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      Clinicopathological Study of 25 Cases of Diverticular Disease of the Appendix: Experience from Farwaniya Hospital

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          Abstract

          Background. Diverticular disease of the appendix (DDA) is a rare disease and it has been shown to be associated with locoregional neoplasms. This study was conducted to characterize clinicopathological features and to investigate its association with appendiceal neoplasms. Methods. We searched the records of the Department of Pathology at Farwaniya Hospital for cases of diverticular disease of the appendix between 2003 and 2011. Histological slides and patient charts were reviewed for relevant information. Consecutive cases of acute appendicitis were selected as a control group. Results. We identified 25 cases of DDA, 24 of which occurred in men. Mean age of DDA patients was 35 ± 10.1 years and was significantly greater than that of appendicitis patients ( P = 0.027). The mean temperature of cases (37.9°) was significantly higher ( P = 0.012) than that of the controls (37.3°). The cases had lower white blood cell (WBC) counts compared to controls (13.6 versus 16.7, P = 0.04). Pathological diagnosis identified 4 cases of diverticulosis, 5 cases of diverticulitis, 6 cases of diverticulosis with acute appendicitis, and 10 cases of diverticulitis and appendicitis. None of the cases was associated with any type of neoplasm. Conclusions. DDA is a rare disease, and clinicians and radiologists should be aware of it. Male sex and adult age seem to be risk factors associated with DDA. The disease may not have any direct association with any neoplasm.

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          Most cited references14

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          A study of 50,000 specimens of the human vermiform appendix.

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            Diverticular disease of the vermiform appendix: a diagnostic clue to underlying appendiceal neoplasm.

            Acquired diverticula of the vermiform appendix are rare and arise as a result of different pathogenetic mechanisms. One of the etiologies includes proximally located, often unsuspected small neoplasms. Although the association of appendiceal diverticulosis and neoplasia is known, it remains underemphasized in the teaching and practice of surgical pathology. To investigate the frequency of appendiceal neoplasms with acquired diverticulosis, we conducted a retrospective analysis of all appendectomy specimens received in our institution for a 55-month period (January 2002-July 2006). A total of 1361 appendectomy specimens were identified. Diverticulosis was diagnosed in 23 (1.7%) of all cases. Eleven (48%) appendectomy specimens with diverticulosis also harbored an appendiceal neoplasm. The association of appendiceal neoplasms with diverticulosis was statistically significant (P < .0001, 2-sided Fisher exact test). Neoplastic processes included 5 well-differentiated neuroendocrine tumors (carcinoids), 3 mucinous adenomas, 1 tubular adenoma, and 2 adenocarcinomas. In one case, routine representative sections sampled only a small focus of carcinoma, which originally went undiagnosed. We stress the need for meticulous gross assessment with histologic examination of the entire appendectomy specimen in cases of appendiceal diverticulosis. Thorough examination is required to rule out an underlying neoplasm as a cause of diverticulosis. As acquired diverticula represent a rare finding, examination of the entire appendix in this setting does not create a significant impact on the workload within the pathologic laboratory.
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              The coexistence of low-grade mucinous neoplasms of the appendix and appendiceal diverticula: a possible role in the pathogenesis of pseudomyxoma peritonei.

              We examined 38 appendectomies with diagnoses of mucocele, diverticulum, or adenoma to study the coincidence of appendiceal diverticula and appendiceal low-grade mucinous neoplasms and to examine the possible role of diverticula in the pathogenesis of pseudomyxoma peritonei. Invasive adenocarcinomas and retention cysts were excluded (six cases). Cases were classified as adenomas or mucinous tumors of unknown malignant potential, with or without diverticula. Medical records were reviewed for multiple parameters, including presenting symptoms, presence of pseudomyxoma peritonei, and presence of associated malignancies. Binomial statistics were used to calculate the probability that the observed prevalence of low-grade mucinous neoplasms and diverticula together was significantly different from the expected prevalence of diverticula or low-grade mucinous neoplasms alone, using historical controls from the literature. Twenty-five percent of the total cases (8 of 32) contained both a low-grade mucinous neoplasm (7 cystadenomas and 1 mucinous tumor of unknown malignant potential) and a diverticulum. Thus, 8 of 19 low-grade mucinous neoplasms (42%) were associated with diverticula. Of the appendices with both low-grade mucinous neoplasms and diverticula, three contained dissecting acellular mucin within the appendiceal wall, four showed diverticular perforation, and one had pseudomyxoma peritonei associated with the ruptured diverticulum. A significant percentage (P < .001) of cases contained low-grade mucinous neoplasms and diverticula together. The case of coexistent low-grade mucinous neoplasm, diverticulum, and pseudomyxoma peritonei suggests that diverticula could play a role in the pathogenesis of pseudomyxoma peritonei. This could occur either by involvement of preexisting diverticula by the neoplasm or by distention of the appendiceal lumen by mucin, leading to increased intraluminal pressure and subsequent diverticulum formation at a weak area in the wall. Either mechanism might allow low-grade mucinous neoplasms to penetrate the appendiceal wall more easily.
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                Author and article information

                Journal
                Patholog Res Int
                Patholog Res Int
                PRI
                Pathology Research International
                Hindawi Publishing Corporation
                2090-8091
                2042-003X
                2013
                2 October 2013
                : 2013
                : 404308
                Affiliations
                1Department of Pathology, Farwaniya Hospital, P.O. Box 3313, 22034 Salmiya, Kuwait
                2Department of Surgery, Farwaniya Hospital, 81004 Sabah Al-Naser, Kuwait
                3Faculty of Medicine, Kuwait University, P.O. Box 24923, 13110 Safat, Kuwait
                Author notes

                Academic Editor: Marco Volante

                Author information
                http://orcid.org/0000-0001-8371-812X
                Article
                10.1155/2013/404308
                3809370
                24224113
                fff4ac46-9f32-4486-9e17-75bb642eac06
                Copyright © 2013 Nabeel Al-Brahim et al.

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 28 May 2013
                : 9 September 2013
                : 16 September 2013
                Categories
                Research Article

                Pathology
                Pathology

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