eP119 - Granulomatous Appendicitis: A Case Series

Purpose/Background: Acute appendicitis is the most common surgical emergency worldwide. Granulomatous appendicitis is an uncommon cause of appendicitis, seen in about 0.1% to 2% of appendectomy specimens. Granulomatous diseases represent a wide array of conditions that can affect multiple organs including the gastrointestinal (GI) tract. Less than 1% of GI involvement presents as isolated lesions to the appendix. Etiologies include infectious causes such as Mycobacterium tuberculosis and non-infectious causes such as Crohn's disease and sarcoidosis. We present a case series of rare occurrences of idiopathic granulomatous appendicitis.Methods/Interventions: Patient A underwent a laparoscopic appendectomy, and patient B underwent an open right hemicolectomy. The specimens were analyzed by pathology.Results/Outcomes: Patient A is a 36-year-old male with a history of symptomatic cholelithiasis who presented to the emergency room (ER) with symptoms of acute cholecystitis. A computed tomography (CT) scan confirmed cholecystitis, with incidental findings of an enlarged and inflamed appendix with appendicolith (Figure 1). During laparoscopic cholecystectomy, the appendix was examined and found to be dilated and severely indurated, with induration extending into the cecum (Figure 2). These findings were concerning for a possible underlying neoplasm. In order to mitigate the risks of rupture and spillage, the procedure was converted to open. A cuff of cecum was resected with the appendix to achieve a healthy transection margin. Pathology revealed non-caseating granulomas with reactive lymph nodes (Figure 3). Further testing was negative for malignancy, fungal organisms, or acid-fast bacilli. A Crohn's serum panel was negative, and a postoperative chest x-ray was without evidence of tuberculosis or sarcoidosis. A colonoscopy is still pending.

Patient B is a 32-year-old male who presented to the ER with a one-year history of intermittent lower abdominal pain. CT scan revealed a thickened appendix (Figure 1). He was treated with antibiotics and underwent workup for Crohn’s disease including a colonoscopy, with no abnormal findings. Due to persistent pain, a laparoscopic appendectomy was planned. Intraoperatively, the appendix was found to be inflamed, dilated, firm, and appeared to be eroding into the perirectal fat. These findings were concerning for malignancy, and an open right colectomy was therefore performed. Pathology showed granulomatous appendicitis with reactive lymphoid hyperplasia, without malignancy (Figure 4). Further workup for granulomatous disorders was negative.Conclusion/

Discussion: Granulomatous appendicitis is usually found in association with systemic granulomatous disorders and is rarely found alone. Further workup is essential to evaluate for systemic disorders as a potential cause. Both patients in this series were found to have granulomatous appendicitis of unknown etiology. They both recovered well from surgery, with complete resolution of their symptoms."Figure 1.

CT scans showing abnormal appendiceal findings (arrows) in patients A and B.
Figure 2.

Patient A: Laparoscopic view of the appendix and cecum.
Figure 3.

Patient A: Microscopic view of the noncaseating granulomas.
Figure 4.

Patient B: Microscopic view of the granulomas.
"