True Stories | |||||
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| Introduction |
As children, all three of us were subjected to repeated injunctions by
our respective mothers that under no circumstances should we swallow
fruit pips or seeds. Underpinning the maternal reasoning was an
unshakeable belief in the inevitable impaction of such ingested
material in the appendix, resulting in inflammation, distress and
eventual "surgical mutilation" (referred to by surgeons as
"operative cure"). We analysed a series of acute appendicitis in
children in an attempt to validate the maternal hypothesis and to
dispel the memories of years of childhood terror.
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| Subjects and methods |
The computerised database at the Department of Histopathology,
Women's and Children's Hospital, Adelaide, South Australia, was
searched for records of all cases of surgical removal of a vermiform
appendix over the period 1972-1997. The cases had been coded using the
SNOMED1 system and were searched for
under the codes T-66000 (appendix), M-41000 (acute inflammation)
and M-30400 (foreign body, NOS [not otherwise specified]).
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| Results |
Among 2224 consecutive cases of surgically removed appendices there
were 1409 cases in which there was sufficient evidence of
acute inflammation to justify a diagnosis of acute appendicitis. In
only one of these cases (1/1409; 0.07%) was a fruit seed discovered.
This seed enteric entrapment disease state (SEEDS) involved a
three-year-old girl who had presented in 1997 with a short history of
right-sided lower-abdominal pain necessitating surgical
intervention.
Pathological examination of the excised appendix revealed a 10 mm round fruit seed in the distal portion of the appendix (Figure) associated with a transmural acute inflammatory infiltrate. Expert analysis of the seed revealed it to be consistent with a cherry pip (unidentified elderly white man representing Fresh Fruit and Vegetables Inc., Adelaide, SA, personal communication). While no subsequent immunohistochemical, electron microscopic or molecular biological evaluations of the foreign body were undertaken, we are in no doubt that, if they had been, the results would also have been consistent with the identification of a cherry pip.
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| Discussion |
Although acute appendicitis is common, its aetiology remains "vague
and indefinite".2 It was rarely recognised
until the latter part of the 19th century, when an eminent text noted
that it had become quite common in "highly civilized countries such as
Great Britain", with lower occurrence rates in Denmark and
Sweden.2 (Whether it occurred in the
Antipodes at that time is not known, as for some reason rates for the
colonies were not given.) A perforated appendix found in an Egyptian
mummy, however, indicates that the disease has been around since
ancient times.3
Originally known as perityphlitis (Greek; peri, around + typhlos, blind + -itis, inflammation), the disease was described by John Hunter in a case at autopsy in 1769;4 the first use of "appendicitis" is credited to Fitz, who used the term at the inaugural meeting of the Association of American Physicians in 1886.4 The appendix is an unusual organ, and is apparently found only in humans, certain apes and the wombat.3 The similarity between humans and wombats certainly comes as no surprise to our group, as, using quite elaborate, expensive and time-consuming immunohistochemical techniques, we have previously been unable to distinguish between wombats and humans.5 However, we did note at the time that wombats tended to be hairier and smaller (R W B, unpublished observation). One of the earliest aetiological theories for acute appendicitis (to which our mothers still subscribe) is that a small foreign body, such as a seed, might lodge in the appendix, thus initiating an acute inflammatory reaction.6,7 This theory has not been universally accepted, with suggestions being made, as early as 1925, that most cases thought to be cherry stones, date seeds and grape seeds found within the appendix are not really seeds at all, but concentrically laminated faecoliths.8 Our study has clearly demonstrated, however, that impaction of fruit seeds within the appendix is a very real, although seemingly rare, possibility, with potentially dire consequences. The case of a boy who "died of his first berry" was reported as early as 1887 by Jacobi.9 Although it may be argued that the rate of SEEDS in our series was rather low, at 0.07%, the impact on the affected individual was obviously quite profound. In searching the literature we have uncovered reports of a host of other swallowed foreign bodies retrieved from appendices. One of the earliest documented cases of foreign body entrapment within the appendix involved perforation by a pin in a 12-year-old boy. The case was reported in 1736 by Claudius Amyand, sergeant-surgeon to George II, under the heading of "Some observations on wounds in the guts".10 As well as further reports of pins becoming lodged in the appendix (so-called "Halloween" appendicitis),11 there were also reports involving needles,9 balls of animal hair,12 snipe shot (birdshot)13 and bullets.14 Thus, it is clearly mandatory that pathologists insist that their registrars carefully scrutinise all faecoliths, diligently searching for such elusive treasures. Although our initial conclusion was that our mothers were entirely correct in espousing the belief that fruit seeds may be potentially lethal, a reviewer for the Journal disagreed and stated that our study demonstrated instead that our mothers were "incorrect in espousing the belief that fruit seeds or pips may cause appendicitis". As publication was at stake, we agreed to reverse our opinions while still using the same data. We would defend this apparent defection from the truth on pragmatic grounds, and also look to Cervantes for support in that "one swallow does not make a summer".14 The reader should be the final arbiter.
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| References |
(Received 6 Feb, accepted 27 Apr 1998) Picture at top: Opened appendix, demonstrating a typical case of seed enteric entrapment disease state (SEEDS) in a three-year-old girl. A cherry stone is firmly embedded in the distal portion of the acutely inflamed appendix.
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| Authors' details |
Department of Histopathology, Women's and Children's Hospital,
Adelaide, SA.
Roger W Byard, MD, FRCPath, Associate Professor, Senior Consultant, Histopathologist Nicholas D Manton, MB BS, Histopathology Registrar Department of Paediatrics, University of Adelaide, SA.
Reprints will not be available from the authors. ©MJA 1998 | ||||
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