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Chronic appendicular abscess presenting as a complex adnexal mass: A case report

Wright, Micah R.
Abernathy, Kent
Street, Darren
Frye, Lance
Po, William

Background: The authors present an unusual presentation of a chronic appendicular abscess. A 57-year-old presented to the emergency department with acute on chronic abdominal pain, worsening abdominal distention and decreased appetite. Abdominal imaging revealed the presence of a multi-septated cystic right adnexal mass concerning for metastatic ovarian carcinoma. Intra-operatively the diagnosis of a likely chronic ruptured appendix at the base of the colon was confirmed. In postmenopausal women the majority of adnexal masses are benign neoplasms, however, the risk of malignancy is much greater than in premenopausal women. Postmenopausal women with clinical symptoms and findings on diagnostic imaging suggestive of malignancy warrant expedited management. While imaging and biomarkers help to give insight into origin of masses and can aid in determining treatment, diagnostic operations may be ultimately required to achieve final diagnosis and direct further management.

Methods: All data collected was de identified and kept within a secure location.

Results: Adnexal masses can present in a variety of ways and yield pathology from simple cysts to infectious process or even metastatic carcinoma. On the contrary, the diagnosis of acute appendicitis is typically straight forward, classically manifesting with acute periumbilical pain localizing to the right lower quadrant, abdominal guarding, and leukocytosis. The atypical presentation of chronic appendicitis can often lead to misdiagnosis, particularly in sexually active females, or as in our case, patients presenting with symptoms consistent with an ovarian malignancy.

Conclusions: Chronic appendicitis (CA) is a rare clinical entity with an incidence of 1.5% in all cases of chronic abdominal pain of unknown etiology. CA poses as a diagnostic and therapeutic dilemma for clinicians since a majority of patients present with atypical symptoms. It is very rarely thought to be the primary diagnosis due to the low frequency of occurrence. A postmenopausal patient with chronic worsening abdominal pain, distention, and decreased appetite presenting with a complex adnexal mass and ascites is highly suspicious for ovarian malignancy. It is imperative to thoroughly review all images and consider subsequent imaging modalities to ensure infectious etiologies are excluded, but ultimately, diagnostic operations may be inevitable.