Lucia Collar Yagas, MD, Joaquin J Estrada, MD, FACS, FACRS, Jan P Kaminski, MD, MBA. Advocate Illinois Masonic Medical Center
Case: A 63-year-old male presented for his first screening colonoscopy. On the day of the procedure, he was asymptomatic and physical examination was unremarkable.
He underwent an uncomplicated colonoscopy. A 6 mm pink-tan, sessile, polypoid lesion was found at the appendiceal orifice with thick yellowish-white oozing.
After the colonoscopy, the patient developed right lower quadrant abdominal pain. On examination McBurney’s sign was positive. A diagnostic laparoscopy was done revealing an inflamed appendix. An appendectomy was performed. Histopathologic examination of the specimen confirmed the diagnosis.
Discussion: In the few cases of appendicitis diagnosed by colonoscopy reported, the scope was performed because a diagnosis other than appendicitis was suggested by atypical clinical presentations or non-diagnostic imaging studies. Less commonly, this diagnosis was made during an endoscopy done in an asymptomatic patient such as in our case. Reported endoscopic findings were bulging near the appendiceal orifice, submucosal tumor-like protruding lesion, and spontaneous discharge of pus from the appendiceal orifice into the cecum.
It has been suggested that appendicitis can develop as a consequence of colonoscopy. Establishing causality is difficult, but there is an association between both entities. This relationship is most likely underreported, but it is estimated to be as high as 3.8 appendicitis cases per 10000 procedures.
The etiology of acute appendicitis is believed to be obstruction of the appendiceal lumen. Related to colonoscopy, the obstruction may occur during the preparation phase because of the aggressive catharsis or even during the procedure. It could be a result of air insufflation forcing fecal material into the appendiceal lumen, or from barotrauma. Other hypotheses are local edema caused by direct intubation of the appendiceal orifice, and mucosal inflammation from exposure to residual glutaraldehyde-type solution used in the cleaning of the endoscope. All these mechanisms could either initiate appendicitis or exacerbate a previously subclinical disease. Early stages of acute appendicitis might be symptom-free when the inflammation is only limited to the mucosa without serositis. It remains to be determined if in this case, appendicitis was caused by the colonoscopy or the patient had an early or subclinical disease when he presented for the procedure. It cannot be assured that colonoscopy did not have a role in the pathogenesis of the disease or the precipitation of symptoms.
Conclusion: Even though acute appendicitis during or after colonoscopy is an uncommon event, a high index of suspicion must be kept to facilitate early diagnosis and treatment.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95886
Program Number: P431
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster