S2189 Appendicular Ulcer- A Rare Cause of Lower GI Bleed

Abstract

INTRODUCTION: Although lower gastrointestinal bleeding (LGIB) is not uncommon, appendicular ulcer as cause is extremely rare. Here, we present a case of young male who presented with LGIB due to appendicular ulcer. CASE DESCRIPTION/METHODS: 30-year-old healthy Asian male presented with loss of consciousness following 3 episodes of painless massive LGIB. On arrival, he was hemodynamically unstable which improved following immediate resuscitation with a bolus of fluids and 2 units of packed red blood cells. On examination, he was very pale, tachycardic and obtunded while abdominal examination was benign. Rectal examination showed bright red blood with no evidence of external hemorrhoids. Initial labs showed hemoglobin of 10 mg/dL. He underwent an urgent upper endoscopy and colonoscopy which showed gastric erosions and diffuse blood in the entire colon with poor visualization of the source of bleed, respectively. He underwent Meckel's scan as well as CT abdomen with negative results. Repeat colonoscopy was done on the following day which showed 7 mm ulcer at appendiceal orifice that was thought to be the source of LGIB due to increased vascularity around the orifice. He was discharged the very next day with recommendation to follow up with outpatient surgery. Due to the concern for malignancy, patient underwent partial Cecectomy and the biopsy of the surgical specimen showed an early appendicular abscess with no evidence of granulomatous findings or malignancy. DISCUSSION: Diverticulosis, angiodysplasia, inflammatory disease are the most common causes for LGIB. LGIB due to appendicular ulcer is an extremely rare cause with only few cases reported so far. Urgent colonoscopy needs to be considered in the hemodynamically unstable patient as it will offer a therapeutic intervention as well. Although it is very efficient and a safe tool for evaluation of LGIB, the chances of finding an appendicular origin bleeding is rare. Treatment needs to be individualized. Although colonoscopy hemostasis can be considered, surgical treatment plays an important role in the management of appendicular bleeding. Open or laparoscopic appendectomy can be considered for local appendicular bleeding but cecectomy , ileo-cecectomy and right hemicolectomy also needs to be considered based on the operative findings. With this case, we would like to educate about the possibility of appendicular ulcer bleedings to be considered as part of differential diagnosis of LGIB, especially in young male patients.