A 34-year-old complained about a sudden onset of right-lower-quadrant pain. Preoperative ultrasound revealed the appendix with a hypoechoic and thickened wall and the so-called dome sign [Figure 1]. Abdominal tenderness and other clinical signs were suggestive of acute appendicitis. On clinical examination tachycardia (108/min), febrile temperature (38.60 C) and dehydration were documented. Blood test results showed leucocytosis (13,2/nl). Emergency laparoscopic appendecectomy was performed. A large inflammatory mass was found involving the appendix [Figure 2]. The histological specimen revealed the combined presentation of congenital and acquired diverticula. Histopathological examination confirmed phlegmonous inflammation of the appendix and periappendicitis caused by inflammation of diverticula [Figure 3].
Here we present the sonographic findings of a diverticulitis of the appendix including histology. The diverticulum could be clearly displayed in an otherwise thickened appendix with well preserved layers. Diverticula of the appendix can be true or congenital or false (due to acquired mechanisms) [Table 1 and 2] [(1)]. The wall of congenital diverticula contains all the normal histological components of the appendiceal wall. The walls of the acquired or false appendiceal diverticulum are only composed of mucosa, some loose areolar tissue and the serosa. This group either develops during the growth of the fetus or before inflammatory changes make there appearence in the appendix. The prevalence of congenital diverticula found in appendicectomy specimens range from 0,004 % to 0,6 % [(2)]. Diverticulitis of diverticula of the appendix is even rarer. Approximately 78% of cases were associated with varying signs and degrees of inflammation at time of their removal [(3)]. Perforation was observed in 66 % of cases with a high mortality (30-fold compared with acute appendicitis). Four subtypes of appendicular diverticulosis have been described in the literature [Table 2] [(1)]. The majority of diverticula of the appendix described in the literature were incidental findings observed during routine X ray examination of the gastrointestinal tract. While it is agreed that many people with appendiceal diverticula live healthy, normal lives, there can be no doubt that with the onset of complications, life is threatened by inflammation and complications.
|Prevalence (Incidence)||0,014 %||1,4 %|
|Solitary / multiple||Solitary||Multiple or solitary|
|Localisation||Antimesenteric border||Mesenteric or antimesenteric border|
|Type 1||Inflamed||Normal||Normal-appearing appendix with an acutely inflamed diverticulum|
|Type 2||Inflamed||Inflamed||Acutely inflamed diverticulum with surrounding appendicitis|
|Type 3||Normal||Inflamed||Conventional appendicitis with an incidental uninvolved diverticulum|
|Type 4||Normal||Normal||incidental appendiceal diverticulum with no appendicitis|