Journal of Visceral Surgery (2011) 148, e323

CORRESPONDENCE
Acute appendicitis and ectopic pregnancy?
Which came rst?
A 41-year-old female patient, with no unusual past history, was pregnant 5 weeks after her last period following
in vitro fertilization (IVF); she presented with right lower
quadrant abdominal pain, progressive over 48 hours, in
association with a temperature of 37.8 , RLQ abdominal
guarding, leukocytosis (WBC: 12,600), and an elevated CRP
(4 mg/100 mL).
Beta-HCG was greater than 100,000 IU/L. Three pelvic
ultrasound examinations performed serially over 48 hours
showed progression of an intrauterine pregnancy and an
8 mm diameter appendix with a fecolith as well as pelvic
uid suggestive of acute appendicitis (AA). The abdomen
was explored through a MacBurney incision revealing an
acutely inamed appendix but also a low-volume hemoperitoneum. Appendectomy was performed. Persistent bleeding
from a source which could not be identied through this
exposure led us to perform a diagnostic laparoscopy; this
led to the diagnosis of an unruptured ectopic pregnancy in
the right tube (Fig. 1). A right salpingectomy was performed.
The clinical diagnosis of acute appendicitis was conrmed
by pathological exam. The appendiceal lumen was dilated
and lled with polymorphonuclear WBCs; the mucosa was
acutely inamed while the muscular wall was normal.
The postoperative course was uncomplicated.
Twenty-two cases of acute appendicitis with simultaneous tubal ectopic pregnancy have been described in the
literature since 1960 [1,2], and three cases of appendicitis in
association with heterotopic pregnancy [3]. A causal relation
between ectopic pregnancy (EP) and AA has been postulated. EP could theoretically result in peri-appendicular
inammation thereby leading to bacterial colonization [4].
This hypothesis is believable in our case due to the precedent interventions of IVF which resulted in the ectopic
pregnancy. In the opposite direction, an antecedent AA with
spontaneous resolution could also conceivably result in peritubular inammatory adhesions favoring the development of
the ectopic pregnancy. It is of particular interest that 75%
of tubal pregnancies involve the right tube [5].
Whatever the etiology, this case should incite the surgeon to vigilance in the management of appendicitis in the
pregnant patient. Both acute appendicitis and ectopic pregnancy should be considered in the differential diagnosis and
searched for; this is all the more so in the context of IVF. If
the diagnosis of appendicitis is in doubt during an appendectomy through a MacBurney incision, the case can be
converted to laparoscopy rather than enlarging the incision to a major laparotomy.

Figure 1.
lopian.

Laparoscopic view: ectopic pregnancy in the right fal-

Disclosure of interest
The authors declare that they have no conicts of interest
concerning this article.
References
[1] Mir IS, Mohsin M, Malik A, Ahad B, Farooq SS. Successful laparoscopic management of concomitant ectopic pregnancy and
acute appendicitis in a patient of failed tubal ligation: case
report with a review of the literature. Case J 2008;1:412.
[2] Hazebroek EJ, Boonstra O, van der Harst E. Concurrent tubal
ectopic pregnancy and acute appendicitis. J Minim Invasive
Gynecol 2008;15:978.
[3] Radwan M, Maciolek-Blewniewska G, Malinowski A. Spontaneous heterotopic pregnancy and acute appendicitis treated by
laparoscopy. Int J Gynaecol Obstet 2007;96:129.
[4] Riggs JC, Schiavello HJ, Fixler RJ. Concurrent appendicitis and
ectopic pregnancy. A case report. Reprod Med 2002;47:5104.
[5] Nguyen H, Le K, Le C, Nguyen H. Concurrent ruptured ectopic
pregnancy and appendicitis. JABFP 2005;18:636.

1878-7886/$ see front matter 2011 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.jviscsurg.2011.06.002

P. David , E. Rosso , P. Pessaux , C. de Saint

Roman , P. Bachellier
Centre de chirurgie viscrale et de
transplantation, hpital de Hautepierre, avenue
de Molire, 67098 Strasbourg cedex, France
Corresponding author.
E-mail address: patrice.david@hotmail.fr (P.
David)

Available online 31 August 2011