Endometriosis and the Appendix - Incidence and Pathologic Analysis

Endometriosis is the presence of endometrial and stromal glands at extrauterine sites. One of
the extrauterine sites that may be involved is the GI tract. The extent of bowel involvement
can range from an incidental spot on the serosa to ectopic endometrium causing a bowel
obstruction. The rate at which the bowel is involved ranges from 3-34%, as noted by Gustofson
in a literature review published in Fertility and Sterility. The symptomatology of GI
endometriosis can be vast. Presenting as cyclic or chronic pelvic pain, right lower quadrant
pain, melena, GI upset/pain, and as serious as intussusception and appendicitis.

The incidence with which endometriosis is identified in the appendix potentially causing the
complications that were noted, is reported as a wide range, 1-22%. The low of 1% is reported
in two separate studies. The first, by Harper and Soules, published in the International
Journal of Gynecology and Obstetrics, and the second, by Weed and Ray, in Obstetrics and
Gynecology. The highest rate of 22% was reported by Berker and colleagues in the Journal of
Minimally Invasive Gynecology. Noting the possibility of greater than 20% of individuals with
endometriosis having appendiceal involvement, incidental appendectomy may be of benefit.

The American College of Obstetrics and Gynecology (ACOG) released a Committee Opinion on
incidental appendectomy that was reaffirmed in 2012. These are the guidelines that are
followed by gynecologists today. ACOG notes that women 35years of age and younger benefit the
most from elective coincidental appendectomy. Others who may be of significant benefit are
those patients with a complicated differential, those in who chemotherapy is anticipated, and
those who are expected to have extensive post-op adhesions.

ACOG goes on to note that the decision to perform an appendectomy at the time of a
gynecologic procedure should be based on individual scenarios after the risks and benefits
are discussed with the patient. The procedure has a low risk of morbidity, and if there is
reasonable probability the benefits outweigh the risks, based on age or history, elective
coincidental appendectomy during primary gynecologic procedure may be appropriate.

Considering the variation seen in publications, the rate of diagnosis that the surgeon may
find may be broad. The reason for this variation, though, is under speculation. Although, it
is most likely multifactorial, the method with which the specimen is analyzed may play a
role. In all of the methods sections in the above mentioned research papers and others
regarding this topic, description of the technique used for pathologic analysis was not
available. Here at Penn State Hershey Medical Center, a 3 slice method is employed. A cut is
made at the proximal and distal end, and a third cut in the center. If this method is
modified to include more cuts, the hypothesis is that endometriosis of the appendix will be
diagnosed at a higher rate. Appendix specimens will be collected as indicated, following ACOG
recommendations. After removal of the appendix patient's will be consented to allow the
second pathologic analysis. Time frame for collection and second analysis will be
approximately 12 months, the anticipated time to obtain 100 specimens.

Inclusion Criteria:

- English Speaking

- Women age 18-51 years of age

- Chronic pelvic pain and/or diagnosis of endometriosis

- Appendix removed at time of laparoscopy for treatment of endometriosis and/or pelvic
pain

Exclusion Criteria:

- Non-English speaking

- Previous appendectomy