SQU Med J, February 2011, Vol. 11, Iss. 1, pp. 112-114, Epub. 12th Feb 11
Submitted 20th Jun 10
Revision ReQ. 21st Sept 10, Revision recd. 7th Oct 10
Accepted 27th Oct 10

S tump appendicitis (SA) is a rare post-appendectomy complication whose exact incidence and prevalence are not clearly 
defined.1 The incidence of SA may be increasing, 
possibly because of widespread utilisation of 
laparoscopic appendectomy. This may result in a 
long appendiceal stump which is the commonest 
aetiology for stump appendicitis.2,3 Confirmation is 
either by imaging studies or diagnostic laparoscopy. 
Only a few cases of SA have been reported in 
English medical literature.3

Case Report
An eighteen-year-old boy who had undergone 
laparoscopic appendectomy one year previously 
presented at Kasturba Medical College Hospital, 
Manipal, India. He had lower abdominal pain of 
three days duration which was most acute in the 
right iliac fossa. It was not associated with fever and 
vomiting. He had had a similar episode six months 
previously, which had subsided with conservative 
treatment. The general physical examination was 

unremarkable. Per abdominal examination revealed 
healed scars of laparoscopic surgery, along with 
tenderness in the right iliac fossa with no palpable 
mass. Laboratory investigations were within normal 
limits. A contrast enhanced computed tomography 
(CECT) scan of the abdomen and pelvis showed a 
short length tubular structure at the caput caecum 
with enhancing wall and stranding of adjacent 
periappendiceal fat consistent with an inflamed 
appendiceal stump [Figure 1]. A preoperative 
diagnosis of stump appendicitis was made and an 
open ‘completion’ appendectomy was performed 
with an uneventful postoperative period.

Discussion
Stump appendicitis is rare following previous 
appendectomy, the known causative factor being 
a long residual stump. The true incidence and 
prevalence of SA are not known largely due to 
under-reporting and its poor definition.3 The first 
case of SA was reported by Rose in 1945 and since 
then thirty-seven cases of ‘residual appendicitis’ 

Departments of 1Surgery and 2Radiology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India.
*Corresponding Author email: rodricksgaby@yahoo.co.in

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aBStract: Stump appendicitis (SA) is a rare clinicopathologic entity characterised by inflammation of the 
appendiceal remnant after incomplete appendectomy. The diagnosis is not routinely suspected in patients who have 
previously undergone appendectomy. We report a case of SA in an adolescent boy who had previously undergone 
laparoscopic appendectomy. The case necessitated surgical completion of the appendectomy.

Keywords: Appendicitis; Stump; Surgery; Case report; India

Stump Appendicitis following Laparoscopic 
Appendectomy

Suresh Parameshwarappa,1 *Gabriel Rodrigues,1 Raghunath Prabhu,1 Charudutt Sambhaji2

CASE REPORT



Suresh Parameshwarappa, Gabriel Rodrigues, Raghunath Prabhu and Charudutt Sambhaji

Case Report | 113

have been reported in English medical literature.2 
The age at presentation of SA ranged from 11 to 
72 years (mean 39 years) with an equal incidence 
in both sexes. The time of onset ranged from two 
weeks to decades after the appendectomy.

Although no relationship between laparoscopic 
appendectomy and SA has yet been conclusively 
demonstrated, the occurrence of SA is more 
prevalent following laparoscopic appendectomy 
than conventional appendectomy.4,5 The causes of 
SA are insufficient inversion of the stump, a long 
proximal remnant of the appendix, incomplete 
removal of the distal remnant and partial 
laparoscopic or laparotomic appendectomy. The 
growing utilisation of laparoscopic appendectomy 
may increase the frequency of stump appendicitis 
due to the potential limitations of this technique. 
These include a smaller field of vision, lack of 
three-dimensional perspective and the absence of 
tactile feedback, thus potentially leaving a longer 
stump.6 Other causes reported in the literature 
include inadequate identification of the appendiceal 
base because of severe local inflammation; a 
retrocecal or sub-serous appendix; simple ligation 
of the appendix without invagination of the stump; 
leaving a long stump due to fear of caecal injury, 
and difficult dissection and local ulceration due to 
faecolith.3,6 A stump longer than 5 mm serves as a 
reservoir for the faecolith, becomes ischaemic and 
eventually perforates. Inversion of the long stump 

into the caecal wall does not necessarily prevent SA 
and other complications.7 Clinically, SA patients 
present with signs and symptoms similar to those 
of appendicitis or acute abdomen and with a 
previous history of appendectomy. The presence of 
an appendectomy scar does not absolutely rule out 
the possibility of SA.4

Ultrasonography (USG) and a CT scan of the 
abdomen constitute the modalities of choice for 
preoperative diagnosis of SA. USG can reveal 
a thickened appendix stump, fluid in the right 
iliac fossa and caecal oedema.8 A CT scan of the  
abdomen and pelvis is more useful than USG for 
the accurate preoperative diagnosis of SA, as it 
also excludes other aetiologies.1 The CT features 
of SA are similar to those of acute appendicitis, 
which include pericecal inflammatory changes, 
abscess formation, fluid in the right paracolic 
gutter, cecal wall thickening, and an ileocecal 
mass. A specific diagnosis of SA can be made 
preoperatively when inflammatory changes 
surround a distended appendiceal stump.3,5 
Barium studies and colonoscopy have also been 
reported as being helpful in diagnosing SA.9,10 

Diagnostic laparoscopy is gaining popularity and 
can be helpful for the diagnosis of SA.6 

SA is most commonly treated by an open 
operation, but cases successfully treated using 
laparoscopic intervention, have been reported.3 

Very rarely, an aggressive surgery such as ileocolic 
resection may be obligatory. Laparoscopy seems to 
be more successful than conventional laparotomy 
as it permits a global inspection of the abdominal 
cavity and an easier adhesiolysis.3 Accurate 
visualisation of the base and leaving a stump less 
than 3 mm in depth can minimise the incidence 
of SA.11 Use of angled scopes may provide good 
visualisation of the appendix.12

Conclusion 
The diagnosis of SA is often missed or delayed. 
It should be considered in patients presenting 
with right lower abdominal pain and a history of 
previous appendectomy. CT imaging studies help 
in preoperative diagnosis of SA. Completion of the 
appendectomy by conventional or laparoscopic 
means is the treatment of choice for SA.

Figure 1: Distended residual appendicular stump (white 
arrow) at the caput cecum with periappendiceal fat 
stranding (black arrow) suggesting inflammation.



Stump Appendicitis following Laparoscopic Appendectomy

114 | SQU Medical Journal, February 2011, Volume 11, Issue 1

References
1. Shin LK, Halpern D, Weston SR, Meiner EM, 

Katz DS. Prospective CT diagnosis of stump  
appendicitis. AJR Am J Roentgenol 2005; 184:S62–4.

2. Aschkenasy MT, Rybicki FJ. Acute appendicitis of 
the appendiceal stump. J Emerg Med 2005; 28:41–3.

3. Gasmi M, Fitouri F, Sahli S, Jemai R, Hamzaoui M. 
A stump appendicitis in a child: a case report. Ital J 
Pediatr 2009; 35:35.

4. Al-Dabbagh AK, Thomas NB, Haboubi N. 
Stump appendicitis. A diagnostic dilemma. Tech 
Coloproctol 2009; 13:734.

5. O'Leary DP, Myers E, Coyle J, Wilson I. Case report 
of recurrent acute appendicitis in a residual tip. 
Cases J 2010; 3:14.

6. Walsh DC, Roediger WE. Stump appendicitis. 
A potential problem after laparoscopic  
appendicectomy. Surg Laparosc Endosc Percut Tech 

1997; 7:357–8.

7. Uludag M, Isgor A, Basak M. Stump appendicitis is a 
rare delayed complication of appendectomy: A case 
report. World J Gastroenterol 2006; 12:5401–3.

8. Baldisserotto M, Cavazzola S, Cavazzola LT, 
Lopes MH, Mottin CC. Acute edematous 
stump appendicitis diagnosed preoperatively on 
sonography. AJR Am J Roentgenol 2000; 175:503–4.

9. De U, De KK. Stump appendicitis. J Ind Med Assoc 
2004; 102:329.

10. Nahon P, Nahon S, Hoang JM, Traissac L, Delas N. 
Stump appendicitis diagnosed by colonoscopy. Am J 
Gastroenterol 2002; 97:1564–5. 

11. Mangi AA, Berger DL. Stump  appendicits. Am Surg 
2000; 66:739–41.

12. Durgun AV, Baca B, Ersoy Y, Kapan M. Stump 
appendicitis and generalized peritonitis due to 
incomplete appendectomy. Tech Coloproctol 2003; 
7:102–4.