Appendicitis complicating colonoscopy

Post-colonoscopy appendicitis: a case report

Appendicitis after colonoscopy is rare, with an estimated incidence of 3.8 cases per 10 000 colonoscopies. Herein, we report a 56-year-old female who visited the emergency department with a history of diffuse abdominal pain and nausea 8 h after a screening colonoscopy. Abdominal examination disclosed deep tenderness at Mc Burney point and positive Rovsign's sign. Laboratory studies revealed elevated white blood cells and neutrophils (WBC 15.37 K/Ul and NEUT 86.5%) with normal C-reactive protein (5 mg/l). The initial diagnosis was acute appendicitis, which was confirmed by the ultrasonographic findings. The patient was admitted to the surgical department, and a laparoscopic appendectomy was performed. Post-colonoscopy appendicitis is increasingly recognized as a complication after colonoscopy in the last decade. Early recognition is vital in preventing morbidity and mortality. It may also be worthwhile to include appendicitis after colonoscopy as a possible complication during the consent before the procedure.

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.

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.

Colonoscopy complications: experience with 8968 consecutive patients in a single institution

OBJECTIVE

to evaluate the incidence, epidemiological characteristics, diagnosis and evolution of patients who returned to the emergency care units of the Albert Einstein Hospital in São Paulo/SP with signs and symptoms suggestive of colonoscopy complications up to 30 days after the procedure.

METHODS

we conducted a retrospective, uni-institutional study of patients submitted to colonoscopy in 2014 who returned to the Emergency department (ED) within 30 days after the procedure.

RESULTS

8968 patients underwent colonoscopies, 95 (1.06%) of whom had complaints related to possible complications. Most of the procedures were elective ones. Minor complications (nonspecific abdominal pain/distension) were frequent (0.49%) and most of the patients were discharged after consultation at the ED. Severe complications were less frequent: perforation (0.033%), lower gastrointestinal bleeding (0.044%), and intestinal obstruction (0.044%). ED consultations in less than 24 hours after the procedure was associated with a higher index of normal colonoscopies (p=0.006), more diagnosis of fever (p=0.0003) and dyspeptic syndrome (p=0.043), and less diagnosis of colitis/ileitis (p=0.015). The observation of fever in patients treated at the ED was associated with the diagnosis of polyps at colonoscopy (p=0.030).

CONCLUSION

the data corroborate the safety of the colonoscopy exam and points to a reduction in major complications rates.

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.

Acute appendicitis following endoscopic mucosal resection of cecal adenoma

Endoscopic mucosal resection (EMR) allows the removal of flat or sessile lesions, laterally spreading tumors, and carcinoma of the colon or the rectum limited to the mucosa or the superficial submucosa. Acute appendicitis is the most common abdominal emergency requiring emergency surgery, and it is also a rare complication of diagnostic colonoscopy and therapeutic endoscopy, including EMR. In the case presented here, a 53-year-old female underwent colonoscopy due to a positive fecal occult blood test and was diagnosed with cecal adenoma. She was referred to our hospital and admitted for treatment. The patient had no other symptoms. EMR was performed, and 7 h after the surgery, the patient experienced right -lower abdominal pain. Laboratory tests performed the following day revealed a WBC count of 16000/mm³, a neutrophil count of 14144/mm³, and a C-reactive protein level of 2.20 mg/dL, indicating an inflammatory response. Computed tomography also revealed appendiceal wall thickening and swelling, so acute appendicitis following EMR was diagnosed. Antibiotics were initiated leading to total resolution of the symptoms, and the patient was discharged on the sixth post-operative day. Pathological analysis revealed a high-grade cecal tubular adenoma. Such acute appendicitis following EMR is extremely rare, and EMR of the cecum may be a rare cause of acute appendicitis.

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.

Design and instrumentation of new devices for performing appendectomy at colonoscopy (with video)

BACKGROUND

There is increasing interest in natural orifice surgery (NOS). Because the lumen of the appendix is connected to the cecum, a minimally invasive method for removing the appendix by colonoscopy may be feasible.

OBJECTIVES

Our purpose was to design, develop, and test new devices for inverting and removing the appendix by colonoscopy.

DESIGN

Prospective prototype development program.

SETTING

University-based study in 25 colons from adult human cadavers.

INTERVENTIONS AND METHODS

Various prototypes were evaluated by inserting them into the appendiceal orifice to its luminal tip, with the intent to invert the appendix in a controlled fashion into the lumen of the cecum. The advantage of using a tubular structure as a counterforce to aid inversion of the appendix was evaluated. When inversion was incomplete, the growing tissue strain was relieved by endoluminal incision of the mesenteric side of the appendix. Closure methods with endoloops or ligating loops were studied. Appendiceal resection was completed by snare diathermy, leaving an inverted intraluminal stump.

MAIN OUTCOME MEASUREMENT

Ability to invert the appendix into the cecum.

RESULTS

The mean appendix length and luminal diameter were 84 +/- 23 mm and 4.9 +/- 1.2 mm, respectively. It was possible to advance various types of inversion devices to the tip of the appendiceal lumen. Partial inversion of the appendix was successful in 22 of 25 tests. Mesenteric tissue tension, tissue volume, and device slippage were the main reasons for incomplete inversion. The complete inversion was achieved with a combination of vacuum, tip grip, counterforce at the appendix base, and eventually endoluminal incision.

CONCLUSIONS

The inversion of the human appendix by colonoscopy seems feasible and may be an alternative approach to conventional appendectomy.

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.