Acute Appendicitis at Colonoscopy

A 37-year-old female presented with chronic lower abdominal pain and diarrhea associated with heavy menses. She was afebrile and her physical exam was substantial for mild lower abdominal tenderness. Her labs were unremarkable with a white blood cell count of 6.8. An MRI of the pelvis showed a left hydrosalpinx. The MRI finding was confirmed on an endovaginal ultrasound. A colonoscopy was performed several days later and in the cecum was noted a bulging appendical orifice with extruding pus (Fig. 1). Because the infected appendix was draining into the colonic lumen and the abdomen was benign, there appeared to be no indication for an emergency procedure. Thus, she was placed on a course of amoxicillin-clavulanate and referred to surgery. An elective appendectomy was performed 12 d later with the finding of acute appendicitis without fecalith or perforation. Acute appendicitis has been described after colonoscopy, but a causal relationship has not been established; rarely has it been diagnosed at colonoscopy.

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FIG. 1.

Purulent drainage from appendicial orifice.

There are only a few similar reports in the literature of appendicitis diagnosed at colonoscopy. Kothari et al. [1] described a case in which a 27-year-old female being evaluated for rectal bleeding and was found to have erythema with whitish bloody purulent discharge exuding from her appendiceal orifice. This patient was managed on a course of amoxicillin-clavulanate and showed improvement. Benatta [2] similarly described a case of a 54-year-old female who received a colonoscopy and was found to have a bulging polypoid mass with purulent discharge from the appendiceal orifice. She was initially started on a course of antibiotics, and, upon discontinuation of the antibiotics, remained asymptomatic without the need for an emergent appendectomy.

In both these cases as well as the case reported here, there was an atypical presentation of appendicitis as compared with the classic picture of periumbilical pain that migrates to the right lower quadrant. This atypical presentation is most likely explained by the fact that the infected appendix was already undergoing spontaneous drainage; into the colonic lumen.