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Acute right iliac fossa pain: Beyond appendicitis

Published:February 20, 2016DOI:https://doi.org/10.1016/j.ejim.2016.02.005
      78 years old woman with long-standing metabolic syndromewent to the ED because of abdominal pain located in the right iliac fossa. She did not report alterations in bowel habits, diarrhea, macroscopic digestive bleeding, fever, nausea, or vomiting. Suspecting appendicitis, an abdominal computerized tomography (CT) was requested to confirm its diagnosis. (See Fig. 1.)
      Figure thumbnail gr1
      Fig. 1Coronal (A) and sagittal (B) multiplanar reconstructions (MPR).
      A. Abrupt transition between the ascending colon walls (arrow) and the thickening of cecum wall. The appendix did not show any alterations (arrow point). B. Cecal thickening with target sign (curved arrow).
      What is the diagnosis?

      1. Diagnosis

      Isolated cecal ischemia.

      2. Discussion

      Our patient presents multiple cardiovascular risk factors that together with the CT findings (cecal thickening with target sign and normal appendix and ileum) lead us to consider an isolated cecal ischemia (
      • Guitart Giménez J.
      • Pagès Llinàs M.
      • Domingo Ayllón M.
      • Rimola Gibert J.
      • Rodríguez Gómez S.
      • Ayuso Colella C.
      Computed tomography characteristics of isolated cecal ischaemia.
      ,
      • Simon A.M.
      • Birnbaum B.A.
      • Jacobs J.E.
      Isolated infarction of the cecum: CT findings in two patients.
      ). The colonoscopy revealed red and sore oedematous mucosa. The histopathological study of the biopsy confirmed the diagnosis. The findings from the isolated cecal ischemia in the CT could simulate complicated or mucinous cecal neoplasia (
      • Guitart Giménez J.
      • Pagès Llinàs M.
      • Domingo Ayllón M.
      • Rimola Gibert J.
      • Rodríguez Gómez S.
      • Ayuso Colella C.
      Computed tomography characteristics of isolated cecal ischaemia.
      ).
      Ischemic colitis is the most frequent form of intestinal ischemia (50%). The three most vulnerable areas are splenic flexure (Griffith's point), rectosigmoid flexure (Sudeck's point) and right colon. Necrosis or isolated cecal ischemia is a rare variant (2.2%) of ischemic colitis (
      • Brandt L.J.
      • Feuerstadt P.
      • Blaszka M.C.
      Anatomic patterns, patient characteristics, and clinical outcomes in ischemic colitis: a study of 313 cases supported by histology.
      ).The cecum is an area that is vulnerable to ischemic accidents because it presents a network of collateral vessels and vasa recta that are less developed than the left colon. There are also anatomical variants (absence of vascular arc between the ileal and colic branches of the ileocolic artery) that bring about a predisposition to ischemia. A distinction is made between two types of cecal necrosis: spontaneous and in association with chronic heart disease, cardiopulmonary bypass surgery, systemic chemotherapy, hemodialysis, diabetes, etc. (
      • Guitart Giménez J.
      • Pagès Llinàs M.
      • Domingo Ayllón M.
      • Rimola Gibert J.
      • Rodríguez Gómez S.
      • Ayuso Colella C.
      Computed tomography characteristics of isolated cecal ischaemia.
      ,
      • Simon A.M.
      • Birnbaum B.A.
      • Jacobs J.E.
      Isolated infarction of the cecum: CT findings in two patients.
      ).
      The test chosen to confirm the diagnosis was the colonoscopy. It is important to perform the endoscopy as soon as possible, preferably during the first 2 or 3 days to confirm the diagnosis. Choice of treatment depends on the grade and extent of the disease. It is usually a self-limiting disease and as with our patient, responds favorably to wide spectrum antibiotics and bowel rest.

      Conflict of interest statement

      The authors state that they have no conflicts of interest.

      References

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        Computed tomography characteristics of isolated cecal ischaemia.
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        Isolated infarction of the cecum: CT findings in two patients.
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        • Brandt L.J.
        • Feuerstadt P.
        • Blaszka M.C.
        Anatomic patterns, patient characteristics, and clinical outcomes in ischemic colitis: a study of 313 cases supported by histology.
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