[Neurogenic appendicitis. A case]

Laparoscopic procedures have changed the indications for appendectomy. Routine exeresis should not be performed if a normal organ is observed during an exploratory procedure, but should be in cases with clinical manifestations of right flank pain since neurogenic appendicitis is not rare. We report a recent case observed in a 76-year-old woman. The patient was initially hospitalized for right flank pain with nausea and irregular episodes of diarrhoea. Clinical examination and complementary exploration led to cholecystectomy via subcostal access. On per-operative cholangiography the common bile duct appeared normal. Immediate follow-up was uneventful and the patient was discharged. Twelve days later, the patient complained of the same type of abdominal pain and was hospitalized with a fever at 38 degrees C and shivers. The right flank was very painful at palpation. Echography and computed tomography eliminated a subphrenic abscess or secondary pancreatitis. Pain localized at MacBurney's point 8 days later. Barium study showed a normal colon with the exception of uncomplicated diverticulosis. Subjective pain persisted and appendectomy was decided. Pathological examination revealed neurogenic appendicitis. First described in 1924, neurogenic appendicitis is relatively frequent. Macroscopically, a sclerous fibromyxomatous nodule obliterates the lumen. Microscopically, the central obliterating lesion is composed of hyperplastic nervous tissue in a fibromyxoid matrix, particularly important at the point of the appendix. Clinically neurogenic appendicitis is usually chronic and the appendix appears healthy in situ. Cure is always achieved with resection. Laparoscopic procedures can identify para-appendicular causes of painful abdominal syndromes and sclero-atrophic appendicitis, but in the absence of another explanation exeresis appears to be justified due to the possibility of neurogenic appendicitis.