An unusual reason for an inguinal swelling: De Garengeot’s hernia

We present the case of a 71-year-old female with an inguinal swelling. Intra-abdominally the appendix was found in a femoral hernia sac (De Garengeot’s hernia). A laparoscopic transabdominal preperitoneal hernia repair procedure was performed with uneventful post-operative course. Clinical presentation of this type of hernia is unspecific and often not to be distinguished from a common incarcerated hernia. Computed tomography can be helpful in obtaining a diagnosis, although the definite diagnosis is mostly found intraoperatively. As surgical options are numerous, there is no consensus on the most suitable one. A laparoscopic approach incorporates the benefit of a total abdominal overview and the possibility of standard procedures. If the appendix appears normal, the use of synthetic mesh is considered safe and an incidental appendectomy is not necessarily required.

Small bowel intussusception and Enterobius vermicularis infestation in a 20-year-old woman

A 20-year-old woman presented with abdominal pain and MRI findings of intussusception of the distal small bowel with no identifiable lead point and no visualisation of the appendix. A diagnostic laparoscopy succeeded in manually reducing the intussusception but was unable to find any candidate lead point. Intraoperatively, hyperperistalsis was observed throughout the small bowel which seemed prone to transient intussusception. Incidental appendectomy revealed an uninflamed appendix with Enterobius vermicularis (pinworm) infestation, the most common parasite present in appendectomy specimens worldwide. Although intussusception in young adults is an uncommon occurrence, the unique nature of this case is amplified by the concurrent finding of E. vermicularis infection of the appendix in an adolescent in western Canada, a phenomenon normally observed in paediatric populations with higher incidence in tropical areas. Although the mechanism of intussusception in this patient remains unclear, it is hypothesised that E. vermicularis colonisation acted as an irritant stimulating intestinal hypercontractility with resulting intussusception. Successful medical eradication of the pinworm in this individual may prevent future recurrence.

Abnormal pathology seen on appendectomy in patients with predominant right-sided pelvic pain

Introduction: Previous studies have linked chronic pelvic pain (CPP) to appendix pathologies. However, few studies have investigated appendix pathology specifically in the context of CPP that is right-side predominant (R-CPP). We hypothesized that women with R-CPP have higher rates of appendix pathology compared with women with CPP that is not right-side predominant (N-CPP). Methods: We conducted a retrospective case–control study of 220 women who underwent diagnostic laparoscopy and planned or incidental appendectomy for CPP and suspected endometriosis between January 2015 and December 2018 at a tertiary care center in Saint Louis, MO. Results: No significant difference in abnormal appendix pathology was found between women with R-CPP and women with N-CPP (30.9% vs 34.5%, p = 0.74, odds ratio = 0.85, 95% CI: (0.44, 1.62)). Gross abnormalities of the appendix were documented in 40 of 220 patients (18.2%), with the most common abnormal gross findings being adhesions (8.2%), followed by abnormal lesions (7.3%). Conclusion: In this study, the presence of abnormal pathology within the appendix did not correlate with R-CPP, indicating triage based on predominant pain location cannot help identify patients with underlying appendix pathology. However, consistent with previous studies, we identified a high rate of abnormal appendix pathology overall, supporting the practice of many surgeons to perform routine appendectomy in women with CPP.

Acute appendicitis is associated with appendiceal microbiome changes including elevated Campylobacter jejuni levels

ObjectivesTo compare the appendiceal microbiomes and examine the prevalence of Campylobacter species in the appendices of adult subjects with confirmed acute non-perforated appendicitis and controls with healthy appendices.DesignArchived samples of formalin-fixed paraffin-embedded appendiceal tissues were obtained from 50 consecutive female subjects who underwent appendectomy for acute, non-perforated appendicitis, and 35 consecutive female controls who underwent incidental appendectomy during gynaecological surgery.Results16S rRNA gene sequencing revealed that the relative abundances (RAs) of the major phyla in appendiceal tissues (Firmicutes, Proteobacteria, Bacteroidetes, and Actinobacteria) were similar in both groups. Beta diversity was significantly different due to differences in Bacteroidetes and Proteobacteria (p<0.0001). Within Proteobacteria, RAs of classes Alphaproteobacteria (~21%, fold change (FC)=1.31, false discovery rate (FDR) p value=0.03) and Epsilonproteobacteria (~1%, FC=0.25, FDR p value>0.05) were increased in acute appendicitis samples. RAs of unknown genera from families Burkholderiaceae and Enterobacteriaceae were decreased in appendicitis samples, and 14 genera were increased, including Neisseria, Acinetobacter and Campylobacter. Quantitative PCR revealed that levels of Campylobacter jejuni DNA, but not other Campylobacter species or pathogens tested, were significantly higher in appendicitis samples than in controls (p=0.013). Using a cut-off of 0.31 pg/µL, 40% of appendicitis cases and 6% of controls were positive for C. jejuni, indicating specificity of 93.7% (95% Cl 79.2 to 99.2), sensitivity of 40.9% (95% Cl 24.7 to 54.5), and OR of 10.38 (Fisher’s p value=0.0006, 95% Cl 2.3 to 47.4).ConclusionsOur findings indicate that Campylobacter jejuni may be a significant cause of acute appendicitis. This supports earlier studies and suggests that targeted antibiotic therapies could be an alternative treatment for a subset of non-complicated acute appendicitis cases.

Apéndice cecal en el conducto herniario. A propósito de un caso

La hernia de Amyand es una enfermedad rara que se observa en aproximadamente el 1 % de todas las hernias, y sus complicaciones como la apendicitis aguda o perforada, son aún más raras, aproximadamente el 0,1 %. Su diagnóstico es muy difícil en el período preoperatorio y suele ser un hallazgo incidental. Se recibió un paciente masculino de setenta y tres años de edad que acudió al servicio de emergencias debido a dolor abdominal tipo punzante de moderada intensidad localizado en región inguinal derecha de 4 días de evolución, no refirió otros síntomas acompañantes. Se diagnosticó una hernia inguinal Nyhus III, Amyand tipo 2 y se le realizó apendicectomía incidental y reducción del saco herniario. Durante el postoperatorio no se observaron complicaciones. Palabras clave: Hernia de Amyand, hernia de Garengeot, hernia inguinal, apendicitis aguda, apéndice cecal. Abstract Amyand's hernia is a rare disease seen in approximately 1% of all hernias, and its complications such as acute or perforated appendicitis are even rarer, approximately 0.1%. Its diagnosis is very difficult in the preoperative period and is usually an incidental finding. A seventy-three-year-old male patient was received who came to the emergency service due to stabbing abdominal pain of moderate intensity located in the right inguinal region of 4 days of evolution, he did not refer other accompanying symptoms. A Nyhus III, Amyand type 2 inguinal hernia was diagnosed and incidental appendectomy and reduction of the hernial sac were performed. During the postoperative period, no complications were observed. Keywords: Amyand hernia, Garengeot hernia, inguinal hernia, acute appendicitis, cecal appendix.