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Imaging in Appendicular Diverticulosis with Appendicitis

Authors:
Aruna R Patil at Apollo Hospitals Bangalore
Aruna R Patil
Bhushan Chaudhari at Apollo Hospitals Bangalore
Bhushan Chaudhari
Satyajit Godhi at Apollo Hospitals Bangalore
Satyajit Godhi
Swarna Shivakumar at Apollo Hospitals Bangalore
Swarna Shivakumar
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Abstract and Figures

Appendicular diverticulosis (AD) is an extremely rare condition. They are either incidentally detected in a normal or inflamed appendix or as diverticulitis manifesting clinically as appendicitis. It is commonly a radiological or pathological diagnosis. On computed tomography (CT), AD can mimic focal perforation. There are reported associations between AD and appendicular adenocarcinoma. This case reports the classical features of AD on CT with background appendicitis.
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THIEME
Case Report
1
Imaging in Appendicular Diverticulosis with
Appendicitis
Aruna R. Patil1 Bhushan Chaudhari1 Satyajit Godhi2 Swarna Shivakumar3
1Department of Radiology, Apollo Hospitals, Bangalore,
Karnataka, India
2Department of Gastrosurgery, Apollo Hospitals,
Bangalore, Karnataka, India
3Department of Pathology, Apollo Hospitals, Bangalore,
Karnataka, India
Address for correspondence Aruna R. Patil, MD, DNB, FRCR,
Department of Radiology, Apollo Hospitals, 154/11, Bannerghatta
Road, Opp. I.I.M., Bangalore, Karnataka, 560076, India
(e-mail: dr.arunarpatil@gmail.com).
Appendicular diverticulosis (AD) is an extremely rare condition. They are either inci-
dentally detected in a normal or inflamed appendix or as diverticulitis manifesting
clinically as appendicitis. It is commonly a radiological or pathological diagnosis. On
computed tomography (CT), AD can mimic focal perforation. There are reported asso-
ciations between AD and appendicular adenocarcinoma. This case reports the classical
features of AD on CT with background appendicitis.
Abstract
Keywords
►appendix
►diverticulosis
►computed
tomography
DOI https://doi.org/
10.1055/s-0040-1715538
ISSN 2581-9933.
©2020 by Indian Society of
Gastrointestinal and Abdominal
Radiology
Introduction
Appendicular diverticulosis (AD) is an extremely rare con-
dition. They are either incidentally detected in a normal or
inflamed appendix or as diverticulitis manifesting clinically
as appendicitis. It is commonly a radiological or pathological
diagnosis. Computed tomography (CT) aids in the diagnosis
of AD, and the commonest differential is a focal perforation.
There are reported associations between AD and appendicu-
lar adenocarcinoma. This case report highlights the classical
features of AD on CT with background appendicitis.
Case Report
A 49-year-old male presented to the emergency department
with right lower abdominal pain for 2 days, low-grade fever,
and nausea. On clinical examination, the patient was febrile.
Tenderness was elicited in the right iliac fossa, otherwise the
abdomen was soft on palpation. Laboratory investigations
revealed mild lymphocytosis. Contrast-enhanced CT (CECT)
was ordered for further evaluation. Images were acquired
in the venous phase after intravenous administration of
Omnipaque (Iohexol 360 mg/mL) at a dose of 1.5 mL/kg.
On CECT, the appendix was dilated and fluid-filled,
measuring 12 mm in caliber. Diffuse wall thickening,
enhancement, and periappendiceal fat stranding were seen.
Additionally, multiple diverticular outpouchings were noted
(at least eight to nine) from the appendix, which were not
separately inflamed (►Fig.1A–C). No solid enhancing lesion
was seen in the appendix. Cecum showed few diverticula
(►Fig.1D). A diagnosis of acute appendicitis with inciden-
tal AD was made. The patient was taken up for laparoscopic
appendectomy. Intraoperatively, the appendix was inflamed
and hyperemic, with multiple nodules studded on the sur-
face (►Fig.2A). Appendectomy was performed. The postop-
erative course was uneventful.
On pathological examination, the appendix showed multi-
ple diverticular outpouchings (►Fig.2B). On histopathology,
the appendicular wall showed multiple outpouchings with
inflammatory infiltrate. Areas of dysplasia were additionally
noted. No obvious malignancy was seen (►Fig.3A, B).
Discussion
AD is a rare condition occurring in 0.004 (2.1%) of appen-
dicectomies.1 It was first described by Kelynack in 1893.2
These are protrusions of the mucosa and submucosa through
muscularis defect and hence are pseudodiverticula. There
may be associated colonic diverticulosis. Some suggest that
these occur due to raised intraluminal pressure second-
ary to luminal obstruction by enterolith or inflammation
or tumor.3 Imaging features of uncomplicated AD is rarely
reported in the literature. They can be incidentally seen on
barium enema studies conducted for different indications.4
The prevalence of appendicitis in AD is not clear as very
few reports are available in the literature.5 Diverticulitis is,
J Gastrointestinal Abdominal Radiol ISGAR
Published online: 2020-08-21
2
Journal of Gastrointestinal and Abdominal Radiology ISGAR
Imaging in Appendicular Diverticulosis with Appendicitis Patil et al.
however, seen in two-thirds of cases.6-8 Many of the divertic-
ulitis cases were diagnosed based on postoperative histopa-
thology rather than preoperative imaging, as differentiation
from just appendicitis may be difficult on imaging unless the
radiologists are aware of this entity and specifically look for
them. Appendicular diverticulitis has a different epidemiol-
ogy from pure appendicitis, with the latter being prevalent
in older age group6,9 and presenting with intermittent pain.
Early perforation, hemorrhage, and pseudomyxoma peri-
tonei are reported with diverticulitis.6-8 On CT, features are
similar to those of diverticulosis elsewhere, for example,
colonic.10 They can be fluid- or air-filled small outpouchings
with a thin wall. Single outpouching in the appendiceal
wall resembles focal perforation. Focal perforation, how-
ever, shows complete wall discontinuity with adjacent col-
lection and significant fat inflammation (►Fig. 4A, B). This
differentiation is mandatory as contained perforations are
initially managed conservatively including drainage followed
by interval removal of the appendix. The association of AD
with neoplasms has a high figure (~7–48%).11,12 Neoplasms
reported include adenoma, adenocarcinoma, and carcinoids.
Hence, isolated AD without inflammation is managed by
prophylactic appendectomy. Though rare, due to eventual
inflammation or tumor association, AD mandates diagnosis
and mention in the radiology report whenever relevant fea-
tures, as described, are seen.
Conict of Interest
None declared.
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Fig. 1 (A, B) Coronal Contrast-enhanced computed tomography
(CT) images show a dilated fluid-filled appendix with wall thicken-
ing and periappendicular inflammation (arrowhead). Arrows show
multiple diverticular outpouchings from the appendicular lumen.
(C) Note clear communication with the lumen. (D) Also noted is a
cecal diverticulum.
Fig. 2 (A) Intraoperative picture of appendicular diverticulosis
seen as multifocal surface nodularity (arrows). Also note hyperemia
suggesting inflammation. (B) Resected specimen reveals the same
findings (arrows).
Fig. 3 (A, B) Low-magnification hematoxylin and eosin staining
shows appendicular lumen with multiple diverticula (arrows) and
areas of lymphocytic infiltration.
Fig. 4 Demonstration of the differences between appendicitis with
contained perforation (A) and appendicular diverticulosis (B) on
computed tomography (CT).
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Imaging in Appendicular Diverticulosis with Appendicitis Patil et al.
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