Recurrent Appendicitis Masquerading as Crohnʼs Disease

Abstract

Purpose: Recurrent appendicitis is the clinical entity in which a patient with pathologically confirmed acute appendicitis describes one or more prior episodes with identical symptoms that resolved without surgical intervention. Although rare, patients report previous episodes of pain and then relief of their symptoms after appendectomy. Methods: A 31-year-old man with a history of HLA-B27 spondyloarthropathy presented to the GI clinic with complaints of two weeks of sharp mid-abdominal pain associated with bloating and cramping. A laboratory evaluation (CBC, Chem 7, LFTs, amylase and sed rate) was within normal limits. A CT scan demonstrated bowel wall thickening and mural stratification in the distal terminal ileum. A colonoscopy showed “nodularity” in the TI to 15 cm but overlying mucosa appeared normal. Small bowel and colonic biopsies were normal. It was thought that the CT abnormalities showed more proximal small bowel disease and, therefore, were not seen on endoscopy. A diagnosis of Crohn's disease was made and the patient's symptoms completely resolved with Infliximab. In 3 months, he returned to the clinic complaining of one week of increasing periumbilical abdominal pain radiating to the RLQ, similar to but not as severe as the prior abdominal pain. Physical exam: +Rovsig's sign. CT enterography was consistent with acute appendicitis. No small bowel abnormalities were seen. Results: The patient underwent a laparoscopic appendectomy that revealed pathologically confirmed acute appendicitis with a large amount of inflammation and adhesions around the appendix. The remainder of the bowel appeared normal. Since appendectomy, the patient has not had recurrent abdominal pain. Conclusion: This case illustrates the importance of correlating endoscopic and CT findings as well as recognizing the existence of recurrent appendicitis. Although this diagnosis is rare, identifying this entity is critical to the institution of appropriate treatment and the prevention of possible peritonitis. This case serves as a reminder not to discount the diagnosis of appendicitis in patients with prior episodes of similar abdominal pain.