Appendicitis as a complication of colonoscopy

A case of acute appendicitis caused by obstruction due to caecal cancer

Acute appendicitis supposedly results from appendix obstruction caused by various conditions, including caecal cancer. Here, we report an adenocarcinoma found in the specimen of a 65-year-old man diagnosed with acute appendicitis. The adenocarcinoma was detected in the appendix stump after emergency laparoscopic appendectomy. The patient was diagnosed with caecal cancer based on post-operative lower endoscopy findings, and an additional laparoscopic right hemicolectomy was performed. Acute appendicitis can occur at any age and may require emergency surgery. It is a benign disease that can be cured entirely by appendectomy in most cases but may result from an underlying malignant disease in some cases, especially in patients >40 years of age. Thus, clinicians should consider the possibility of a malignancy while diagnosing and treating acute appendicitis.

Colonoscopy-induced acute appendicitis: A case report

BACKGROUND

Colonoscopy is widely used for examination, diagnosis, and treatment because of its low incidence of associated complications. Post-colonoscopy appendicitis (PCA) is very rare and is easily misdiagnosed as electrocoagulation syndrome or colon perforation. Therefore, clinicians should pay close attention to this complication.

CASE SUMMARY

A 47-year-old female patient underwent a colonoscopy for a systematic physical examination, and the procedure was uneventful with normal endoscopic and histologic findings. However, the bowel preparation was suboptimal (Boston 2-3-2). After the examination, the patient experienced pain in the lower abdomen, which progressively worsened. Computed tomography of the lower abdomen and pelvis revealed appendiceal calcular obstruction and appendicitis. As the patient refused surgery, she was managed with antibiotics and recovered well.

CONCLUSION

In the current literature, the definition of PCA remains unclear. However, abdominal pain after colonoscopy should be differentiated from acute appendicitis.

An Incidental Finding of Suppurative Appendicitis During Colonoscopy

Colonoscopic diagnosis of acute appendicitis is extremely rare. Although a few appendicitis cases were reported in literature following colonoscopy, we present a case today of a patient who underwent elective colonoscopy for colorectal cancer screening. The presence of an inflamed appendiceal orifice with projecting pus was documented, and the patient was referred to the surgical team for intervention. Endoscopic and intra-operative results are also illustrated.

Post-colonoscopy appendicitis: Systematic review of current evidence

BACKGROUND AND AIM

Appendicitis after colonoscopy is an exceedingly rare complication. It remains to be explored if this entity is truly a complication of colonoscopy or a coincidental occurrence of appendicitis post-colonoscopy. The aim of this study was to systematically review all the available evidence since it was first described in 1988.

METHODS

The literature on post-colonoscopy appendicitis was searched using PubMed, EMBASE, and Cochrane databases. Additional manual search was performed and cross-checked for additional references. The search was performed up to November 2019. Data collected included demographics, reason for colonoscopy, time to diagnosis, imaging performed, management, and outcome.

RESULTS

Fifty-three cases were found in the systematic review with a median age of 55 years (24-84 years). The time to diagnosis post-colonoscopy was mostly within 24-48 h. Clinical features mimicked those of common acute appendicitis. In the past decade, computed tomography scan has been the imaging choice to investigate abdominal pain after colonoscopy, mainly to rule out perforation. The mainstay of management was appendectomy (open or laparoscopy). Four of the 12 cases (33.3%) were treated successfully with antibiotics alone. There has been a twofold increase in cases reported in the past decade (2009-2019, n = 31 vs 1999-2008, n = 15).

CONCLUSION

There is a considerable variation in the definition of post-colonoscopy appendicitis in the current literature. Regardless of whether post-colonoscopy appendicitis is a true entity, it should be considered as a differential diagnosis in any patient presenting with acute abdomen following colonoscopy.

Postcolonoscopy Appendicitis: A Review of 57 Cases

The purpose of this study is to review the cases of postcolonoscopy appendicitis (PCA) reported in the literature. A comprehensive search using PubMed, EMBASE, Scopus, and Google Scholar identified 57 cases. The median age at presentations of PCA was 55 years. PCAs typically occurred during the first 24 hours after colonoscopy, and the majority developed after diagnostic colonoscopy. Clinical presentations were similar to those with common acute appendicitis, though with a high perforation rate. Most patients were correctly diagnosed using ultrasound or computed tomography scan. Treatment included open appendicectomy, laparoscopic appendicectomy or cecotomy, radiologic drainage of the abscess, nonoperative treatment with antibiotics. In addition to barotrauma, fecalith impaction into the appendiceal lumen, direct trauma to the appendiceal orifice, and underlying ulcerative colitis, a pre-existing subclinical disease of the appendix seems to play an important role in the pathogenesis. For PCA, timely diagnosis and management are crucial to attain a satisfactory outcome.

A different type of perforation: appendicitis after colonoscopy

Physicians who perform colonoscopy should consider appendicitis in the differential diagnosis of post procedure abdominal pain. Diagnostic laparoscopy is a safe adjunct for evaluation in patients with suspected perforation after colonoscopy. It is important that all physicians be aware of this complication to ensure prompt diagnosis and intervention.

An unusual cause of acute abdomen: Post-colonoscopy appendicitis

Colonoscopy is commonly performed for diagnostic and therapeutic purposes and has a relatively low morbidity rate. Nevertheless, it is necessary for operators to be aware of the rare complications of colonoscopy due to a large number of procedures performed in daily practice. Acute appendicitis is an unusually rare occurrence after colonoscopy, with no clear association being found between the colonoscopy and acute appendicitis. A rapid diagnosis of this complication is possible by widespread awareness in surgeons regarding this condition. Acute appendicitis cannot be reliably resulted in as the cause of acute abdominal pain due to relatively subtle signs, symptoms, and studies performed for bowel perforation. The diagnosis of postcolonoscopy appendicitis is difficult, and strategies for its treatment show significant variation. This report presents a patient having undergone urgent laparotomy within 12 h after colonoscopy on having signs and symptoms of acute appendicitis-induced peritonitis.

Perforated appendicitis after colonoscopy: cause or coincidence?: A rare case report and literature review

RATIONALE

Colonoscopy is a relatively safe and common procedure with low risks of complications, and acute appendicitis with perforation is an extremely rare complication of colonoscopy. The current study presents an unusual case of acute gangrenous appendicitis with perforation following a screening colonoscopy.

PATIENT CONCERNS

A 73-year-old man presented to our emergency department with lower right abdominal pain 3 days after a routine screening colonoscopy. On physical examination the patient had signs of generalized peritonitis. Abdominal and pelvic computed tomography (CT) revealed the presence of multiple free gas in the right subphrenic space and abdominal cavity with exudate effusions in both sides of the paracolic sulci and the pelvic cavity, especially around the ascending colon and caecum. The CT scan also showed a dilated and inflamed appendix with fecaliths.

DIAGNOSES

The patient was diagnosed with acute gangrenous appendicitis with perforation after colonoscopy.

INTERVENTIONS

The patient underwent emergency exploratory laparotomy. Intraoperative findings revealed an inflamed gangrenous appendix with focal perforation and impacted fecaliths. The colon showed no evidence of perforation or other areas of concern and thus, a conclusive diagnosis was achieved. An appendectomy was performed and the abdominal cavity was rinsed and drained thoroughly.

OUTCOMES

The postoperative course was uneventful.

LESSONS

This study may increase clinical awareness with regard to perforated appendicitis after colonoscopy. Acute appendicitis should be included in the differential diagnosis of lower right abdominal pain following a colonoscopy, in addition to possible colonic injury. Furthermore, emergency surgery should be recommended for the typical signs of perforation with peritonitis and free pneumoperitoneum. Early recognition and prompt surgical treatment are critical, which can avoid severe outcomes and improve the prognosis.

Diagnostic Colonoscopy Leading to Perforated Appendicitis: A Case Report and Systematic Literature Review

Introduction. Intestinal perforation is a known complication after colonoscopy. However, appendiceal involvement with inflammation and perforation is extremely rare and only 37 cases of postcolonoscopy appendicitis have been reported so far. We describe a case of perforated appendicitis 24 hours after colonoscopy that was treated successfully in our Department. Case Report. A 60-year-old female patient underwent a colonoscopy during the investigation of nontypical abdominal pain without pathologic findings. 24 hours after the examination she presented gradually increased right lower quadrant abdominal pain and a CT scan was performed, showing an inflammation of the appendiceal area with free peritoneal air. Through laparotomy, perforated appendicitis was diagnosed and an appendectomy was performed. The patient was discharged on the tenth postoperative day in good health condition. Discussion. The characteristics of all cases reported in the literature are described, including our case. Perforated appendicitis soon after a colonoscopy is a rare, but serious complication; therefore, it is crucial to be included in the differential diagnosis of postcolonoscopy acute abdominal pain.

Hemoperitoneum as a Consequence of Colonoscopy

Hemoperitoneum without evidence of organ damage is a rare complication of colonoscopy. It is most frequently seen in association with splenic rupture due to traction on the splenocolic ligament. In our case, we present a 48-year-old cirrhotic man who developed peritoneal bleeding during a diagnostic colonoscopy for iron deficiency anemia. However, he was without signs of splenic damage or colon perforation. We suggest that the most likely source of bleeding is a ruptured portal-caval collateral vessel based on a computed tomography performed following the procedure.

Acute Abdominal Pain Following Optical Colonoscopy: CT Findings and Clinical Considerations

OBJECTIVE

Optical colonoscopy is a common procedure; more than 14 million are performed annually in the United States. Serious colonoscopy complications are uncommon, but they can be life-threatening if not quickly recognized.

CONCLUSION

Optical colonoscopy complications that can be detected at CT include bowel perforation, postprocedural hemorrhage, postpolypectomy syndrome, splenic injury, appendicitis, and diverticulitis. Radiologist awareness of optical colonoscopy complications seen at CT is imperative for appropriate diagnosis and prompt patient management.

Post-colonoscopy appendicitis: A case report and systematic review

Colonoscopy is a widely used diagnostic and therapeutic modality with a relatively low morbidity. However, given the large volume of procedures performed, awareness of the infrequent complications is essential. Perforation is an established complication of colonoscopy, and can range from 0.2%-3% depending on the series, population and modality of colonoscopy. Acute appendicitis after colonoscopy is an extremely rare event, and a cause-effect relationship between the colonoscopy and the appendicitis is not well documented. In addition, awareness of this condition can aid in prompt diagnosis. Relatively mild symptoms and exclusion of bowel perforation by contrast studies do not exclude appendicitis from the differential diagnosis for post-colonoscopy pain. In addition to the difficult diagnosis inherent to postcolonoscopy appendicitis, treatment strategies have varied greatly. This paper reviews these approaches. We also expand upon prior articles by giving guidance for the role of nonoperative management in these patients. This case and review of the literature will help to create awareness about this complication, and guide optimal treatment of pericolonoscopy appendicitis.

Transmission of infection by flexible gastrointestinal endoscopy and bronchoscopy

Flexible endoscopy is a widely used diagnostic and therapeutic procedure. Contaminated endoscopes are the medical devices frequently associated with outbreaks of health care-associated infections. Accurate reprocessing of flexible endoscopes involves cleaning and high-level disinfection followed by rinsing and drying before storage. Most contemporary flexible endoscopes cannot be heat sterilized and are designed with multiple channels, which are difficult to clean and disinfect. The ability of bacteria to form biofilms on the inner channel surfaces can contribute to failure of the decontamination process. Implementation of microbiological surveillance of endoscope reprocessing is appropriate to detect early colonization and biofilm formation in the endoscope and to prevent contamination and infection in patients after endoscopic procedures. This review presents an overview of the infections and cross-contaminations related to flexible gastrointestinal endoscopy and bronchoscopy and illustrates the impact of biofilm on endoscope reprocessing and postendoscopic infection.

Complications of colonoscopy

Colonoscopy is a relatively invasive modality for the diagnosis and treatment of colorectal disease and for the prevention or early detection of colorectal neoplasia. Millions of colonoscopies are performed each year in the United States by endoscopists with varying levels of skill in colons that present varying levels of challenge. Although better scope technology has made colonoscopy gentler and more accurate, the sheer number of examinations performed means that complications inevitably occur. This article considers the most common complications of colonoscopy, and advises how to minimize their incidence and how to treat them if they do occur.

An unusual cause of postcolonoscopy abdominal pain

Colonoscopy is a common procedure used for screening, diagnosis, and treatment of gastrointestinal disease. Life-threatening complications are uncommon (28/10 000 procedures) but include perforation, hemorrhage, diverticulitis, and postpolypectomy syndrome. Although previously reported, the association between appendicitis and colonoscopy is not widely known. This case report highlights the underlying pathophysiology, clinical presentation, and diagnosis of postcolonoscopy appendicitis. A 52-year-old man presented to the emergency department with abdominal pain 8 hours after an uncomplicated routine screening colonoscopy. He initially reported mild generalized abdominal discomfort which 3 hours after the procedure intensified and localized to the periumbilical region. Computed tomography of the abdomen with oral and intravenous contrast revealed appendicitis as the cause of his abdominal pain. He underwent laparoscopic appendectomy and recovered uneventfully. Colonoscopy is a common procedure that rarely has life-threatening complications. Although establishing causality is difficult, there is an association between colonoscopy and appendicitis, which may be underreported with literature-based estimates as high as 3.8 appendicitis cases per 10 000 procedures. Timely diagnosis of postcolonoscopy appendicitis may prove challenging given limited knowledge of this association between colonoscopy and appendicitis and similarity of presentation with other more well-known complications. This case report demonstrates that a recent history of colonoscopy should not preclude consideration of a traditionally broad differential diagnosis for abdominal pain, including appendicitis.

Post-colonoscopy appendicitis: a rare entity

A 35-year-old woman was admitted to the surgical ward complaining of right-sided lower abdominal pain. She had undergone colonoscopy a week previously. She was diagnosed with acute appendicitis following colonoscopy and laparoscopic appendectomy was performed via the 2-port technique. Post colonoscopy appendicitis is very rare with 14 cases reported since 1988.

Postcolonoscopy Appendicitis

Outpatient colonoscopy has been proven safe but can rarely be associated with serious complications. The addition of polypectomy to the procedure increases the incidence of all complications with hemorrhage accounting for approximately half. The use of electrocautery for hot biopsy or polyp removal can result in a full-thickness burn without perforation in approximately 1 per cent of cases and typically presents as focal peritonitis without pneumoperitoneum. This so-called “postpolypectomy syndrome” or “serositis” is often successfully managed medically with resolution of symptoms in 24 to 48 hours. Bowel perforation occurs in less than 1 per cent of patients but requires emergent laparotomy. Appendicitis, both acute and perforated, has been reported as a rare complication of colonoscopy.

Acute appendicitis caused by colonoscopy

A 48-year-old woman who was without any abnormal past medical history underwent colonoscopy as a screening procedure for colorectal disease. The procedure was uneventful and there was no sign of inflammation around the appendicular orifice or the luminal surface of the cecum. The patient did not complain of pain or significant discomfort throughout the procedure. She then developed pain in the right lower quadrant of the abdomen that evening and this persisted for four days. She visited the outpatient department and underwent abdominal ultrasonography, which showed a swollen appendix with a collection of pericecal fluid. Surgical exploration and appendectomy were performed; the final diagnosis was acute suppurative appendicitis. Colonoscopists should be aware of this rare complication and consider it when making the differential diagnosis of post-colonoscopy abdominal pain.

Asymptomatic early acute appendicitis initiated and diagnosed during colonoscopy: A case report

Colonoscopic diagnosis of asymptomatic early acute appendicitis is exceedingly rare. Although obstruction of the lumen due to various causes is believed to be the most common physiologic mechanism of acute appendicitis, all of the previously documented cases in the literature have only shown a patent appendiceal lumen with pus flowing into the cecum. We present the case of a patient undergoing colonoscopy for colorectal cancer evaluation with no abdominal symptoms. An obstructed, swollen appendix was seen. The process was probably initiated during the colonoscopy, documenting perhaps the earliest stage of acute appendicitis for the first time. Endoscopic, CT and microscopic documentation of the case is also presented.

Barium enema and endoscopy for the detection of colorectal neoplasia: sensitivity, specificity, complications and its determinants

AIM

To analyse sensitivity, specificity and complication rate of endoscopy, and barium enema for the detection of colorectal neoplasia.

MATERIALS AND METHODS

A MEDLINE search was performed (1980-2000) directed at the endoscopic and radiologic literature on barium enema. Articles were selected based on the type of study, availability of sensitivity and specificity values in sizeable patient groups, and reports on complications. Sixty articles were included in the analysis.

RESULTS

Endoscopy proved to have superior sensitivity for polyps in patients at high-risk for colorectal neoplasia. The role of endoscopy and radiology in average-risk screening populations is not known. Sensitivity and specificity rates ranged widely, probably due to bias. For the detection of small polyps endoscopy has superior performance, whereas sensitivity is similar for endoscopy and barium enema for the detection of larger (>1 cm) polyps and tumours. Overall, endoscopy is associated with a higher complication rate.

CONCLUSION

Endoscopy is the preferred detection method in high-risk patients. The role of endoscopy and radiology in a screening setting requires evaluation. This review provides the test characteristics of endoscopy and radiology which are relevant for a cost-effectiveness analysis. Double-contrast barium enema may play an important role for screening purposes, owing to its good sensitivity for detecting larger (>1 cm) polyps and its lack of major complications. de Zwart, I. M.et al. (2001). Clinical Radiology56, 401-409.