case_images: PMC11251912_01
case_images: Results of the sonographic examination. A small amount of hypoechoic and echo-inhomogeneous free peritoneal fluid could be detected between the cecum and the uterus (A; white star). Moreover, a structure with a diameter of approximately 1 cm and a thickened, hypoechoic wall was found - most likely corresponding to the vermiform appendix (B). Additionally, the walls of the cecum and the terminal ileum appeared hypoechoic and thickened (C).
case_images: fmed-11-1387043-g001.jpg
case_images: PMC11251912_01_fmed-11-1387043-g001.jpg
case_images: fig1
case_images: In contrast, a recent ultrasound examination revealed a small quantity of echo-poor and echo-inhomogeneous free peritoneal fluid between the cecum and the uterus (Figure 1A). While the ascending colon appeared normal, a slight wall thickening of the cecum and the terminal ileum could be found (Figure 1C). After prolonged searching, a tubular structure with a diameter of approximately 1 cm and a thickened, hypoechoic wall of unknown origin was found (Figure 1B).
case_images: MRI examination. A small margin of free peritoneal fluid was found at the presumed base of the appendix (A,B; white arrows).
case_images: fmed-11-1387043-g002.jpg
case_images: PMC11251912_01_fmed-11-1387043-g002.jpg
case_images: fig2
case_images: As a next step, our surgical colleagues arranged an additional magnetic resonance tomography (MRI) examination (Figure 2), in which the vermiform appendix could not be identified. A small margin of free peritoneal fluid was found at the presumed base of the appendix (Figure 2, white arrows), which underlined an irritative process in this region.
case_images: Laparoscopic and histopathological findings. The vermiform appendix showed a bulgy thickening at the apex and the walls of the cecum and the appendix were perforated (A). Apex of the vermiform appendix (H&E, 25x) with masses of decidualized endometrium (star) comprising the entire wall and perforating into the lumen of the appendix (arrowheads), leading to perforation due to gestational increase in volume. Normal mucosa on the right side (m) (B). Higher magnification (H&E, 50x) shows decidualized stroma with myxoid changes and endometrioid glands (star) within the wall of the appendix (C).
case_images: fmed-11-1387043-g003.jpg
case_images: PMC11251912_01_fmed-11-1387043-g003.jpg
case_images: fig3
case_images: The vermiform appendix showed a bulgy thickening at the tip, and the cecum and appendix were perforated (Figure 3A). Formations of decidualized endometrium with partly myxoid loosening and variously sized glands, which were lined by cubic epithelium, were found both at the appendiceal apex and in the resected cecal parts (Figures 3B,C). One of the largest decidua complexes appeared within the wall of the apex of the vermiform appendix, leading to subsequent perforation (Figure 3B).