JOURNAL OF THE ROYAL SOCIETY OF MEDICINE
Finally, we should comment on the initial management
j| ~Fioure 3 The
11)}
MII
I' denture
possibility of abscess needs to be excluded early. Such
abscesses are potentially lethal because the retropharyngeal
space is contiguous with the superior and posterior
mediastinum. As well as mediastinitis, abscess rupture can
result in severe pneumonia. In this patient we also needed
to exclude tuberculosis of the cervical spine, which can
present with a retropharyngeal mass2A, but the absence of
bony erosion on the lateral neck X-ray made this diagnosis
unlikely. The presence of plasma cell infiltration in the
histological specimen was another distraction, but such
infiltrates can be secondary to chronic inflammation.
Extramedullary plasmacytoma, which is rare below the
age of 40, typically presents as a soft-tissue mass in the
upper respiratory tract5; retropharyngeal plasmacytoma
does not seem to have been reported. A case very similar to
this was reported in 1988 by Youngs and co-authors6; they,
and others subsequently78, called for incorporation of
radio-opaque material to aid radiographic localization after
swallowing.
Ultrasound appearances in
chronic appendicitis
J M Wide MRCP FRCR G Lamont DM FRCR(Paed)l
A Boothroyd MBChB FRCR
J R Soc Med 1999;92:251-252
Acute appendicitis is usually diagnosed on the basis of
physical signs and symptoms, but where there is doubt
Departments of Radiology and Surgery', Royal Liverpool Children's NHS Trust,
Eaton Rd, Liverpool L12 2AP, UK
Correspondence to: Dr A Boothroyd, Consultant Radiologist
Volume 92 May 1 999
in Tanzania. Dentures of this size and shape in the pharynx
or upper oesophagus can usually be removed with forceps
through a rigid endoscope under general anaesthesia,
especially soon after the incident. Attempts to railroad an
upper aerodigestive tract foreign body are not generally
advisable, because of the high risk of viscus perforation and
subsequent infection9.
Acknowledgments We thank Mr A A Moir and Mr T
Alun-Jones for permission to report this patient under their
joint care and Mr A Narula for reading the manuscript.
REFERENCES
I Goldenberg D, Golz A, Joachims HZ. Retropharyngeal abscess: a
clinical review. J Laryngol Otol 1 997; 1 1 1:546-50
2 Neumann JL, Schlueter DP. Retropharyngeal abscess as the presenting
feature of tuberculosis of the cervical spine. Am Rev Respir Dis
1974;1 10:508-11
3 Neal SL, Kearn MJ, Seeling JM, Harris JP. Manifestations of Pott's
disease in the head and neck. Laryngoscope 1986;96:494-7
4 Al Soub H. Retropharyngeal abscess associated with tuberculosis of the
cervical spine. Tuberc Lung Dis 1996;77:563-5
5 Singh B, Kantu M, Har-El G, Lucente FE. Complications associated
with 327 foreign bodies of the pharynx, larynx, and oesophagus. Ann
Otol Rhinol Laryngol 1998;106:301-4
6 Youngs RP, Gatland D, Brookes J. Swallowed radiolucent dental
prostheses: risk of extraluminal oesophageal perforation. J Laryngol Otol
1988;102:71-3
7 Knowles JEA. Inhalation of dental plates hazards of radiolucent
materials. J Laryngol Otol 1991;105:681-2
8 Mucci B, Eyre T. Soft tissue neck radiography for displaced dental
prostheses. Clin Radiol 1993;47:424-5
9 Rubin E, Farber JLF, eds. Pathology, 2nd edn. Philadelphia: Lippincott,
1988;1037, 1092
about the diagnosis ultrasound can be of valuel2. Despite
the frequency of acute appendicitis the concept of chronic
appendicitis as a cause of recurrent abdominal pain is
controversial. We report a case with sequential ultrasound
examinations.
CASE HISTORY
A 7-year-old boy was admitted after 24 hours of central
abdominal pain and vomiting. He had a slight headache and
sore throat but no alteration in bowel habit or urinary
symptoms. There was a history of intermittent abdominal
pain for which medical advice had not been sought. He was
apyrexial and examination revealed diffuse tenderness over
the lower abdomen. His white cell count was normal as was
urine analysis; he was thought to have either mesenteric
adenitis or non-specific abdominal pain. Ultrasound of the 251
 JOURNAL OF THE ROYAL SOCIETY OF MEDICINE
22wiffa2mme WHOMMM-11 -W W L'S -V -V - I -
Figure 1 Ultrasound of the right iliac fossa: thickened, non-
compressible appendix with a thickened, echobright mesentery
(arrow)
lower abdomen demonstrated free fluid in the right iliac
fossa around the caecal pole; a thickened, non-compressible
appendix was identified arising from the caecal pole. The
appendiceal mesentery was thick and echobright and
contained several prominent vessels (Figure 1). Appearances
were felt to be consistent with an inflammatory process of
the appendix and mesentery. Despite these striking findings
at ultrasound the patient improved over the subsequent 24
hours and was discharged. 48 hours later a further
ultrasound showed almost complete resolution of the free
fluid though the appendix remained inflamed and non-
compressible. The appendix was now surrounded by
echogenic material, presumed to be omental fat. No abscess
was detected (Figure 2). Four weeks later the only
abnormality seen on ultrasound was some thickening of
the appendix wall (Figure 3). The patient was discharged
Figure 2 Appendix remains thickened and non-compressible but
252 the free fluid has resolved and appendix is now surrounded by fat
Volume 92 May 1 999
Figure 3 The appendix wall (arrow) is now only mildly thickened
from follow-up but returned to hospital five days later with
further abdominal pain. On examination the only finding
was of localized pain in the right iliac fossa on deep
palpation. At urgent operation a large but not acutely
inflamed appendix was removed; no free fluid was present.
On histological examination the serosal surface of the
appendix showed dilated and hyperaemic vessels and the
lumen contained faecal material. There was diffuse fibrous
thickening of the appendix wall but no necrosis or
haemorrhage. The lamina propria was hyperplastic and
lymphoid tissue showed reactive non-specific hyperplasia.
Postoperative recovery was uneventful and when seen a
year later the boy had had no further pain.
COMMENT
Reports of chronic appendicitis are uncommon. Seidmen et
al. have described two cases of chronic appendiceal disease
though in only one case was ultrasound performed3. A
prospective study of 170 patients by Rioux4 demonstrated a
sensitivity of 93% in detecting acute appendicitis; and of 45
patients with proven appendicitis 5 had histological
evidence of a chronic inflammatory process with super-
imposed acute changes. Histologically, the chronic changes
consisted of replacement of submucosal fat by fibrous
tissue as observed in our patient. Of these 5 patients 4
were symptom-free shortly before surgery. Rioux also
described 4 further cases of 'false-positive' appendicitis
where ultrasound showed a non-compressible appendix but
because of rapid symptom resolution appendicectomy was
not performed. It was suggested that these cases might
represent subacute or chronic appendicitis. Our patient, we
believe, fits into this category. Falk et al. in a pathological
study of 47 cases, judged that a category of chronic
recurrent appendicitis is warranted on both histological and
immunohistological findingss. The major feature described
 JOURNAL OF THE ROYAL SOCIETY OF MEDICINE
was fibrosis. 80% of cases showed a slight inflammatory cell
infiltrate whilst 60% showed activated lymphoid follicles
with large germinal centres. In 28% lymphoid hyperplasia
was recorded.
Ultrasound has high sensitivity and specificity in the
diagnosis of acute appendicitis, but false-positive and false-
negative results still occur and the decision to operate
remains a clinical one. So far, there are few reported cases
of chronic appendicitis, but the increased use of ultrasound
may reveal that chronic or subacute appendicitis is more
common than we had supposed.
Double pylorus as a cause of
gastrointestinal bleeding
Dirk Ehrhardt Matthias Lohr Stefan Liebe
J R Soc Med 1999;92:253-254
The most common causes of upper gastrointestinal tract
bleeding are peptic ulcer, haemorrhagic gastritis, oesopha-
geal varices, Mallory-Weiss syndrome, and tumours;
haemangiomas and bleeding from the biliary tract
contribute a few casesl. For a double pylorus to present
in this way is very unusual.
CASE HISTORY
A man aged 57 was admitted via the emergency room with
haematemesis and severe epigastric pain. He was an
alcoholic and a smoker. 9 years previously a gastric ulcer
had been diagnosed radiologically (but not endoscopically)
and treated with H2-receptor antagonists; thereafter he had
been free of abdominal pain until the present episode.
There had been no melaena.
On examination he was normotensive but anaemic
(haemoglobin 7.9 g/dL, haematocrit 37%). Quick test was
76% normal, activated prothrombin time 28.7 s. At
endoscopy there was no blood in the stomach but clot
was seen adhering to the stomach wall in the prepyloric
region. This could not be removed with forceps. Gastric
Division of Gastroenterology, Klinik fur Innere Medizin, Universitat Rostock,
Germany
Correspondence to: Professor M Lohr, Division of Gastroenterology,
Department of Intemal Medicine, University of Rostock, E. Heydemann Str. 6,
D-18055 Rostock, Germany
E-mail: loehr@med.uni-rostock.de
Volume 92 May 1 9991
REFERENCES
1 Sivet CJ, Newman KD, Boenning DA, et al. Appendicitis: usefulness of
ultrasound in diagnosis in a pediatric population. Radiology
1992;185:549-52
2 Siegel MJ. Acute appendicitis in childhood: the role of ultrasound.
Radiology 1992;185:341-2
3 Seidmen JD, Andersen DK, Ulrich S, et a]. Recurrent abdominal pain
due to chronic appendiceal disease. South MedJ 1991;84:913-16
4 Rioux M. Sonographic detection of the normal and abnormal appendix.
AmJ Roentgenol 1991;158:773-8
5 Falk S, Schutze U, Guth H, et a]. Chronic recurrent appendicitis. A
clinicopathologic study of 47 cases. EurJ Pediatr Surg 1991;1:277-81
Figure 1 Endoscopic
MM appearance of gastric
outlet with view of
double pylorus
ulcer was diagnosed and he was treated with intravenous
omeprazole 40 mg twice daily and intravenous amoxycillin
100 mg three times daily. Within a few days the abdominal
pain ceased entirely. At a second endoscopy there were no
signs of gastric bleeding, but in the prepyloric antrum the
entrance to a fistula was suspected (Figure 1). Double
pylorus was confirmed by side-view duodenoscopy,
cannulation and contrast radiography (Figure 2). Thence-
forth the patient's course was unremarkable, apart from
development of gouty arthritis in the left foot which
responded to colchicine. He was discharged on day 14 and
did not return for follow-up.
COMMENT
A duplicated gastric outlet is thought to arise in two ways.
A congenital double pylorus is a rare anomaly caused by
gastric and duodenal duplication3'4. An acquired double
pylorus is a complication of prepyloric or postpyloric ulcer,
which perforates the gastric and duodenal walls and gives
rise to a fistula. The prevalence in routine endoscopic and
radiodiagnostic procedures is estimated at between 0.02
and 0.13%5, with a distinct overrepresentation of males6.
The ulcers that give rise to these fistulas commonly show
themselves by bleeding, and there is often an underlying
disease such as alcoholism, diabetes or chronic renal 253