Appendiceal inflammatory vascular congestion in a child: a case report

Introduction: Appendiceal varices are an exceedingly rare entity in pediatric patients and are usually associated with portal hypertension. Severe inflammatory vascular congestion in acute appendicitis may closely mimic this condition intraoperatively. Case presentation: An 8-year-old female child presented with a 24-h history of right lower quadrant abdominal pain associated with low-grade fever and vomiting. There was no history of gastrointestinal bleeding, liver disease, portal hypertension, or previous abdominal surgery. Physical examination revealed localized tenderness and guarding in the right iliac fossa. Laboratory investigations showed leukocytosis with neutrophil predominance. Abdominal ultrasonography demonstrated a non-compressible tubular structure in the right iliac fossa with surrounding inflammatory changes, consistent with acute appendicitis. Open appendectomy was performed through a Lanz incision. Intraoperatively, the appendix was markedly inflamed, edematous, and dusky in appearance with very large, prominent serpiginous vessels along the mesoappendix and appendiceal wall. These dilated veins were not detected preoperatively on imaging and raised suspicion of appendiceal varices. The dilated vessels were carefully controlled using standard ligation of the mesoappendix, and appendectomy was completed uneventfully without excessive bleeding. Gross examination showed a thickened inflamed appendix. Histopathological examination demonstrated transmural acute inflammation with marked vascular congestion but no venous ectasia or true varices. The postoperative course was uncomplicated, and the patient was discharged on the second postoperative day. At follow-up, the child remained asymptomatic with no clinical or radiological evidence of portal hypertension or recurrent symptoms. Conclusion: Appendiceal varices in the context of acute appendicitis may be secondary to the inflammatory process and not a sign of portal hypertension.