The inverted appendix – a potentially problematic diagnosis: clinicopathologic analysis of 21 cases

Jacqueline Birkness, Dora Lam-Himlin, Kathleen Byrnes, Laura Delong Wood, Lysandra Voltaggio

Research output: Contribution to journalArticle

Abstract

Aims: Inverted appendices are rare, but have the potential to cause diagnostic confusion among endoscopists and pathologists. The aim of this study was to describe the clinicopathological features of inverted appendices seen at our institution over the last 30 years. Methods and results: Twenty-one inverted appendices were identified and the clinical and pathological features reviewed. Patients were predominantly middle-aged women. Most cases were detected incidentally on colonoscopy. Endoscopically, inverted appendices appeared polypoid in the proximal caecum. All resections featured associated pathological processes, including endometriosis (n = 3), inflammatory mucocoele (n = 1), low-grade appendiceal mucinous neoplasm (n = 2), traditional serrated adenoma (n = 1) and inflammatory fibroid polyp (n = 1). Five cases were endoscopically mischaracterised as caecal polyps and removed via polypectomy; initial pathological impressions were erroneous in most cases. All polypectomies featured a dome-like configuration covered by mucosa on the convex surface; the majority had aggregates of ganglion cells and neural plexi embedded in muscularis propria. The vast majority of cases, regardless of the procedure, showed lymphoid aggregates. Among post-polypectomy patients with follow-up, none experienced perforation-associated morbidity despite the histological presence of muscularis propria. Conclusions: The diagnosis of an inverted appendix should be considered in polypectomy specimens from the caecum or appendiceal orifice with (i) dome-like tissue configuration covered by mucosa on the convex surface, (ii) a deep, robust smooth muscle component with ganglion cells (muscularis propria) and (iii) associated lymphoid aggregates. Prompt recognition on H&E will avoid unnecessary time and resource investment.

Original languageEnglish (US)
JournalHistopathology
DOIs
StatePublished - Jan 1 2019

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Polyps
Ganglia
Appendiceal Neoplasms
Mucous Membrane
Mucocele
Leiomyoma
Pathologic Processes
Endometriosis
Colonoscopy
Adenoma
Smooth Muscle
Morbidity
Pathologists

Keywords

  • appendiceal intussusception
  • inverted appendix
  • low-grade appendiceal mucinous neoplasm
  • neuroendocrine tumour
  • traditional serrated adenoma

ASJC Scopus subject areas

  • Pathology and Forensic Medicine
  • Histology

Cite this

The inverted appendix – a potentially problematic diagnosis : clinicopathologic analysis of 21 cases. / Birkness, Jacqueline; Lam-Himlin, Dora; Byrnes, Kathleen; Wood, Laura Delong; Voltaggio, Lysandra.

In: Histopathology, 01.01.2019.

Research output: Contribution to journalArticle

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abstract = "Aims: Inverted appendices are rare, but have the potential to cause diagnostic confusion among endoscopists and pathologists. The aim of this study was to describe the clinicopathological features of inverted appendices seen at our institution over the last 30 years. Methods and results: Twenty-one inverted appendices were identified and the clinical and pathological features reviewed. Patients were predominantly middle-aged women. Most cases were detected incidentally on colonoscopy. Endoscopically, inverted appendices appeared polypoid in the proximal caecum. All resections featured associated pathological processes, including endometriosis (n = 3), inflammatory mucocoele (n = 1), low-grade appendiceal mucinous neoplasm (n = 2), traditional serrated adenoma (n = 1) and inflammatory fibroid polyp (n = 1). Five cases were endoscopically mischaracterised as caecal polyps and removed via polypectomy; initial pathological impressions were erroneous in most cases. All polypectomies featured a dome-like configuration covered by mucosa on the convex surface; the majority had aggregates of ganglion cells and neural plexi embedded in muscularis propria. The vast majority of cases, regardless of the procedure, showed lymphoid aggregates. Among post-polypectomy patients with follow-up, none experienced perforation-associated morbidity despite the histological presence of muscularis propria. Conclusions: The diagnosis of an inverted appendix should be considered in polypectomy specimens from the caecum or appendiceal orifice with (i) dome-like tissue configuration covered by mucosa on the convex surface, (ii) a deep, robust smooth muscle component with ganglion cells (muscularis propria) and (iii) associated lymphoid aggregates. Prompt recognition on H&E will avoid unnecessary time and resource investment.",
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