1888 Colonoscopy as a Cause of Appendicitis

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INTRODUCTION: Millions of colonoscopies are performed annually in the United States. Acute appendicitis is a rare complication of colonoscopy which many general providers may remain oblivious of. Albeit a rare entity, it can lead to patient mortality. We present a case of acute appendicitis which occurred after colonoscopy in which there was no evidence of pre-existing appendiceal disease. Increased physician awareness may help reduce delays in diagnosis and treatment. CASE DESCRIPTION/METHODS: A 55-year-old woman underwent a routine outpatient screening colonoscopy. She had no complaints prior to the procedure. Bowel preparation was adequate. A 6mm sessile polyp was noted in the cecum and was resected by cold snare polypectomy. The appendiceal orifice was normal in appearance. No other significant findings were noted. About 12 hours after colonoscopy, she started experiencing severe right lower quadrant abdominal pain and presented to the emergency room. Vital signs were within normal limits besides a pulse was 101 beats per minute. Right lower quadrant abdominal tenderness was noted on exam. Laboratory results noted WBC count of 12.9 x 103/ul (3.8-10.7 x 103/ul) and rest of basic labs were normal. A computed tomography (CT) scan of abdomen noted a dilated 13mm appendix with surrounding inflammatory changes in the surrounding fat and an impacted appendicolith [Figure 1] She underwent open appendectomy with findings of acute appendicitis with no signs of perforation. Post-operatively, patient recovered quickly and discharged home after 24 hours. At a one week follow up she was still recuperating well with no concerns. DISCUSSION: Acute appendicitis following colonoscopy has an estimated incidence of 0.038%. Different causal mechanisms proposed include fecalith impaction, barotrauma from overinsufflation of air or direct trauma to the appendiceal orifice. The majority of patients present within 24hrs of colonoscopy. Abdominopelvic CT imaging remains the most useful diagnostic modality. The majority of reported cases have required surgical management with intraoperative findings ranging from acute appendicitis to gangrenous or perforated appendicitis. It can mimic more benign conditions such as post-colonoscopy gas pain, cramping or post-polypectomy electrocoagulation syndrome. Greater provider and patient cognizance of the risk of appendicitis following colonoscopy will enhance prompt diagnosis and appropriate treatment.