Discussion
Endometriosis is a common cause of lower abdominal, pain and affects about 15% of females in the reproductive age[]. Endometriosis of the gastrointestinal tract can be localized by the frequency of occurrence to the rectosigmoid (72%), recto vaginal septum (13%), small bowel (7%), cecum (4%), appendix (3%), and other intestinal sites (0.5%)[]. Endometriosis is characterized by the ectopic growth of hormonally responsive endometrium outside the uterus. The most widely accepted mechanism for its development is the retrograde menstruation through the fallopian tube into the peritoneum, with subsequent growth of the displaced cells[]. Involvement of distant sites such as the pericardium or pleura is best explained by the vascular dissemination of endometrial cells. As with endometriosis elsewhere in the intestinal tract, endometriosis of the appendix may be asymptomatic[], may result in perforation or intussusception[] The present case presented with nonspecific lower abdominal pain unrelated to her menstrual cycles. The diagnosis of endometriosis of the appendix is invariably incidental and histological. Transabdominal ultrasonography is reported to have a diagnostic sensitivity of up to 94% for acute appendicitis[], but transvaginal ultrasonography can also be beneficial in explaining endometriosis-related vague intestinal symptoms[] CT and magnetic resonance imaging scans are usually nonspecific because of the small size of the endometriosis implants.
The appendix is a key organ in the evaluation of undiagnosed chronic pelvic pain[]. Laparoscopy has emerged as a valuable tool in the management of unexplained abdominal pain. Laparoscopic visualization and diagnostic yield are of profound significance to women in whom gynecologic diseases such as endometriosis, pelvic inflammatory disease, ruptured ovarian follicles or tubal pregnancy may be the source of pain and mimic appendicitis []. Laparoscopic appendectomy itself is feasible and readily accepted therapeutic procedure[]. Our patient was treated by laparoscopic appendectomy with favorable outcome. Definite diagnosis of appendicular endometriosis is made by surgical exploration and tissue analysis[]. On histologic examination, secretory glands lined by cuboidal endometrial cells are seen surrounded by endometrial stroma embedded in fibrous tissue (17). The serosal implants are functionally active and tend to bleed into various tissues leading to desmoplastic response, mucosal ulceration and ischemia. Such pathophysiological changes may lead to the varying presentations and diagnostic confusion.
In conclusion, endometriosis of the appendix may present as appendicitis and its related affections and the treating physician should have a high index of suspicion while managing women of reproductive age with chronic lower abdominal and pelvic pain.
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