25%)
Palpable mass (in upto 50 %)
Acute/ Chronic lower quadrant pain
+/- elevated CEA, CA 125, CA 19-9

25. Radiographic features
• Fluoroscopy: barium enema
• If a contrast examination is performed, there is usually non-
filling or partial-filling of the appendix.
• Globular, smooth walled, broad based mass invaginating into
cecum.
• Peripheral punctate / rim like calcifications (porcelain
appendix)

29. Ultrasound
• Typically cystic mass
• variable internal echogenicity .
• The presence of an "onion sign"
• (sonographic layering within a cystic mass)

35. • CT
• well-circumscribed, low-attenuation, spherical or tubular
mass contiguous with the base of the caecum
• curvilinear mural calcification
• air-fluid level - superinfection,

43. NUC:
Intense early gallium uptake
( affinity to acid mucopolysaccharides of mucus)

44. • MRI
• Seen as a rounded right iliac fossa mass.
• Typical signal characteristics include:
• T1: depending on the mucin concentration, the signal may be
variably hypointense to isointense
• T2: hyperintense

46. • Treatment and prognosis
• Treatment is usually surgical.

47. Variants
• myxoglobulosis:
• multiple small intraluminal globules which can calcify and
produce 1-10 mm mobile calcifications

48. Complications:
1) Rupture can lead to pseudomyxoma peritonei.
2) Torsion -> gangrene and hemorrhage
3) Herniation into cecum -> bowel obstruction
4) intussusception

49. THANK YOU.