We report two rare cases of fistulae from the vermiform appendix to the umbilicus and discuss the underlying etiopathogenesis.

A full term male baby was admitted at 2 months of age for treatment of what was thought to be a patent omphalomesenteric duct (POMD). There was redness and feculent discharge per umbilicus starting 25 days of life. Fistulogram delineated a track towards right iliac fossa ending into a globular structure, cecum getting partially delineated in later films. Exploration through an umbilical incision with right transverse extension revealed a track communicating with the lateral aspect of vermiform appendix. Rest of bowel and intra abdominal structures was normal. The appendix and the track were removed and the patient made good post operative recovery. Histopathology con-firmed a POMD opening into vermiform appendix.

A 3-year-old boy with a normal birth history was referred for recent onset feculent discharge per umbilicus for 20 days. Child had an episode of right lower abdomen pain associated with vomiting and fever 2 months prior which was treated with intravenous antibiotics. A fistulogram done through umbilical opening revealed an irregular track extending towards right iliac fossa. No clear distal communication with the gut could be seen.

Exploration revealed dense adhesions in the right iliac fossa and the track was found communicating with the tip of the thickened vermiform appendix. Omentum was found wrapping the junction and the adjoining structures. Appendectomy and excision of the track was performed. Child had smooth recovery and is doing well at 8 months follow up.

Histopathology revealed a fibrous track with granulation tissue communicating with appendix. Appendix showed moderately dense acute and chronic inflammatory cell infiltrate forming focal foamy aggregates.

Reports of fistulous connection between appendix and umbilicus are rare. Collins(1) reported only 3 cases in a review of 50,000 specimens of the human vermiform appendix (0.006%), but did not describe their etiology as congenital. POMD usually arises from ileum but may unusually arise from cecum, ascending colon or appendix leading to lateral appendico-umbilical, terminal appendico-umbilical or ceco-umbilical fistulae(2). Our first case represents a type of lateral appendico-umbilical fistula (AUF). Delay of involution of the omphalomesentric duct and appendico-umbilical connection of POMD has been postulated as the underlying etiology(3).

Our second patient developed AUF secondary to appendicular inflammation. Acquired AUFs are described as a result of injury; either from a clamp to the tip of the appendix within the cord, or ligature of a unrecognised exomphalos(4). Appendicocutaneous fistulae may also occur as a result of inflammatory processes(5), associated tumors or subsequent to surgical or percutaneous drainage of appendicular abscesses(6).

Kamalesh Pal,
V.P. Singh,
Department of Pediatric Surgery,
Christian Medical College and Hospital,
Ludhiana 141 008, India.
E-mail: [email protected]
[email protected]  

1. Collins DC. A study of 50,000 specimens of the human vermiform appendix. Surg Gynecol Obstet 1955; 101: 437-445.

2. Zaidenstein L, Freud E, Schwartz M, Zer M. Clinical presentation of rare appendico- omphalic anomalies. J Pediatr Surg 1995; 30: 1702-1703.

3. Crankson SJ, Ahmed GS, Palkar V. Patent omphalomesenteric duct of the vermiform appendix in a neonate: Congenital appendico-umbilical fistula. Pediatr Surg Int 1998; 14: 229-230.

4. Kadzombe E, Currie ABM. Neonatal fistula from the appendix to the umbilicus. J Pediatr Surg 1988; 23: 1059-1060.

5. Ucchedu A. Primary appendiculo-cutaneous fistula caused by appendicitis: Description of a case and review of the literature. Ann Chir 1984; 38: 216-219.

6. Jeffrey RB, Tolentino CS, Federle MP. Percutaneous drainage of periappendiceal abscess, review of 20 patients. Am J Roentgenol 1987; 149: 59-62.