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[page 79]                                                       [Emergency Care Journal 2014; 10:4406]

Mucocele of the appendix: 
a simple ultrasonographic 
diagnosis for a rare disease
Bahjat Barakat,1 Raffaele Pezzilli2
1Department of Emergency, S. Orsola-
Malpighi University Hospital, Bologna;
2Department of Digestive Diseases and
Internal Medicine, S. Orsola-Malpighi
University Hospital, Bologna, Italy

Appendiceal mucocele is a rare disease due
to accumulation of mucus inside the appendix
and it represents a heterogeneous group of
histopathologic lesions including mucosal
hyperplasia, cystadenoma and cystadenocarci-
noma. Its prognosis depends on the pathologi-
cal subtypes.
We report the case of a 54 year old man who

visited the emergency room for a pain local-
ized in the right side of the lower abdomen of
10 h duration; the pain worsened with cough
and walk. He had fever of 37.7°C. There was
abdominal rigidity and guarding, and pain at
digital rectal exam. Blood examination
revealed only an increase in white blood cell
count (13.400 mm3). The patient underwent
transabdominal ultrasonography (US) and
then contrast-enhanced computer tomography
(CT) examination (Figures 1 and 2, respec-
tively). The patient was subsequently operated
on and the final diagnosis was that of appen-
diceal mucocele.
Usually, the most common symptom of

appendiceal mucocele is the pain localized in
the lower part of the abdomen; if there is no
pain, the main finding is a palpable mass in
the right lower quadrant and the preoperative
diagnosis is given after abdominal US and con-
firmed with CT scan.1,2 In our case, the patient
presented the typical US pattern characterized
by a cystic lesion with the onion skin sign that
is considered as a specific marker for appen-
diceal mucocele (Figure 1),1,2 while the CT
imaging showed a capsulated cystic mass with
or without calcification of the wall (Figure
2).3,4 In our case the imaging was pathological-

ly confirmed (Figure 3). This case confirms
that US is the best choice in emergency situa-
tion to diagnose the mucocele of the
appendix.5

References

1. Caspi B, Cassif E, Auslender R, et al. The
onion skin sign: a specific sonographic
marker of appendiceal mucocele. J Ultras
Med 200;23:1117-21.

2. Sasaki K, Ishida H, Komatsusa T, et al.
Appendiceal mucocele: sonographic find-
ings. Abdom Imaging 2003;28:15-8.

3. Kunin N, Musolino A, Skufca J, Cisero N.
Mucocele appendiculaire; images en
chirurgie. J Chir-Paris 2003;140:47-70.

4. Zissin R, Gayer G, Kots E, et al. Imaging of
mucocele of the appendix with emphasis
on the CT findings; a report of 10 cases.
Clin Radiol 1999;54:826-32.

5. Attarde V, Patil P, Apte A, et al. Sonographic
appearance of a giant appendicular muco-
cele. J Clin Ultrasound 2011;39:290-2.

                             Emergency Care Journal 2014; volume 10:4406

Correspondence: Raffaele Pezzilli, Department of
Digestive Diseases and Internal Medicine, S.
Orsola-Malpighi University Hospital, via
Massarenti 9, 40138 Bologna, Italy.
Tel. +39.051.6364148 - Fax: +39.051.6364148.
E-mail: raffaele.pezzilli@aosp.bo.it

Key words: mucocele, computed tomography,
ultrasongraphy, clinical evaluation.

Conflict of interest: the authors declare no poten-
tial conflict of interests.

Received for publication: 4 June 2014.
Revision received: 4 September 2014.
Accepted for publication: 11 September 2014.

This work is licensed under a Creative Commons
Attribution 3.0 License (by-nc 3.0).

©Copyright B. Barakat and R. Pezzili, 2014
Licensee PAGEPress, Italy
Emergency Care Journal 2014; 10:4406
doi:10.4081/ecj.2014.4406

Figure 1. Ultrasonographic appearance of
unilocular, ovoid, anechoic, numerous fine
echo spots capsulated cystic mass with the
onion skin sign in the appendiceal area.

Figure 2. Contrast-enhanced computed
tomography scan shows tubular dilatation
of cystic mass of the appendix containing
fluid.

Figure 3. Pathological specimen demon-
strates villiform mucin-secreting epitheli-
um lining appendiceal lumen.

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