Clinical, ultrasonographic, and pathologic characteristics of patients with chronic right-lower-quadrant abdominal pain that may benefit from appendectomy

The approach to chronic pelvic pain in the adolescent

Adolescents present to outpatient and acute care settings commonly for evaluation and treatment of chronic pelvic pain (CPP). Primary care providers, gynecologists, pediatric and general surgeons, emergency department providers, and other specialists should be familiar with both gynecologic and nongynecologic causes of CPP so as to avoid delayed diagnoses and potential adverse sequelae. Treatment may include medications, surgery, physical therapy, trigger-point injections, psychological counseling, and complementary/alternative medicine. Additional challenges arise in caring for this patient population because of issues of confidentiality, embarrassment surrounding the history or examination, and combined parent-child decision making.

Endoscopic imaging of the vermiform appendix (with video)

BACKGROUND

Chronic appendicitis may be detected in as many as 10% of patients with right lower quadrant pain. Although the appendiceal orifice is easily identified during colonoscopy, its lumen has not been investigated so far.

OBJECTIVES

To determine the feasibility of endoscopic appendix imaging to identify features of chronic appendicitis in patients with recurrent right lower quadrant pain.

DESIGN

Prospective, proof-of-concept study.

SETTING

University-based tertiary referral hospital.

PATIENTS

Colonoscopy scheduled because of right lower quadrant pain.

INTERVENTIONS

First, the appendix orifice was cannulated with a guidewire and a Jagtome. Next fluoroscopic imaging was performed by injection of contrast agent into the appendix orifice, and then a SpyGlass endoscope was inserted for imaging of the appendiceal mucosa and for biopsy. Patients were monitored 3 hours after investigation, with follow-up at 4 weeks.

MAIN OUTCOME MEASUREMENTS

Cannulation rate.

RESULTS

Thirteen patients were included. Endoscopic imaging of the appendix was successful in 9 of 13 patients (69%). In 10 patients, a guidewire was placed; in 7 patients, biopsy specimens were taken, revealing histological signs of inflammation in 5. In 4 patients, visible fecoliths were removed by flushing. All patients were discharged on the same day. No adverse events occurred. Three patients reported resolution of pain at follow-up. One patient with strictures at appendicoscopy underwent surgical appendectomy. Histology confirmed the findings of chronic appendicitis with fibrosis.

LIMITATIONS

Patient number limits power for analysis.

CONCLUSION

Endoscopic imaging of the appendix is feasible, safe, and clinically useful in patients with suspected chronic appendicitis.