International Journal of Health Sciences and Research: Appendiceal Mucocele: A Masquerade

International Journal of Health Sciences and Research
www.ijhsr.org
ISSN: 2249-9571
Case Report
Appendiceal Mucocele: A Masquerade

Shilpa Narchal1*@, Sunita B Patil1**, Madhura Paricharak1*, P V Purohit2***
*
Post Graduate Resident, **Assistant Professor, ***Consultant Pathologist

1
D.Y Patil Medical College and Research Centre, Kolhapur
2
Consultant Pathologist, Purohit Laboratories, Opp. Railway station, Kolhapur
@
Received: 29/01//2013
Correspondence Email: drshilpahastir@gmail.com

Revised: 27/02/2013
Accepted: 06/03/2013
ABSTRACT
Appendiceal mucocele is a rare disease entity that has been infrequently diagnosed before surgery
because of its lack of specific diagnostic features. Most often it is asymptomatic but sometimes mimics
acute appendicitis like symptoms , adnexal mass especially in females. We herein, report and discuss such
a case in a 58 years old female patient to highlight this appendiceal pathology.
Keywords: Appendix, Mucocele, Appendicitis.
INTRODUCTION
Mucocele of the appendix is a
descriptive term for an abnormal mucous
accumulation distending the appendiceal
lumen, regardless of the underlying cause.
This process is slow and gradual, with no
signs of infection inside the organ. It was
first described by Rokitansky in 1842. [1]
They are found in 0.2%-0.3% of
appendicectomies.[2,3,4]
CASE REPORT
A 58 years old female patient
presented with history of right sided
abdominal pain, dull and intermittent in
nature since two months. Her past history is
insignificant.
On physical examination, her abdomen was
soft. A tender palpable mass measuring
approximately 12x8cm was noted in right
iliac fossa without rigidity, muscle guarding

and rebound tenderness. No signs of
peritoneal irritation were elicited. No
associated vomiting or fever was observed.
There were no associated urinary or bowel
symptoms.
The laboratory findings include total
leucocyte count of 11,000 cells/mm. [3] CRP
was within normal limits. Serum CA-125,
CEA were within normal limits.
Ultra sonography revealed mixed
echogenic mass measuring 14x9cm in right
lower abdomen with an echogenic rim.
CT scan demonstrated a well
demarcated cystic mass measuring 14x9cm
in right lower quadrant of abdomen.
Surgical exploration revealed grossly
dilated appendix, excision of portion of
terminal ileum and ascending colon with
International Journal of Health Sciences & Research (www.ijhsr.org)

Vol.3; Issue: 3; March 2013
68
appendix was performed and the same was

subjected for histopathological evaluation.
On gross examination, specimen
consisted of portion of terminal ileum and
ascending colon with appendix measuring
altogether 14x9x4cm. The appendix was
markedly dilated, already opened with
smooth inner surface showing large amounts
of mucin. The appendiceal wall was
markedly thickened and parchment like. The
terminal ileum and ascending colon were
unremarkable.
Histology of H&E stained sections

of
appendix
revealed
hypertrophic
appendiceal wall. Mucinous material noted
in mucosa. No lining epithelium was
identified.
Muscularis
propria
was
thickened. No evidence of any malignancy.
Terminal ileum and ascending colon were
unremarkable morphologically. With the
above features, we could arrive at the
diagnosis of Retention cyst (Mucocele) of
appendix.
Figure 1: Mucocele: cut opened gross specimen showing dilated

appendix with mucin on the inner surface.
Figure 2: Mucocele: Photomicrograph showing mucin coated

thickened appendiceal wall. No evidence of lining epithelium.
H&E stain, 10X.
DISCUSSION
In 1940, Woodruff and Mc Donald
classified appendiceal mucoceles into a
benign type, representing a mucocele caused
by obstruction of the appendiceal lumen,
and a malignant type, representing a mucin
secreting adenocarcinoma. Higa et al
preferred to consider all mucoceles as
mucinous
neoplasms
within
a
clinicopathologic spectrum comprising
mucinous
hyperplasia,
mucinous
cystadenoma,
and
mucinous
cystadenocarcinoma. The term mucocele has
been retained by popular usage; those
without an apparent pathogenesis are called
primary, and those with an evident
pathogenesis are termed secondary.[1]
Of all mucoceles, 23% - 50% are

incidental findings at surgery.[1,4]
Mucoceles of appendix has been
described to occur more often in females
with a female predominance of 4:1. [5] The
average age at time of diagnosis is 54 years
for benign mucoceles and 64 years for
malignant disease.[3]
Various etiologies have been
reported. [5] Appendiceal mucocele may
come as a consequence of obstructive or
inflammatory processes. Causes
for
obstruction of the appendiceal lumen may
include inflammatory stricture, carcinoid,
carcinoma, villous adenoma, appendicolith,
mucosal web, endometriosis, and extrinsic
compression.[1] Besides these cause, other

69
tumour lesions in the appendix or caecum

may present as mucocele. There has been
one report of a mucocele secondary to
diverticulitis .[5]
An association between appendiceal
mucocele and synchronous colon neoplasms
has been previously noted. The most
common synchronous neoplasms occur in
the large bowel (19.5%-21%).[3]
The external appearance is gross
enlargement of the appendix, the lumen is
distended by mucin .[6]
The neoplastic diagnosis is only
determined by pathology.[5]
Histopathologic classification of
appendiceal mucoceles is dependent on the
characteristics of their lining epithelium,
these include retention cysts (18%),
mucoceles with mucosal hyperplasia (20%),
mucinous cystadenomas (32%), and
mucinous cystadenocarcinomas (10%).
Classification is important, because the
course of the disease and prognosis are
related to these subtypes.[3]
Simple mucoceles (retention cysts)
are characterized by degenerative epithelial
changes and may result from appendiceal
obstruction and distension. There is no
evidence of hyperplasia or neoplasia of the
mucosa.[3]
Hyperplastic mucoceles are sessile or
pedunculated
lesions
that
represent
hyperplastic polyps of the colon and are not
known to have any malignant potential.[3]
Mucinous cystadenomas also have been
referred to as low-grade appendiceal
mucinous neoplasms. They typically are
circumferential cystic lesions composed of
mucin rich epithelium.They can be
considered as the equivalent of adenomatous
colon polyps.[3]
The mucinous cystadenocarcinoma
presents with high grade cellular dysplasia
and stromal invasion.[3]
Myxoglobulosis is a variant of
mucocele seen in 0.35%-8% of cases, in
which appendix is filled with many solid

translucent globules. [1]
The preoperative clinical diagnosis
of appendiceal mucoceles can be difficult
because
of
lack
of
clinical
symptomatology.[4]
Occasionaly, it may present with
palpable abdominal mass, lower right
abdominal pain, gastrointestinal bleeding or
non specific signs including weight loss,
nausea, vomiting, changes in bowel habits,
hematuria, unexplained anemia and acute
appendicitis .[2,6,7]
In women presenting with right iliac
fossa mass and clinical features not
indicative of gynaecological pathology, an
appendiceal origin should be considered in
the differential diagnosis.[3]
However, most of them are found
incidentally by imaging studies or during
surgery.[7] Symptomatic patients were
reported, more likely, to have a malignant
disease . [6]
Both
Benign
and
malignant
mucoceles may spontaneously rupture,
secondary presumably to hypersecretion of
mucus. These patients may present with a
peritoneal cavity filled with mucus,
informally described as jelly belly.[5]
Cheng considered jelly belly or
pseudomyxoma peritonei a type of foreign
body peritonitis where all the gelatinous
material originates from the mucocele and
induces a fibrotic response in the peritoneum
leading to encapsulation.[1]
The
ultrasound
shows
an
encapsulated cystic lesion in the lower
quadrant of the abdomen with a liquid
content of variable echogenicity, according
to the density of the mucus .[5]
On ultrasound, they have been
known to mimic ovarian cyst torsion .[5]
On CT, the typical feature of
mucocele of the appendix is a cystic mass
with a thin wall and of low density, which
communicates directly with the caecum.[5]

70
The porcelain appendix and the so

called volcano sign are two non specific
diagnostic clues, but CT remains the most
suggestive diagnostic tool.[5]
However, careful handling of the
specimen is recommended as spillage of the
contents can lead to pseudomyxoma
peritonei.[4] So, the mucocele should be
removed intact. [7]
Prognosis is related to the
histopathological subtypes.[5]
The 5 year survival rate for simple or
benign neoplastic mucocele ranges from
91% to 100%. [3]
Simple and benign mucoceles have
an insidious evolution and are rarely
perforated; on the other hand malignant
mucocele evolution is faster, like in acute
appendicitis, usually presenting as an organ
perforation .[1]
CONCLUSION
In conclusion, mucocele of appendix
is very rare. It is very difficult to diagnose
pre-operatively as it lacks specific
symptomatology. A variety of abnormalities
(benign and malignant) of the appendix
emphasizes the need for routine pathologic
examination of the appendix.
2.
3.
4.
5.
6.
7.
REFERENCES
1. Dachman AH, Lichtenstein JE,
Friedman AC. Mucocele of the
Appendix
and
Pseudomyxoma
Peritonei. AJR, May 1985; 144: 923929.

Karakaya K et al. Appendiceal
mucocele: Case reports and review
of current literature. World J
Gastroenterol, April 2008; 14(14):
2280-2283.
Shetty PK, Ramesh M, Ramesh S.
Case Report: Mucocele of Appendix
Secondary to Cystadenoma a
Diagnostic
Challenge.
Online
Journal of Health and Allied
Sciences, Apr-Jun 2010; 9(2): 1-3.
Bartlett C, Manoharan M, Jackson A.
Mucocele
of
the
appendix-a
diagnostic dilemma: a case report.
Journal of Medical Case Reports,
2007; 1(183): 1-3.
Oliphant
UJ,
Rosenthal
A.
Hematuria: An Unusual Presentation
for Mucocele of the Appendix. Case
Report and Review of the Literature.
JSLS, 1999; 3: 71-74.
Lakatos PL et al. Mucocele of the
appendix: An unusual cause of lower
abdominal pain in a patient with
ulcerative colitis: A case report and
review of literature. World J
Gastroenterol, 2005; 11(3): 457-459.
Ouladsahebmadarek E, Tabrizi AD,
Pouya K, Arash TK. Mucinous
Cystadenoma
of
Appendix
mimicking an Ovarian Cyst: A Case
Report. Advances in Environmental
Biology, 2011; 5(10): 3117-3119.
How to cite this article: Narchal S, Patil SB, Paricharak M et. al. Appendiceal Mucocele: A
masquerade. Int J Health Sci Res. 2013;3(3):68-71.
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International Journal of Health Sciences and Research

Appendiceal Mucocele: A Masquerade

Post Graduate Resident, **Assistant Professor, ***Consultant Pathologist

Correspondence Email: drshilpahastir@gmail.com

iliac fossa without rigidity, muscle guarding

International Journal of Health Sciences & Research (www.ijhsr.org)

appendix was performed and the same was

Histology of H&E stained sections

Figure 1: Mucocele: cut opened gross specimen showing dilated

Figure 2: Mucocele: Photomicrograph showing mucin coated

Of all mucoceles, 23% - 50% are

International Journal of Health Sciences & Research (www.ijhsr.org)

tumour lesions in the appendix or caecum

which appendix is filled with many solid

International Journal of Health Sciences & Research (www.ijhsr.org)

The porcelain appendix and the so

Peritonei. AJR, May 1985; 144: 923929.

International Journal of Health Sciences & Research (www.ijhsr.org)

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Post Graduate Resident, Assistant Professor, *Consultant Pathologist