ENDOSCOPIC DIAGNOSIS OF ACUTE APPENDICITIS

Abstract

The clinical role of colonoscopy in the diagnosis of acute appendicitis in asymptomatic patients has been described in isolated case reports. We report a patient who presented for routine surveillance colonoscopy, in whom acute appendicitis was diagnosed endoscopically. A 72 year old male had a past medical history significant for hypertension and multiple colonic polyps. The patient presented to the endoscopy unit following completion of a standard phosphosoda bowel prep the evening before. He noted some vague right lower quadrant cramps, without fevers or chills, on the morning of the procedure. The patient attributed his symptoms to the bowel prep. On examination prior to the procedure, the patient was noted to be afebrile with stable vitals signs. Abdominal examination revealed minimal right lower quadrant tenderness without rebound or guarding. Colonoscopy revealed erythema and swelling of the appendiceal orifice consistent with acute appendicitis. Care was taken to decompress the colon as the colonoscope was withdrawn. Diverticulosis and a small polyp were also noted. The patient had no pain at the end of the procedure. Nevertheless, given the endoscopic findings and his initial right lower quandrant discomfort, acute appendicitis was suspected. The patient was sent for a CBC, CT scan of the abdomen and pelvis and was referred for surgical evaluation. Laboratory studies were notable for a white blood cell count of 10k/ul with bandemia. CT scan confirmed the diagnosis of acute appendicitis. Emergent appendectomy was then performed. Intraoperative findings were consistent with acute exudative appendicitis, confirmed on pathology. The patient made an uneventful recovery and went home the next day. Acute appendicitis may present atypically, but is usually diagnosed by a combination of history, clinical exam and imaging studies. Colonoscopy is not routinely used to evaluate patients with suspected appendicitis. Endoscopic findings in patients with atypical presentation or unsuspected appendicitis may be useful in directing further management. Erythema and swelling around the appendiceal orifice and/or pus draining from the appendiceal orifice on colonoscopy should trigger a careful and immediate evaluation for acute appendicitis.