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outCoMeS froM A SCreeninG proCedure for orophArynGeAL dySphAGiA 16. McCullough GH, Wertz RT, Rosenbek JC, Dinneen C. Clinicians’ preferences and practices in conducting clinical/bedside and videofluoroscopic swallowing examinations in an adult neurogenic population. American Journal of Speech- Language Pathology. 1999;8:149-163. 17. Farrell Z, Murphy E. A comment on “the natural history of dysphagia following a stroke” (Dysphagia 1997;12:188-193). Dysphagia. 1998;13(4):230-231. 18. Garon BR, Engle M, Ormiston C. Reliability of the 3-oz water swallow test utilizing cough reflex as sole indicator of aspiration. J Neurol Rehabil. 1995;9(3):139-143. 19. Garon BR, Engle M, Ormiston C. Silent aspiration: results of 1,000 videofluoroscopic swallow evaluations. J Neurol Rehabil. 1996;10(2):121-126. 20. Trapl M, Enderle P, Nowotny M, et al. Dysphagia bedside screening for acute-stroke patients: the Gugging Swallowing Screen. Stroke. 2007;38(11): 2948-2952. 21. Martino R, Pron G, Diamant N. 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Authors: Alexander D. Wade, MD Department of Medical Education Gundersen Lutheran Medical Foundation Frank J. Aberger, MD Department of Gastroenterology Gundersen Lutheran Health System Address for correspondence: Frank J. Aberger, MD Mail Stop H05-007 Gundersen Lutheran Health System 1900 South Avenue La Crosse, WI 54601 Telephone: (608) 775-2702 Facsimile: (608) 775-6395 email: fjaberge@gundluth.org A Colonoscopic Diagnosis of Appendicitis in a Patient with Ulcerative Colitis: A Case Report and Review of the Literature AbStrACt ppendicitis is a common cause of acute abdominal pain. Over the past 2 decades, a number of cases of appendicitis due to colonoscopy have been reported, 1-8 as well as cases of appendicitis diagnosed by colonoscopy, 9-18 often when other diagnostic modalities have failed to diagnose appendicitis or have suggested other diagnoses. Unusual presentations of appendicitis, particularly in patients with abdominal comorbidities, sometimes lead to colonoscopy, which is almost never used as a first line of investigation because of the risk of complications such as bleeding or perforation, and because noninvasive tests such as ultrasonography and computed tomography (CT) are highly sensitive. 19 CASe report A 17-year-old boy came to our urgent care clinic with a 2-week complaint of increasing periumbilical and right lower quadrant abdominal pain and recent rectal bleeding. He was known to have ulcerative colitis, diagnosed in 2001 by colonoscopy with biopsies. He had been hospitalized in 2005 for ulcerative colitis, at which time CT scan documented a 6- to 7-mm appendix but no inflammation. He was compliant with his medication (sulfasalazine 1000 mg by mouth twice a day), and his ulcerative colitis had been quiescent. His temperature was normal, his white blood cell (WBC) count was 14 000/µL (75.2% neutrophils, 26% of which were bands), and his erythrocyte sedimentation rate (ESR) (105 mm/h, reference range = 0-15) and C-reactive protein (CRP) concentration (13.1 mg/L, reference range = 0.08-3.1) were elevated. Results of an abdominal CT scan were normal (Figure 1). The patient’s gastroenterologist was notified and scheduled the patient for flexible sigmoidoscopy the following day, which documented normal rectal mucosa, decreasing the likelihood that the patient’s symptoms were attributable to ulcerative colitis. With his pain, rectal bleeding, and normal flexible sigmoidoscopy findings, Crohn disease was believed to be a possible diagnosis. A 17-year-old boy with a known history of ulcerative colitis came to urgent care with a 2-week history of periumbilical pain and an episode of rectal bleeding. His evaluation included a computed tomographic (CT) scan, gastroenterology consultation, flexible sigmoidoscopy, CT enterography, abdominal ultrasonography, double-contrast upper gastrointestinal study, esophagogastroduodenoscopy, and, ultimately, a complete colonoscopic examination that revealed pus exuding from the appendiceal orifice. Repeat CT scan, with knowledge of the colonoscopy results, was interpreted as normal. Laparoscopic appendectomy was performed and confirmed the diagnosis of suppurative appendicitis. The patient had a benign postoperative course, and his symptoms have not recurred. We review the English-language literature regarding colonoscopically diagnosed appendicitis. To our knowledge, this is the first report in the literature of a case of colonoscopically diagnosed appendicitis in a patient with ulcerative colitis. CT enterography demonstrated normal small bowel caliber and wall thickness. The patient’s pain persisted. He was scheduled for ultrasonographic examination of the abdomen, as well as a doublecontrast upper gastrointestinal (GI) series. The gastroenterologist suggested a complete colonoscopic examination to look for possible Crohn disease if these studies failed to diagnose the etiology of the pain. Two days later, because of persisting pain, the patient underwent abdominal ultrasonography. A single loop of slightly thick-walled small bowel (4.7 mm) was identified as the only abnormality. This was followed by a double-contrast upper GI series and small bowel follow-through that revealed a normal esophagus and stomach, and no evidence of hiatal hernia or gastroesophageal reflux. Transit time through the small bowel into the colon was approximately 2 hours. The small bowel loops, including the terminal ileum, appeared normal. By this time, the patient’s leukocytosis had normalized, although his ESR (78 mm/hr) and CRP concentration (2.8 mg/L) remained elevated. Almost 2 weeks after his initial visit, the patient was again seen by his gastroenterologist. He remained symptomatic, complaining of diarrhea and abdominal pain. Laboratory studies revealed a WBC count within reference range, with neutrophilia (77.9%, reference range = 34%-67%) and a persistently elevated ESR (46 mm/hr). Mild anemia was also detected (hemoglobin concentration 11.9 g/dL). His CRP concentration was within normal range. Findings from an upper endoscopic examination were unremarkable. He underwent a colonoscopy, the results of which proved negative for colitis. The rectum appeared normal, indicating that the symptoms were not related to his ulcerative colitis. The cecum and the distal ileum were examined and appeared normal, thus reducing the likelihood of Crohn disease as the etiology for the symptoms. A small amount of mucin or pus was seen to emanate 14 Gundersen Lutheran Medical Journal • Volume 6, Number 1, June 2009
Page 1 and 2: Th e Gundersen Lu T h e r a n M e d
Page 3 and 4: editor David E. Hartman, PhD, BC-AN
Page 5 and 6: through our online Scholarly Activi
Page 7 and 8: competition practice of each subjec
Page 9 and 10: effect. These data suggest that the
Page 11 and 12: Authors: David E. Hartman, PhD, BC-
Page 13 and 14: discharge. Twelve patients (2%) dev
Page 15: pneumonia rates of 2.4%, versus 5.4
Page 19 and 20: Since that report, other authors ha
Page 21 and 22: Authors: Abhishek Tandon, MD Depart
Page 23 and 24: cancer, duodenal ulcers, inflammato
Page 25 and 26: figure 1. Radiograph depicting a 4-
Page 27 and 28: Authors: Meghana Raghavendra, MB, B
Page 29 and 30: Authors: Ines H. Berger, MD, PhD De
Page 31 and 32: and nerve root avulsion. Simmel, in
Page 33 and 34: Authors: Brian E. Udermann, PhD, AT
Page 35 and 36: figure 2. Longtime LEHP member Don
Page 37 and 38: Summer Splendor Kelly Hodgson Kline

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