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Abdominal pain is not always appendicitis

Julie Edmiston, PA-C, RT

A 68-year-old woman presented to the ED with

gradual onset of right lower quadrant abdomi-
nal pain that had progressively worsened over
the last 24 hours. The patient complained of appendiceal mucocele
fullness in the right lower abdomen. The pain with wall calcification
worsened with ambulation. She denied any
associated vomiting, diarrhea, nausea, or fever.
She had not had any recent weight loss and
reported being very active overall. On physical
examination, she appeared in mild discomfort.
The upper abdomen was completely nontender
and unremarkable. The lower abdomen was
tender, particularly on the right, and a palpable
mass was noted on the right. Bowel sounds were
present. The ED physician, suspecting appen-
dicitis, ordered a CT scan of the abdomen and
pelvis with contrast.
The CT demonstrated a dilated tubular struc-
ture, 5.8 cm in diameter and 12 cm long, in the
right lower quadrant at the base of the cecum.
The wall of the mass was mildly thickened and
peripherally calcified (Figures 1 and 2). The
patient had no surrounding edema or abscess,
no ascites or lymphadenopathy, and no other
significant findings were present. What is the FIGURE 1. Axial CT showing appendiceal mucocele with wall calcification
most likely diagnosis?
and mucinous cystadenocarcinoma. Mucinous cystade-
DISCUSSION noma, a benign neoplasm and the most common cause of
The patient was diagnosed with an appendiceal mucocele. an appendiceal mucocele, accounts for about 50% of cases.5
Appendiceal mucoceles are rare and present in only 0.2% Mucinous cystadenocarcinomas are malignant and occur
to 0.4% of appendectomy specimens.1,2 Many are seen in in about 10% of cases.5
patients older than 50 years.3 Mucoceles typically develop Mucoceles secondary to non-neoplastic conditions rarely
over time due to progressive dilation of the appendix; exceed 2 cm in diameter and compose the remaining 40%
mucus accumulates secondary to an obstruction. The of cases.2 Many appendiceal mucoceles are asymptomatic
obstruction can be caused by: and found incidentally during physical examination, imag-
• non-neoplastic conditions including obstruction by a ing, or surgery. In the symptomatic patient, the presentation
fecalith, scarring from prior appendicitis, endometriosis, may include right lower quadrant pain, a palpable mass,
volvulus, or adhesions.4 or gastrointestinal bleeding. Other uncommon presenta-
• neoplastic conditions including mucinous cystadenoma tions consist of abdominal bloating or increased abdomi-
nal girth, ureteral obstruction, or intussusception.
Imaging is particularly useful, not just for excluding acute
Julie Edmiston works in radiology in Hammond, Louisiana, and is the
former department editor for Diagnostic Imaging Review. The author
appendicitis or other diagnoses, but for surgical planning.
has indicated no relationships to disclose relating to the content of this CT can provide the most information but is not always
article. available and not always the first to be done depending on
Bryan Walker, MHS, PA-C, department editor the patient’s clinical presentation. Abdominal radiographs
DOI: 10.1097/01.JAA.0000435184.64458.02 may demonstrate a rounded or oval soft tissue density in
Copyright © 2013 American Academy of Physician Assistants the right lower abdomen with or without peripheral calci-

JAAPA Journal of the American Academy of Physician Assistants 53

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

fication. On ultrasound, a mucocele may be

round or oval and in the right lower abdomen.
Mucoceles can have variable echogenicity,
appearing anechoic, hypoechoic, or heteroge-
neous. Some have echogenic layers, described as
the onion peel sign.3,5 The presence of this sign
should put a mucocele at the top of the differen-
tial diagnoses. If calcification is present within
the wall of the mucocele, acoustic shadowing
will be seen. Another sonographic finding which
favors a mucocele is an appendix with a diam-
eter greater than or equal to 15 mm.1 A normal
appendix on ultrasound has a diameter less than
6 mm; in patients with acute appendicitis, the
diameter is typically more than 6 mm.6
In women, imaging studies that show normal
ovaries can exclude an ovarian neoplasm, hydro- appendiceal
salpinx, or tubo-ovarian abscess. Other diag- mucocele

noses in patients with a right lower quadrant

mass should include carcinoid tumor, lym-
phoma, mesenteric cyst, enteric duplication cyst,
and periappendiceal abscess.4
On CT, an appendiceal mucocele will appear
as a cystic mass with Hounsfield units similar
to water. If IV contrast is given, the wall of the
appendix may enhance. Calcification within the
wall may or may not be present. The lack of an FIGURE 2. Axial CT showing a fluid-filled structure in the right lower quad-
rant adjacent to the cecum, with no adjacent inflammation or abscess
adjacent abscess or inflammation of the mes-
entery favors mucocele over acute appendicitis.6
Occasionally gas or an air-fluid level is visualized within ment of the patient. Imaging, especially CT, can assist
the lumen of the mucocele, indicating infection. Up to 30% with preoperative planning as well as exclude other
of patients with a mucocele may have a synchronous tumor diagnoses. JAAPA
in the colon or ovary.3 Patients with a mucocele are at 6
times greater risk for having a colonic adenocarcinoma REFERENCES
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54 Volume 26 • Number 10 • October 2013

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.