Clin J Gastroenterol (2014) 7:32–35 DOI 10.1007/s12328-013-0443-5
CASE REPORT
Acute appendicitis as a rare complication after colonoscopy Motoaki Kuriyama
Received: 8 November 2013 / Accepted: 1 December 2013 / Published online: 11 December 2013 Ó Springer Japan 2013
Abstract Complications due to colonoscopy are uncommon, and acute appendicitis is a very rare complication of colonoscopy. We present the case of an 83-year-old man who underwent colonoscopy and subsequently developed acute appendicitis. In patients with abdominal pain who have had a recent colonoscopy, a high index of suspicion is necessary for the accurate diagnosis of appendicitis. Colonoscopists should be aware of this rare complication and consider it when making a differential diagnosis of postcolonoscopy abdominal pain. Keywords Acute appendicitis Colonoscopy Complication
Introduction Colonoscopy is usually performed to identify or correct a problem in the colon and/or distal small bowel, and its clinical applications have increased enormously in recent years. Intestinal perforation and hemorrhage are well known complications of colonoscopy, but the incidence of these problems is very low. Furthermore, the incidence of appendicitis caused by colonoscopy is very rare. Here we describe an 83-year-old man who developed acute appendicitis after colonoscopy.
M. Kuriyama (&) Department of Internal Medicine and Gastroenterology, Kurashiki City Kojima Hospital, 2-39 Kojima Ekimae, Kurashiki, Okayama 711-0921, Japan e-mail: [email protected]
123
Case report An 83-year-old man with hypertension and asthma underwent a screening colonoscopy. Colonoscopy of the cecum was performed easily and uneventfully using an Olympus CF type PCFQ260AZI colonoscope and intravenous diazepam for sedation. The bowel preparation was excellent, and good visualization was obtained. There were no signs of inflammation around the cecum end or appendicular orifice (Fig. 1). The colonoscopy revealed two polyps (8, 6 mm) at the cecum and one polyp (8 mm) at the hepatic flexure. The two polyps of the cecum were at a distance of more than 3 cm from the appendicular orifice. The lesions were diagnosed as adenomas, and endoscopic mucosal resection with saline injection and a bipolar snare was performed uneventfully and successfully. After endoscopic mucosal resection, the mucosal wounds were closed by clips (Figs. 2, 3). No abdominal symptoms such as pain or discomfort were recognized throughout the procedure. Intubation into the cecum was performed within 7 min, and the procedure time taken for polyp removal of the cecum was 21 min and total procedure time was 55 min. Histologic examination confirmed that the resected lesions were two tubular adenomas (low grade), and one tubulovillous adenoma (high grade). The patient left the hospital the following day without any symptoms, but that evening he experienced abdominal fullness, and the next evening he developed right lower abdominal pain and returned to our hospital. His abdomen was soft with right lower quadrant tenderness with rebound tenderness and guarding. On examination he was found to have blood pressure of 137/64, a pulse of 56 bpm, and a temperature of 37 °C. His white blood cell count was 10,200 cell/mm3, with 70.9 % neutrophils. Colonic perforation was suspected as a delayed complication, but no free air or fluid collection was
Clin J Gastroenterol (2014) 7:32–35
revealed by an abdominal computed tomography scan. However, this showed that fecal matter was impacted in the appendicular lumen, and moreover, it revealed a swollen appendix with a diameter of 15 mm and surrounding inflammatory changes consistent with early acute appendicitis (Fig. 4).
33
The patient was admitted to our hospital and treated with intravenously administered antibiotics (sulbactam sodium, ampicillin sodium 4 g/day). His symptoms resolved within 2 days and laboratory parameters were improved 4 days later (white blood cell count 4,200 cell/ mm3; and C-reactive protein 0.5 mg/dl). Oral intake was restarted on the third day of hospitalization, and the patient was discharged uneventfully on the sixth day.
Discussion
Fig. 1 Colonoscopic view of the appendicular orifice. There were no signs of inflammation around the cecum end or appendicular orifice
Colonoscopy is a fairly safe procedure, with bleeding and perforation reported as the most common complications; appendicitis occurs only infrequently. Computed tomography can be useful when the diagnosis is not clear in a patient who has recently undergone colonoscopy and presents with significant physical findings. To the best of our knowledge, Houghton and Aston [1] were the first to describe appendicitis as a rare complication of colonoscopy, and we found only 20 previous reports in the English-language literature when we searched PubMed for the years 1985 through 2013, using the search terms ‘‘acute appendicitis and colonoscopy’’ [1–20]. In this literature 28 cases (including the present case) are reported and are summarized in Table 1. Symptoms developed
Fig. 2 Endoscopic mucosal resection at the cecum. a The colonoscopy revealed one polyp (8 mm). b Saline was injected in the submucosa. c Endoscopic mucosal resection was performed with a bipolar snare. d The mucosal wound was closed by clips
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Clin J Gastroenterol (2014) 7:32–35
Fig. 3 Endoscopic mucosal resection at the cecum. a The colonoscopy revealed one polyp (6 mm). b Saline was injected in the submucosa. c Endoscopic mucosal resection was performed with a bipolar snare. d The mucosal wound was closed by clips
Fig. 4 Abdominal computerized tomography (CT) image of the cecum. a Fecal matter (white arrow) was impacted in the appendicular lumen. b Swollen appendix (white arrow) with a diameter of 15 mm and surrounding inflammatory changes consistent with early acute appendicitis
immediately to 5 days after the procedure. Five cases (18 %) were treated successfully using a conservative approach with antibiotics, and in the remaining 23 cases (82 %) appendectomy was performed. One patient died despite appendectomy [8], suggesting that this complication has the potential to be fatal if not treated promptly and correctly. The delay in diagnosis in that case may have
123
been due to the confusion engendered by postpolypectomy syndrome and unfamiliarity with acute appendicitis as a post-colonoscopy complication. Hypotheses that have been proposed to explain colonoscopy-induced appendicitis include [13, 17, 20]: (a) introduction of a fecalith into the appendix, causing obstruction or inflammation; (b) pre-existing subclinical
Clin J Gastroenterol (2014) 7:32–35
35
Table 1 Summary of the reported cases
Disclosures
Number of patients
28
Gender (male/female)
19/9
Conflict of Interest: conflict of interest.
Median age (range)
55 (24–84)
Endoscopic therapy Nontherapy
9 (32 %)
Therapy
19 (68 %)
Biopsy
4
Hemostasis therapy
1
Polypectomy
14
Motoaki Kuriyama declares that he has no
Human/Animal Rights: All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008(5). Informed Consent: Informed consent was obtained from all patients for being included in the study.
Onset daya Day 0
11 (39 %)
Day 1
7 (25 %)
Day 2
9 (32 %)
Treatment
a
Conservative Surgery
5 (18 %) 23 (82 %)
Death
1
One case not informative
disease of obstruction of the appendix; (c) barotrauma resulting from overinsufflation; (d) trauma caused by the colonoscopy itself or local intervention performed in or around the appendiceal orifice; or (e) exposure of the mucosa to the residual glutaraldehyde-type solution used in cleaning the endoscope. In the present case, we believe that the introduction of a fecalith into the appendix caused obstruction and inflammation. We think the effects of the saline injections and mucosal wounds by the endoscopic mucosal resection on appendicitis were slight, since the two polyps of the cecum were small and enough distance away from the appendicular orifice. However, the total procedure time was very long; particularly at the cecum, barotrauma resulting from overinsufflation might influence the appendicitis. There were five cases of acute appendicitis with fecalith after colonoscopy [1, 3, 7, 12, 15]. As one possible factor of luminal obstruction and subsequent inflammation of the appendix, it has been suggested that air pressure in the closed lumen stretches the appendicular orifice, with acute inflammation occurring in response to this stretching trauma. The coincidental presence of fecal impaction at the appendicular orifice, leading to the development of an obstructive appendicitis, is thought to be an additional factor [6]. The onset of symptoms after the procedure indicated that this was colonoscopy-induced appendicitis. In conclusion, appendicitis is a very rare but important complication of colonoscopy. Although rare, clinicians should consider post-colonoscopy appendicitis in any patient with post -procedure abdominal pain.
References 1. Houghton A, Aston N. Appendicitis complicating colonoscopy. Gastrointest Endosc. 1988;34(6):489. 2. Brandt E, Naess A. Acute appendicitis following endoscopic polypectomy. Endoscopy. 1989;21(1):44. 3. Vender R, Larson J, Garcia J, Topazian M, Ephraim P. Appendicitis as a complication of colonoscopy. Gastrointest Endosc. 1995;41(5):514–6. 4. Hirata K, Noguchi J, Yoshikawa I, Tabaru A, Nagata N, Murata I, Itoh H. Acute appendicitis immediately after colonoscopy. Am J Gastroenterol. 1996;91(10):2239–40. 5. Lipton S, Estrin J. Postcolonoscopy appendicitis: a case report. J Clin Gastroenterol. 1999;28(3):255–6. 6. Takagi Y, Abe T. Appendicitis following endoscopic polypectomy. Endoscopy. 2000;32(8):S49. 7. Doohen RR, Aanning HL. Appendiceal colic: a rare complication of colonoscopy. S D J Med. 2002;55(12):526–7. 8. Srivastava V, Pink J, Swarnkar K, Feroz A, Stephenson BM. Colonoscopically induced appendicitis. Colorectal Dis. 2004; 6(2):124–5. 9. Petro M, Minocha A. Asymptomatic early acute appendicitis initiated and diagnosed during colonoscopy: a case report. World J Gastroenterol. 2005;11(34):5398–400. 10. Rosen MJ, Sands BE. Acute appendicitis following colonoscopy. J Clin Gastroenterol. 2005;39(1):78. 11. Izzedine H, Thauvin H, Maisel A, Bourry E, Deschamps A. Postcolonoscopy appendicitis: case report and review of the literature. Am J Gastroenterol. 2005;100(12):2815–7. 12. Volchok J, Cohn M. Rare complications following colonoscopy: case reports of splenic rupture and appendicitis. JSLS. 2006;10(1):114–6. 13. Pellish R, Ryder B, Habr F. An unusual complication: postcolonoscopy appendicitis. Endoscopy. 2007;39:138. 14. Horimatsu T, Fu KI, Sano Y, Yano T, Saito Y, Matsuda T, Fujimori T, Yoshida S. Acute appendicitis as a rare complication after endoscopic mucosal resection. Dig Dis Sci. 2007;52(7):1741–4. 15. Chae HS, Jeon SY, Nam WS, Kim HK, Kim JS, Kim JS, An CH. Acute appendicitis caused by colonoscopy. Korean J Intern Med. 2007;22(4):308–11. 16. Johnston P, Maa J. Perforated appendicitis after colonoscopy. JSLS. 2008;12(3):335–7. 17. Moorman ML, Miller JP, Khanduja KS, Price PD. Postcolonoscopy appendicitis. Am Surg. 2010;76(8):892–5. 18. Bachir NM, Feagins LA. Postcolonoscopy appendicitis in a patient with active ulcerative colitis. World J Gastrointest Endosc. 2010;2(6):232–4. 19. Penkov P. Acute appendicitis following colonoscopy: causality or coincidence. ANZ J Surg. 2011;81(6):491–2. 20. Musielak M, Patel H, Fegelman E. Postcolonoscopy appendicitis: laparoscopy a viable option. Am Surg. 2012;78(11):1300–3.
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CASE REPORT
Acute appendicitis as a rare complication after colonoscopy Motoaki Kuriyama
Received: 8 November 2013 / Accepted: 1 December 2013 / Published online: 11 December 2013 Ó Springer Japan 2013
Abstract Complications due to colonoscopy are uncommon, and acute appendicitis is a very rare complication of colonoscopy. We present the case of an 83-year-old man who underwent colonoscopy and subsequently developed acute appendicitis. In patients with abdominal pain who have had a recent colonoscopy, a high index of suspicion is necessary for the accurate diagnosis of appendicitis. Colonoscopists should be aware of this rare complication and consider it when making a differential diagnosis of postcolonoscopy abdominal pain. Keywords Acute appendicitis Colonoscopy Complication
Introduction Colonoscopy is usually performed to identify or correct a problem in the colon and/or distal small bowel, and its clinical applications have increased enormously in recent years. Intestinal perforation and hemorrhage are well known complications of colonoscopy, but the incidence of these problems is very low. Furthermore, the incidence of appendicitis caused by colonoscopy is very rare. Here we describe an 83-year-old man who developed acute appendicitis after colonoscopy.
M. Kuriyama (&) Department of Internal Medicine and Gastroenterology, Kurashiki City Kojima Hospital, 2-39 Kojima Ekimae, Kurashiki, Okayama 711-0921, Japan e-mail: [email protected]
123
Case report An 83-year-old man with hypertension and asthma underwent a screening colonoscopy. Colonoscopy of the cecum was performed easily and uneventfully using an Olympus CF type PCFQ260AZI colonoscope and intravenous diazepam for sedation. The bowel preparation was excellent, and good visualization was obtained. There were no signs of inflammation around the cecum end or appendicular orifice (Fig. 1). The colonoscopy revealed two polyps (8, 6 mm) at the cecum and one polyp (8 mm) at the hepatic flexure. The two polyps of the cecum were at a distance of more than 3 cm from the appendicular orifice. The lesions were diagnosed as adenomas, and endoscopic mucosal resection with saline injection and a bipolar snare was performed uneventfully and successfully. After endoscopic mucosal resection, the mucosal wounds were closed by clips (Figs. 2, 3). No abdominal symptoms such as pain or discomfort were recognized throughout the procedure. Intubation into the cecum was performed within 7 min, and the procedure time taken for polyp removal of the cecum was 21 min and total procedure time was 55 min. Histologic examination confirmed that the resected lesions were two tubular adenomas (low grade), and one tubulovillous adenoma (high grade). The patient left the hospital the following day without any symptoms, but that evening he experienced abdominal fullness, and the next evening he developed right lower abdominal pain and returned to our hospital. His abdomen was soft with right lower quadrant tenderness with rebound tenderness and guarding. On examination he was found to have blood pressure of 137/64, a pulse of 56 bpm, and a temperature of 37 °C. His white blood cell count was 10,200 cell/mm3, with 70.9 % neutrophils. Colonic perforation was suspected as a delayed complication, but no free air or fluid collection was
Clin J Gastroenterol (2014) 7:32–35
revealed by an abdominal computed tomography scan. However, this showed that fecal matter was impacted in the appendicular lumen, and moreover, it revealed a swollen appendix with a diameter of 15 mm and surrounding inflammatory changes consistent with early acute appendicitis (Fig. 4).
33
The patient was admitted to our hospital and treated with intravenously administered antibiotics (sulbactam sodium, ampicillin sodium 4 g/day). His symptoms resolved within 2 days and laboratory parameters were improved 4 days later (white blood cell count 4,200 cell/ mm3; and C-reactive protein 0.5 mg/dl). Oral intake was restarted on the third day of hospitalization, and the patient was discharged uneventfully on the sixth day.
Discussion
Fig. 1 Colonoscopic view of the appendicular orifice. There were no signs of inflammation around the cecum end or appendicular orifice
Colonoscopy is a fairly safe procedure, with bleeding and perforation reported as the most common complications; appendicitis occurs only infrequently. Computed tomography can be useful when the diagnosis is not clear in a patient who has recently undergone colonoscopy and presents with significant physical findings. To the best of our knowledge, Houghton and Aston [1] were the first to describe appendicitis as a rare complication of colonoscopy, and we found only 20 previous reports in the English-language literature when we searched PubMed for the years 1985 through 2013, using the search terms ‘‘acute appendicitis and colonoscopy’’ [1–20]. In this literature 28 cases (including the present case) are reported and are summarized in Table 1. Symptoms developed
Fig. 2 Endoscopic mucosal resection at the cecum. a The colonoscopy revealed one polyp (8 mm). b Saline was injected in the submucosa. c Endoscopic mucosal resection was performed with a bipolar snare. d The mucosal wound was closed by clips
123
34
Clin J Gastroenterol (2014) 7:32–35
Fig. 3 Endoscopic mucosal resection at the cecum. a The colonoscopy revealed one polyp (6 mm). b Saline was injected in the submucosa. c Endoscopic mucosal resection was performed with a bipolar snare. d The mucosal wound was closed by clips
Fig. 4 Abdominal computerized tomography (CT) image of the cecum. a Fecal matter (white arrow) was impacted in the appendicular lumen. b Swollen appendix (white arrow) with a diameter of 15 mm and surrounding inflammatory changes consistent with early acute appendicitis
immediately to 5 days after the procedure. Five cases (18 %) were treated successfully using a conservative approach with antibiotics, and in the remaining 23 cases (82 %) appendectomy was performed. One patient died despite appendectomy [8], suggesting that this complication has the potential to be fatal if not treated promptly and correctly. The delay in diagnosis in that case may have
123
been due to the confusion engendered by postpolypectomy syndrome and unfamiliarity with acute appendicitis as a post-colonoscopy complication. Hypotheses that have been proposed to explain colonoscopy-induced appendicitis include [13, 17, 20]: (a) introduction of a fecalith into the appendix, causing obstruction or inflammation; (b) pre-existing subclinical
Clin J Gastroenterol (2014) 7:32–35
35
Table 1 Summary of the reported cases
Disclosures
Number of patients
28
Gender (male/female)
19/9
Conflict of Interest: conflict of interest.
Median age (range)
55 (24–84)
Endoscopic therapy Nontherapy
9 (32 %)
Therapy
19 (68 %)
Biopsy
4
Hemostasis therapy
1
Polypectomy
14
Motoaki Kuriyama declares that he has no
Human/Animal Rights: All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008(5). Informed Consent: Informed consent was obtained from all patients for being included in the study.
Onset daya Day 0
11 (39 %)
Day 1
7 (25 %)
Day 2
9 (32 %)
Treatment
a
Conservative Surgery
5 (18 %) 23 (82 %)
Death
1
One case not informative
disease of obstruction of the appendix; (c) barotrauma resulting from overinsufflation; (d) trauma caused by the colonoscopy itself or local intervention performed in or around the appendiceal orifice; or (e) exposure of the mucosa to the residual glutaraldehyde-type solution used in cleaning the endoscope. In the present case, we believe that the introduction of a fecalith into the appendix caused obstruction and inflammation. We think the effects of the saline injections and mucosal wounds by the endoscopic mucosal resection on appendicitis were slight, since the two polyps of the cecum were small and enough distance away from the appendicular orifice. However, the total procedure time was very long; particularly at the cecum, barotrauma resulting from overinsufflation might influence the appendicitis. There were five cases of acute appendicitis with fecalith after colonoscopy [1, 3, 7, 12, 15]. As one possible factor of luminal obstruction and subsequent inflammation of the appendix, it has been suggested that air pressure in the closed lumen stretches the appendicular orifice, with acute inflammation occurring in response to this stretching trauma. The coincidental presence of fecal impaction at the appendicular orifice, leading to the development of an obstructive appendicitis, is thought to be an additional factor [6]. The onset of symptoms after the procedure indicated that this was colonoscopy-induced appendicitis. In conclusion, appendicitis is a very rare but important complication of colonoscopy. Although rare, clinicians should consider post-colonoscopy appendicitis in any patient with post -procedure abdominal pain.
References 1. Houghton A, Aston N. Appendicitis complicating colonoscopy. Gastrointest Endosc. 1988;34(6):489. 2. Brandt E, Naess A. Acute appendicitis following endoscopic polypectomy. Endoscopy. 1989;21(1):44. 3. Vender R, Larson J, Garcia J, Topazian M, Ephraim P. Appendicitis as a complication of colonoscopy. Gastrointest Endosc. 1995;41(5):514–6. 4. Hirata K, Noguchi J, Yoshikawa I, Tabaru A, Nagata N, Murata I, Itoh H. Acute appendicitis immediately after colonoscopy. Am J Gastroenterol. 1996;91(10):2239–40. 5. Lipton S, Estrin J. Postcolonoscopy appendicitis: a case report. J Clin Gastroenterol. 1999;28(3):255–6. 6. Takagi Y, Abe T. Appendicitis following endoscopic polypectomy. Endoscopy. 2000;32(8):S49. 7. Doohen RR, Aanning HL. Appendiceal colic: a rare complication of colonoscopy. S D J Med. 2002;55(12):526–7. 8. Srivastava V, Pink J, Swarnkar K, Feroz A, Stephenson BM. Colonoscopically induced appendicitis. Colorectal Dis. 2004; 6(2):124–5. 9. Petro M, Minocha A. Asymptomatic early acute appendicitis initiated and diagnosed during colonoscopy: a case report. World J Gastroenterol. 2005;11(34):5398–400. 10. Rosen MJ, Sands BE. Acute appendicitis following colonoscopy. J Clin Gastroenterol. 2005;39(1):78. 11. Izzedine H, Thauvin H, Maisel A, Bourry E, Deschamps A. Postcolonoscopy appendicitis: case report and review of the literature. Am J Gastroenterol. 2005;100(12):2815–7. 12. Volchok J, Cohn M. Rare complications following colonoscopy: case reports of splenic rupture and appendicitis. JSLS. 2006;10(1):114–6. 13. Pellish R, Ryder B, Habr F. An unusual complication: postcolonoscopy appendicitis. Endoscopy. 2007;39:138. 14. Horimatsu T, Fu KI, Sano Y, Yano T, Saito Y, Matsuda T, Fujimori T, Yoshida S. Acute appendicitis as a rare complication after endoscopic mucosal resection. Dig Dis Sci. 2007;52(7):1741–4. 15. Chae HS, Jeon SY, Nam WS, Kim HK, Kim JS, Kim JS, An CH. Acute appendicitis caused by colonoscopy. Korean J Intern Med. 2007;22(4):308–11. 16. Johnston P, Maa J. Perforated appendicitis after colonoscopy. JSLS. 2008;12(3):335–7. 17. Moorman ML, Miller JP, Khanduja KS, Price PD. Postcolonoscopy appendicitis. Am Surg. 2010;76(8):892–5. 18. Bachir NM, Feagins LA. Postcolonoscopy appendicitis in a patient with active ulcerative colitis. World J Gastrointest Endosc. 2010;2(6):232–4. 19. Penkov P. Acute appendicitis following colonoscopy: causality or coincidence. ANZ J Surg. 2011;81(6):491–2. 20. Musielak M, Patel H, Fegelman E. Postcolonoscopy appendicitis: laparoscopy a viable option. Am Surg. 2012;78(11):1300–3.
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