Acute Appendicitis Secondary to Endometriosis A unique cause of a common surgical emergency in a woman of reproductive age
Hanah Sabrina Cavazos B.S.1, Michael Miguez M.D.2, Ahsan Raza M.D, FACS, FASCRS3*
¹Third Year Osteopathic Medical Student, Edward Via College of Osteopathic Medicine, Monroe, Louisiana
²Delta Pathology Group, Rapides Regional Medical Center, Alexandria, Louisiana
³Department of Surgery, Rapides Regional Medical Center, Alexandria, Louisiana
*Corresponding author
Ahsan Raza , Department of Surgery, Rapides Regional Medical Center, Alexandria, Louisiana
DOI: 10.55920/JCRMHS.2025.11.001506
Abstract
Introduction and Importance: Endometriosis is known to infiltrate the peritoneum of the abdominal cavity and result in different pathological presentations. Appendicitis, while a common surgical emergency, is rarely secondary to cellular infiltration by endometrial tissue1-4. This presentation is a crucial contribution to our understanding of the elusive pathophysiology of endometriosis.
Case Presentation: This case discusses an African American 34-year-old female who presented with appendicitis secondary to endometriosis. The patient is a multiparous female with a prior cesarean section at 37 weeks for twin gestation. She was treated according to her acute presentation with an appendectomy and the inflamed appendix was collected for pathological analysis. The pathology report found endometrial infiltration in the appendicular wall which caused the acute inflammatory response.
Clinical Discussion: The following case is a rare presentation of a common gynecologic pathology. The patient presented with classic findings associated with appendicitis and the specimen revealed endometrial cells. Endometrial infiltration into the lumen of the appendix resulting in appendicitis is an atypical cause of such a surgical emergency. The current guidelines for appendicitis is an appendectomy.
Conclusion: Highlighted here is the surgical course of a seemingly common surgical emergency of appendicitis secondary to endometriosis. This case sheds light on the need for heightened diagnostic standards and further education for reproductive aged women. Not only are we looking through a gynecologic lens but also that of a general surgeon, all to ensure better patient outcomes and comprehensive care.
Key Words: Endometriosis, Appendicitis, General Surgery, Obstetrics, and Gynecology
Introduction and Importance
Acute Appendicitis is a prevalent surgical emergency and requires urgent treatment to forgo life-threatening complications. Its presentation of acute pain incited in the McBurney point area of the abdomen is a classic clinical finding in the disease process¹-2.
The inflammatory process of appendicitis results from an obstruction of the lumen of this finger-like process found projecting from the cecum. Due to its narrow diameter, blockage of the proximal lumen increases pressure in the distal section, driven by continuous mucus secretion and gas production from colonic bacteria. As the appendix becomes progressively distended, venous drainage is compromised, leading to mucosal ischemia. If the obstruction persists, this can escalate to full-thickness ischemia, resulting in perforation¹. Definitory diagnosis of this obstruction can be seen with an ultrasound or a contrast-enhanced low-dose CT. In acute presentations, clinicians often use ultrasound to narrow the differential and determine case acuity4. Ultrasounds are useful in acute abdomen assessments and can confirm a suspected clinical diagnosis to justify surgical intervention.
In rare instances, appendicitis can present secondary to gynecologic pathologies. In this patient, her appendiceal obstruction was secondary to endometrial cell infiltration resulting in an inflammatory response, prompting surgical removal3-4. Endometriosis is the disease state responsible for this rare pathology and affects 35-50% of women who experience pelvic pain5. The typical presentation of endometriosis is chronic pelvic pain and dysmenorrhea due to the ectopic endometrial cells within the peritoneal cavity, ovary, or urinary tract6. These cells remain responsive to the fluctuations of hormones in the female menstrual cycle so symptoms are often cyclical. Our understanding of how these cells congregate in the surrounding pelvic structures is not concrete but retrograde menstruation is what the scientific community currently uses to define its pathophysiology. The theory outlines that endometrial products within menstrual blood can find passage into the abdominal cavity through the fallopian tubes7.
The following discussions report on a unique presentation of appendicitis due to endometrial cells within the appendicular lumen of a 34-year-old female. Reporting this case will provide insight for guiding differential diagnoses and screening in young women who present with acute abdominal pain. To ensure the integrity of the reported case the SCARE criteria was utilized to create this manuscript10.
Case Presentation
The patient presented as a previously healthy 34-year-old female to the emergency department with right lower quadrant pain and nausea. Upon admission, there was no leukocytosis and the patient was afebrile. Upon inspection of the patient, there was notable right lower quadrant tenderness. A subsequent CT was ordered and revealed an anteriorly positioned appendix with some wall thickening (Figure 1). Based on the history, physical exam, and CT imaging we were able to confirm the suspected diagnosis of acute appendicitis8. The patient underwent a robotic appendectomy to address her diagnosis. During the procedure, the appendix was inflamed and the surgical team took care to take down any inflammatory adhesions. No other pathologies were apparent upon visual inspection in the right lower quadrant. The appendix was subsequently sent to pathology and the specimen revealed endometrial invasion of the appendiceal wall (Figure 2).
Clinical Discussion
The patient had a successful robotic appendectomy and an uneventful postoperative course.
This case report is novel due to the cause of the inflamed appendix. There is limited documentation of endometriosis seeding the appendiceal lumen, and this case will guide a better understanding of the pathophysiology of endometriosis. The different theories of endometrial infiltration into the pelvic cavity have long left the scientific community without a concrete understanding of a common gynecologic diagnosis. More importantly, it is vital that our knowledge of this pathology can be translated into care for young women who present with acute abdominal symptoms such as those defined in this case. Patient awareness of symptoms to expect and potential complications of endometriosis could prevent a critical situation, such as acute appendicitis, from becoming a perforation or all-out sepsis²-3;6-7.
Conclusion
Our patient was fortunate to have a good postoperative outcome and successful recovery but her presentation is one that the medical community needs to be aware of. This case brings to light a rare complication of a gynecological pathology that resulted in a surgical emergency for this patient. Endometriosis can be a debilitating disease and this multiparous female was unaware of her diagnosis before this emergent surgical intervention. This case calls to attention a deficit in screening of reproductive age women for endometriosis which can be a cunning disease. Many women like this one, could have exposure to gynecologists, obstetricians, and other providers and still have no diagnosis until much later in life. Patient education backed by continued screening in the form of yearly gynecologic exams and history taking is a key to ensuring patients with endometriosis are adequately cared for.
CT demonstrating Acute Appendicitis: CT scan findings for mentioned patient with acute appendicitis. Findings are consistent with acute appendicitis, with an enlarged thick-walled appendix and some fat stranding. No evidence of perforation or abscess formation at this time.
Endometrial Infiltration of Appendiceal Lumen: The above image is from the appendiceal specimen collected during the robotic assisted appendectomy. The pathology reveals endometrial cells within the appendiceal lumen. The appendix has a characteristic structure with a simple columnar epithelium (right arrow), allowing for differentiation form the glandular and stromal elements that signify endometrial tissue (left arrow).
Acknowledgements: Special thanks to the affiliated Medical Center for their support. This report has no competing interests or associated incentives. The drafting of the above contents took place in a community hospital setting. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Consents: Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.
Conflicts of Interest: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Sources of Funding: This Case Report is associated with no funding from external bodies, all resources were attained via independent research.
Ethical Approval: This Case Report was sourced with no patient identifiers and represents a crucial depiction of a surgical emergency. Ethical approval by the affiliated ethics review committee would be exempt due to the nature of this article.
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