Playing Peekaboo: A Rare Case of Lower Gastrointestinal Hemorrhage

Abstract

Lower gastrointestinal bleeding (LGIB) can arise from many causes, with acute bleeding from the appendix being extremely rare and difficult to identify. Various etiologies of appendiceal hemorrhage have been reported in the English literature including appendiceal intussusception, diverticulitis, Crohn's Disease, tumors, ulcers and erosions. We present a unique case of large volume LGIB secondary to an appendiceal tubulovillous adenoma. A 70 year white woman with a past medical history of polycythemia vera, dyslipidemia, and sigmoidectomy for recurrent diverticulitis presented to the hospital for evaluation of maroon colored blood in the stool for the past 10 days. Admission vital signs were stable, and physical exam was unremarkable other than maroon blood on rectal exam. Hemoglobin was 12.9 g/dL (baseline 16.4 g/dL), Hematocrit 37.6 %, and other labs were within normal limits. Colonoscopy revealed a normal terminal ileum with yellow bile and fresh blood pooling at the appendiceal orifice. On initial examination, the appendiceal orifice appeared normal (Image 1) other than active oozing. With careful examination and manipulation of the cecum and appendiceal orifice, a bleeding polypoid mass was seen slowly emerging through the orifice into the cecum (Image 2). The mass was not amenable to endoscopic resection and the bleeding continued despite attempting hemostasis using epinephrine injection. Due to persistent bleeding and suspected malignancy a right hemicolectomy was performed the same day. Surgical pathology showed a 1.3 cm by 1 cm polypoid mass protruding from the appendiceal orifice extending 1.7 cm into the appendix with the lumen containing blood clots. Histologically the mass was consistent with tubulovillous adenoma. Appendiceal neoplasms are commonly found incidentally during an appendectomy performed for an unrelated condition. LGIB from an appendiceal neoplasm as a presenting symptom is uncommon. In general, patients with LGIB originating from the appendix are treated with an appendectomy and for malignant lesions a right hemicolectomy is the current standard treatment. Our case highlights the importance of a close, repetitive and careful appendiceal examination in a patient with obscure or recurrent LGIB to rule out an appendiceal etiology.Figure 1Figure 2