What is the management of lymphoid hyperplasia of the appendix?

Management of Lymphoid Hyperplasia of the Appendix

For lymphoid hyperplasia of the appendix, appendectomy is the recommended treatment when it presents with symptoms of acute appendicitis, as simple appendectomy is sufficient for most cases with well-differentiated histology. 1

Diagnosis and Initial Assessment

• Lymphoid hyperplasia of the appendix is often identified incidentally during appendectomy performed for suspected appendicitis 1
• Ultrasound examination can help distinguish between suppurative appendicitis and lymphoid hyperplasia:
  • Appendiceal wall thickening alone (without fluid) often correlates with lymphoid predominant pathology 2
  • Fluid-filled appendix typically indicates suppurative or mixed pathology requiring surgical intervention 2

Treatment Algorithm

Asymptomatic Incidental Finding

• If discovered incidentally during imaging for other conditions and patient is asymptomatic:
  • Observation may be appropriate 3
  • Monitor for development of symptoms 1

Symptomatic Presentation

• For patients presenting with symptoms of acute appendicitis:

  • Primary treatment: Appendectomy 1
    • Simple appendectomy is sufficient for most cases 1
    • Laparoscopic approach is a viable option 1

• For patients with appendiceal mass or abscess:

  • Percutaneous drainage plus antibiotics if abscess is present 1
  • If percutaneous drainage is not available, surgical intervention is recommended 1
  • Consider interval appendectomy for patients with recurrent symptoms 1

Special Considerations

• In selected cases with early symptoms (<24 hours of pain), localized tenderness, and hemodynamic stability:
  • Non-operative management with antibiotics may be considered, especially in children 3
  • This approach showed 93.7% success rate in a small pediatric study 3

Pathological Considerations

• Lymphoid hyperplasia is frequently associated with luminal obstruction of the appendix 3, 4
• About 25% of acutely inflamed appendices show significant lymphoid hyperplasia 4
• Important to rule out neoplastic causes:
  • Approximately 7.1% of appendicitis cases may be associated with underlying neoplasia 5
  • These patients typically present at an older age with longer duration of symptoms 5

Post-Treatment Surveillance

• No specific surveillance is required after successful appendectomy for simple lymphoid hyperplasia 1
• If there are any concerning features on pathology (such as atypical cells), follow-up should be guided by the specific findings 1

Pitfalls and Caveats

• Do not mistake lymphoid hyperplasia for carcinoid tumors, which require different management approaches 1
• Be vigilant for signs of adenocarcinoma or "goblet cell carcinoid" which would require management according to colon cancer guidelines 1
• Incidental appendectomy during other procedures may increase wound infection rates and length of hospital stay 6
• Lymphoid hyperplasia with specific features (appendix length ≥8 cm, hyperemic, subserosal, nodular appearance) may warrant removal even when found incidentally 6

Remember that while lymphoid hyperplasia is often benign, it can be difficult to distinguish from early neoplastic processes without proper histopathological examination, making appendectomy the safest approach when symptomatic 1, 5.