Patient is a 27 year old female presents to endoscopy suite for colonoscopy for evaluation of rectal bleeding. Patient denies abdominal pain, fever, chills, nausea, vomiting, bowel – bladder complaints.Patient denies history of surgery and family history of GI cancers or polyps. On physical examination, found to be normal with normal vital signs. Coronal CT abdomen with contrast images show a dilated appendix with no periappendiceal inflammatory change
On colonoscopy, the cecum revealed mild erythematous mucosa and whitish discharge from the appendiceal orifice. Otherwise colonoscopy revealed normal findings.
We see a inflamed appendiceal orifice with whitish exudate. On careful examination, bloody discharge was seen exuding from the orifice. The terminal ileum was easily intubated and appeared completely normal. Biopsies were obtained from the inflamed appendiceal orifice.
Coronal CT abdomen with contrast images show a dilated appendix with no periappendiceal inflammatory change.
The biopsy result of the appendiceal orifice revealed stromal abscess, cryptitis consistent with acute appendicitis.
Although asymptomatic, the patient was recommended for appendectomy. Appendectomy was performed in 2 weeks and the gross specimen of the appendix revealed hemorrhagic material in the lumen. Pathology commented on the non-necrotizing granulomas with multi-nucleated giant cells present in the subserosal soft tissue. Final diagnosis was acute erosive purulent appendicitis and granulomatous disease.
In order to determine the granulomas etiology, stains – GMS for fungus, Acid fast bacilli were done, which were negative. Parasites were not seen.
Patient was discharged home on antibiotics and recovered well post appendectomy without any complications.
This is one of the very few reported cases, where early acute appendicitis was diagnosed during colonoscopy.
Truptesh H. Kothari, MD, Lenox Hill Hospital
David H. Robbins, MD, Lenox Hill Hospital