A CASE OF APPENDICEAL MUCOCELE WITH A HIGH LEVEL OF CEA IN CYSTIC FLUID
Takayuki NAKAZAKIKoji TobinagaKatsuro TAKETOMIKouji KIMINOTomonori NakasoneHideki YamashitaMasao Kishikawa
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Abstract:
Appendiceal mucocele is a relatively rare disease. We report a case of appendiceal mucocele with a high level of CEA in the cystic fluid. A 74-year-old woman was admitted to the hospital because of an ileocecal mass. Barium enema and colonoscopy revealed a submucosal tumor in the cecum. Abdominal computed tomography and ultrasonography showed a cystic mass in the ileocecum. Appendectomy was performed with the diagnosis of appendiceal mucocele. The appendix swelled to be 7.0×4.0cm in size. The CEA level of the cystic fluid was extremely high, 62577ng/ml. Pathologically, it was diagnosised as mucinous cystadenoma and immunohistochemical staining of CEA was positive.Keywords:
Mucocele
Mucinous cystadenoma
Barium enema
Cecum
Mucocele of the appendix is a rare lesion, characterized by distension of the lumen due to accumulation of mucus material. Correct preoperative diagnosis is seldom achieved. If left untreated, the mucocele may rupture producing a potentially fatal peritoneal spread. The type of surgical treatment is related to the dimensions and histology of the mucocele. In this paper, the case of a 49-year-old woman, with a previous appendectomy, suffering from a painful mass in the right lower quadrant of the abdomen, is reported. Imaging showed a large, cystic structure at the base of the cecum. Surgery revealed a 8x5.5 cm calcified tumor, which was excided together with the appendiceal remnant. Pathological diagnosis was that of a mucocele arising from the appendiceal stump due to the development of a benign mucinous cystadenoma.
Mucocele
Mucinous cystadenoma
Cystadenoma
Pseudomyxoma Peritonei
Abdominal distension
Cystadenocarcinoma
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Barium enema and colonoscopy share common problems, including patient preparation and cooperation, technical difficulties in reaching the cecum, and variables relating to the expertise of the person performing the procedure. On the other hand, it has been well documented that colonoscopy has the advantage of detecting a larger number of lesions and smaller lesions, and the ability to be therapeutic as well as diagnostic. Colonoscopy also guides the surgeon in doing proper resections, based on tissue diagnoses, in cases when there are several lesions in different locations in colon. When colon lesions are suspected, barium enema as the first diagnostic procedure means that the patient must undergo a second bowel preparation prior to colonoscopy. Thus, instead of using colonoscopy to confirm or rule out the findings, the most logical approach is to do colonoscopy first, which avoids the repetition of bowel preparation and the cost of barium enema. If colonoscopy cannot be performed, or cannot be completed to the cecum, then the next best choice is to proceed to double contrast barium enema.
Barium enema
Enema
Cecum
Bowel preparation
Double-contrast barium enema
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Examination of the cecum and the proximal ascending colon with ingested barium has received little mention in the radiological literature. Ross Golden has strongly recommended this type of investigation in studies of the cecum and the colon just distal to the ileocecal valve (3, 4). Others have also mentioned that the procedure may often be worthwhile in evaluating the right colon (1, 2, 5). We have found it an extremely useful maneuver as an adjunct to the barium-enema study of the large intestine. The cecum can be difficult to examine thoroughly by barium enema. Since it is the last portion of the colon to be filled, debris and fluid may occasionally be brought to it by the enema, from the distal colon. During filling of the proximal colon the patient may be uncomfortable and unco-operative, so that an adequate fluoroscopic spot-film study is hard to obtain (Fig. 1). On occasion, it is difficult to be certain that the cecum is filled by the enema. Since elucidation of the differential diagnosis of lesions in this region requires thorough study of the mucosa and of adjacent structures (the appendix and terminal ileum), a method which will allow meticulous filming and fluoroscopic observation is valuable (Figs. 2 and 3). Further examination with oral barium is a simple additional procedure which usually solves the dilemma without discomfort to the patient (Fig. 2). Advantages of Ingested Barium The use of ingested barium for study of the proximal right colon has many advantages. The examination becomes a comfortable one for the patient and the radiologist is therefore able to study the lesion carefully and thoroughly at fluoroscopy. Spot-films with and without pressure are readily made in the supine and prone positions (Figs. 1 and 4). The relationships of the cecum to the appendix, terminal ileum, and ileocecal valve are easily demonstrable. Filling of the entire colon is assured, and the length of the right colon can be determined (Fig. 2). The ileocecal valve is easily identified and can be distinguished from a cecal abnormality (Fig. 4). The proximal margin of a right-sided colonie lesion, which produces obstruction to the retrograde flow of barium administered by enema, can be visualized (Fig. 2). Lesions of the colon in the vicinity of the ileocecal valve may obstruct the retrograde flow of barium but will not necessarily interfere with the antegrade flow. It is worthy of emphasis that the colonic contents in this region are liquid. Adequate mucosal detail is more consistently demonstrated by this method than by the barium enema, for it is not uncommon that in the post-evacuation phase of the latter examination the mucosa of the proximal colon is not well delineated. Indications We have found that there are three distinct indications for oral ingestion of barium after the barium-enema study has been performed.
Cecum
Ascending colon
Barium enema
Ileocecal valve
Barium sulfate
Large intestine
Barium meal
Enema
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Mucocele of the appendix is a rare clinicopathological entity simulating acute appendicitis. The most common form of the mucocele is cystadenoma, which is characterized by luminal dilatation producing large amounts of mucin. We present a new case of a giant mucocele of appendix with mucinous cystadenoma. A 61-year-old female was admitted with complaints of severe lower right quadrant pain. Ultrasonography and computed tomography (CT) suggested that it was a mucocele, but due to severity of pain, she underwent an emergency operation. Fortunately, without a perforation, it was a giant mucocele and the operation was terminated with an uneventful appendectomy with segmental cecal resection. The histopathological evaluation of the specimen reported to be a mucocele with mucinous cystadenoma with negative surgical margins. The patient was discharged postoperative 6th day, and a control colonoscopy and abdominal CT was planned for 6 months following surgery. Appendicular mucocele is rare and difficult to diagnose preoperatively, and sometimes it may be of large size which increases the risk of perforation. Pseudomyxoma peritonei (PP) is the most feared complication of mucocele perforation. Appendectomy with negative margins is a requirement for adequate treatment for most cases. Utmost care should be taken during surgery to avoid perforation of mucocele.Sertkaya M, Emre A, Pircanoglu EM, Peker O, Cengiz E, Karaagaç M. Giant Appendicular Mucocele Due to Mucinous Cystadenoma. Euroasian J Hepato-Gastroenterol 2016;6(2):186-189.
Mucocele
Mucinous cystadenoma
Pseudomyxoma Peritonei
Perforation
Cystadenoma
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Premedication
Barium enema
Enema
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Mucocele arised at the vermiform appendix is uncommon, either benign or malignancy and their clinical presentation is not specific. The preoperative diagnosis is rare, and their diagnosis is an incidental event. Mucocele seems to be developed due to chronic obstruction of the lumen of the appendix. Higa and Cowerkers classified 73 cases of 'mucocele' into three clinicopathologic entities; focal or diffuse mucosal hyperplasia, mucinous cystadenoma, mucinous cystadenocarcinoma. Appendiceal mucoceles are rare lesions of the appendix, characterized by a gross enlargement of the appendix from accumulation of mucoid substance within the lumen. It is encountered in only 0.1-0.4% of all appendectomies with a female predominance and an average age at the time of diagnosis over 50 years. A case of appendiceal mucocle found during total hysterectomy is presented with a brief review of the literatures.
Mucocele
Mucinous cystadenoma
Vermiform
Pseudomyxoma Peritonei
Cystadenocarcinoma
Mucinous cystadenocarcinoma
Lumen (anatomy)
Cystadenoma
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Background: Appendiceal mucocele is a well-recognised entity that can present in a variety of clinical syndromes or can occur as an incidental surgical finding. The term mucocele is inherently imprecise and inclusive of both benign and malignant lesions. Mucocele of the appendiceal stump is a rare entity.Aim: We present a case of an appendiceal stump mucocele caused by a mucinous cystadenoma clinically presented as a giant retroperitoneal mass. Diagnosis was made postoperatively, after pathological study of the surgical sample.Case report: The case of a 54-year-old woman, with a previous appendectomy, suffering from a painful mass in the right lower quadrant of the abdomen, is reported. Imaging showed a large cystic structure at the base of the caecum. Surgery revealed a 13 x 5.5 cm retroperitoneal cystic mass, which was excised together with the appendiceal remnant. Pathological diagnosis was that of a mucocele arising from the appendiceal stump due to the development of a benign mucinous cystadenoma. The patient was discharged on the fourth post-operative day after an uneventful recovery.Conclusion: Mucocele of the appendiceal stump is a rare entity. In spite of extensive pre-operative investigations, preoperative diagnosis may still remain elusive and may only be made at the time of surgery.
Mucocele
Mucinous cystadenoma
Presentation (obstetrics)
Cystadenoma
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Cecum
Barium enema
Barium meal
Barium
Enema
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