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Background
Stump appendicitis is a rare entity. A 2011 review of the literature found only 40 reported cases of stump appendicitis in the English medical literature. 1 The first documented case was reported in 1945. 2 Stump appendicitis usually presents with symptoms and examination findings similar to appendicitis, with or without signs of abscess formation or perforation. The Society of American Gastrointestinal Endoscopic Surgeons (SAGE) Guidelines state that complication rates are comparable between open versus laparoscopic approaches in uncomplicated appendicitis, but they do not comment on rates of incomplete appendicectomy. 3 There has been an increase in frequency of stump appendicitis alongside the rise of laparoscopic surgery. 4 Its incidence may be reduced with accurate visualisation of the base of the appendix and creation of a stump smaller than 3 mm. 4 No relationship has been identified between rates of stump appendicitis and simple ligation or inversion of the stump. 4
Incorrect identification of the caecal/appendiceal junction increases the incidence of incomplete appendicectomy; this can be influenced by severe inflammation and a fear of caecal perforation affecting tissue handling. An appendix lying in a retrocaecal position also increases the incidence. 1 Treatment of stump appendicitis is by completion appendicectomy, which is usually performed open rather than laparoscopically. 5 Average stump length at completion appendicectomy is 3.4 cm. 1
Case presentation
A 63-year-old man presented to the emergency department with 3 weeks of lower abdominal pain, which had worsened over 24 h and migrated to the right iliac fossa, with associated anorexia. The pain felt 'similar to the pain from his appendix' he had experienced before undergoing laparoscopic appendicectomy 2 years prior ( figure 1 ), which, histologically, had proven appendicitis. On examination, he was haemodynamically stable but was febrile at 38°C. He was tender in the right iliac fossa with voluntary guarding.