Introduction: Colon cancer has seen a steady decline in incidence as colonoscopy use has increased. With this increase in use, the number of post-colonoscopy complications like perforation, with an incidence rate of 0.21%, and post-colonoscopy appendicitis, with an incidence rate of 0.038% are expected to rise.
Case Description/Methods: A 77-year-old Caucasian male with no known medical history underwent a routine colonoscopy. After the patient was discharged home without complaint, he later that day presented to the emergency department with acute onset generalized abdominal pain. On presentation, vital signs revealed blood pressure of 175/82 mmHg, heart rate of 86 beats/min, respiratory rate of 22 breaths/min and temperature of 103.1 F. On physical examination, his abdomen was minimally distended with right lower quadrant tenderness. Laboratory investigations were only significant for a white blood cell count of 16.5 x 103 cells/uL. Abdominal and pelvic computer tomography with contrast revealed no evidence of acute appendicitis or focal inflammatory changes and he was started on broad-spectrum antibiotics. The next day, he developed worsening abdominal pain with generalized tenderness and right lower quadrant distention with guarding. Based on clinical condition and worsening leukocytosis, 23.7 x 103 cells/uL, he was taken to surgery for a diagnostic laparoscopy with possible exploratory laparotomy. After finding frank pus laparoscopically around the cecum and appendix, the surgery was converted to an exploratory laparotomy for suspicion of colonic perforation. Subsequently, a perforated 7cm long and 1.5cm wide gangrenous appendix containing fecaloid material was found with surrounding purulence and an notably erythematous and indurated cecum without evidence of colonic perforation. Histological examination later confirmed the diagnosis of gangrenous appendicitis with periappendicitis. Patient later developed post-op ileus that required conservative medical management prior to discharge.
Discussion: As colonoscopy use becomes more widespread we anticipate a decline of colon cancer rates and increased rates of colonoscopy-associated complications, such as post-colonoscopy appendicitis. In the literature reviewed, detection and management of PCA is often delayed leading to serious outcomes such as death. With its anticipated increase in incidence, it is necessary for providers to consider PCA as an important differential for all patients presenting with abdominal pain after a colonoscopy.
Figure: Figure 1 A. Appendiceal Orifice B. Ileo-Cecal Valve C. Severe Diverticulosis of the Left Colon D. Diverticulosis E. Polyp (1.6cm) in the ascending colon F. Post-polypectomy retroflexed view in the rectum
Sean-Patrick Prince indicated no relevant financial relationships.
Andrew Santos indicated no relevant financial relationships.
Qitan Huang indicated no relevant financial relationships.
Varun Patel indicated no relevant financial relationships.
Sreekanth Chandrupatla indicated no relevant financial relationships.
Sean-Patrick Prince, MD, MPH, Andrew Santos, MD, Qitan Huang, DO, Varun Patel, MD, Sreekanth Chandrupatla, MD. P1206 - Post-Colonoscopy Appendicitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.