https://orcid.org/0000-0002-0131-885X
Acute appendicitis is inflammation of the appendix typically causing symptom of severe abdominal cramping, nausea/vomiting, and occasionally diarrhea.1 In a patient with inflammatory bowel disease (IBD), these symptoms could easily be confused for a potential flare.2 This case presents an unexpected finding of asymptomatic acute appendicitis in an IBD patient during routine screening colonoscopy. A 49-year-old male with ulcerative pancolitis presented to the emergency department following a screening colonoscopy where he was noted to have purulent drainage and prominence of the appendiceal orifice, concerning for acute appendicitis (Figure 1a). He had been clinically stable, and endoscopic results related to his colitis showed quiescent disease. He stated he had a single episode of “cramping” pain in the right lower quadrant of his abdomen earlier that day but assumed it was from colonoscopy prep or new active disease. Vital signs were within normal limits. Physical exam was positive only for right lower quadrant abdominal tenderness to deep palpation without rigidity, guarding, or peritoneal findings. Psoas and obturator signs and Markle test were notably negative. Complete blood count showed no leukocytosis, and venous blood gas revealed no lactic acid elevation. Computed tomography (CT) of the abdomen and pelvis exhibited a dilated appendix with wall thickening and minimal inflammatory changes consistent with uncomplicated acute appendicitis with appendicoliths within the base/mid appendix (Figure 1b). The patient was started on vancomycin and metronidazole and seen by general surgery. General surgery felt patient would benefit from complete source control given immunocompromised status leading to high risk for sepsis and admitted the patient to their service. He had an uncomplicated laparoscopic appendectomy and was subsequently discharged the following day.
(a) Endoscopic imaging of prominent appendiceal orifice with purulent drainage; (b) CT imaging displaying dilated appendix with wall thickening and appendicoliths within base/mid-appendix.
Informed consent was obtained from the patient, and permission was given regarding publication of their information and imaging.
Appendicitis diagnosed during endoscopy has been well-described in the literature.3 However, it is an uncommonly used modality for diagnosis given the high sensitivity of CT scans and increased risk of bowel perforation if performed on a routine diagnostic basis.4 To our knowledge, this is the first case of asymptomatic appendicitis diagnosed on endoscopy in an IBD patient acknowledged in the literature. Inflammatory bowel disease patients, particularly Crohn’s Disease patients, are often misdiagnosed with acute appendicitis in the setting of an IBD flare.5-6 This case highlights that IBD patients are similarly at risk of developing acute appendicitis and may present in an atypical fashion that could easily be mistaken for active disease. Therefore, all gastroenterologists should be readily able to recognize this endoscopic finding so appropriate timely management can be initiated.
Author Contribution
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Funding
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Conflicts of Interest
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