Abstract
Introduction: Endometriosis occurs when endometrial glands and stroma are found outside the uterine cavity or musculature. The most common extra-pelvic organ system affected by endometriosis is the gastrointestinal system, and appendiceal endometriosis constitutes less than 1% of all endometriosis cases. For many patients, receiving a diagnosis of endometriosis is a long process, averaging 4-11 years from symptom onset to surgical diagnosis. Endometriosis is a complicated and poorly understood disease, and for patients already dealing with painful symptomatology, psychosocial impacts, and delay of diagnosis, the variety in presentation, both symptomatically and pathologically, presents a barrier to receiving adequate treatment and resolution of symptoms.
Case Description: We present the case of a 24-year-old female with a past medical history of Endometriosis who presented to the clinic complaining of right lower quadrant pain of eight months duration. Associated symptoms include bloating, a sense of heaviness in the pelvic region, and bowel habit changes including diarrhea and constipation. The patient also described a constant, aching pain that was frequently interrupted by bouts of severe pain, stabbing in nature and accompanied by nausea. The patient takes Norethindrone 5 mg daily. The patient has a history of two laparoscopic procedures for excision of an endometrioma, endometriotic lesions, and adhesions in locations including bilateral ovaries, bladder wall, uterine wall, and abdominal wall. On physical examination, the patient has right lower quadrant hypertonicity and tenderness with guarding and rebound. Pelvic exam, laboratory studies, and ultrasound imaging failed to reveal acute or abnormal pathology. Laparoscopic exploration for recurrent endometriosis was decided on. The appendix was found to be mildly dilated with significant scar tissue around the appendix and the cecum. The appendix was excised and pathology demonstrated focal endometriosis and diffuse serosal fibrovascular adhesions involving the appendiceal serosa/subserosa, as well as a dilated lumen filled with hemorrhagic content. The patient’s symptoms have since resolved.
Discussion: While rare, appendiceal endometriosis should be considered in differential diagnosis of females with pelvic pain. The variety in gross appearance of endometriotic lesions presents a challenge for complete surgical excision. While typical endometriotic lesions have a blue-black pigment, there are a variety of atypically-presenting lesions that can impede gross recognition of endometriosis during laparoscopy. Research has clearly defined a high prevalence of appendiceal pathology in patients with pelvic pain, even without gross visualization of pathologic changes. Resolution of symptoms and prevention of recurrent disease in patients with endometriosis is of high priority. Therefore, prophylactic appendectomy appears to be a worthwhile consideration in patients with chronic pelvic pain, given the high frequency of appendiceal pathology.
