Correspondence

Polyp of the Appendix

N Engl J Med 1994; 330:1159April 21, 1994

Article

To the Editor:

The case of a polyp of the appendix described by Sticca and Palmer in the Images in Clinical Medicine section (Dec. 2 issue)1 reflects what is terribly wrong with American medicine today. First of all, most would agree that persistently guaiac-positive stools should be evaluated colonoscopically, not radiographically, since such an examination would detect angiodysplasias and allow therapeutic maneuvers such as polypectomy. Furthermore, the authors state that the tiny appendiceal polyp was probably not the cause of bleeding. Why, therefore, was the patient subjected to a laparoscopic appendectomy? Finally, diverticulitis is generally not an asymptomatic condition and is not generally associated with guaiac-positive stools but rather with occasional torrential hemorrhage.

Thus, although the radiograph obtained after a barium enema and the views of the pathological specimen certainly demonstrate an interesting curiosity, the clinical vignette that accompanies them suggests that an inappropriate diagnostic test resulted in an inappropriate therapeutic intervention.

Steven Brozinsky, M.D.
752 Medical Center Court, Chula Vista, CA 91911

1 References

1. 1

   Sticca RP, Palmer ML. Polyp of the appendix. N Engl J Med 1993;329:1709-1709
   Full Text | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: The patient we described had persistent guaiac-positive stools over a two-year period, and she was evaluated endoscopically through both the upper and lower gastrointestinal tracts on her initial presentation. The cause of the occult blood loss was not found, and after a prolonged period a barium enema was ordered. The mass in the appendix was an incidental finding, and colonoscopy was performed to attempt to visualize the mass, obtain a biopsy specimen, and possibly remove the lesion. When the lesion could not be removed through the endoscope, appendectomy was performed, because we were concerned that the polyp might be malignant or premalignant. We recognized, of course, that the incidence of adenocarcinoma of the appendix and adenomatous polyps of the appendix is low, approximately 0.1 percent in most series1,2.

We believe that any lesion with a malignant potential in an otherwise healthy patient should be removed whether it is an incidental finding or a cause of clinical symptoms.

Robert P. Sticca, M.D.
Greenville Hospital System, Greenville, SC 29605

Michael L. Palmer, M.D.
Foxhall Surgical Associates, Washington, DC 20016

2 References

1. 1

   Collins DC. 71,000 Human appendix specimens: a final report, summarizing forty years' study. Am J Proctol 1963;14:365-381
   

2. 2

   Wolff M, Ahmed N. Epithelial neoplasms of the vermiform appendix (exclusive of carcinoid). II. Cystadenomas, papillary adenomas, and adenomatous polyps of the appendix. Cancer 1976;37:2511-2522
   CrossRef | Web of Science | Medline