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figure 1. Axial reformatted computed tomographic scan of the
abdomen and pelvis performed on the day of presentation. The
appendix appears normal, and no other pathology is present to
explain the patient’s pain.
from the appendiceal orifice (Figure 2). This was aspirated and sent
to the laboratory, where analysis detected a large number of white
blood cells, gram-negative rods, and gram-positive cocci. Results of
the biopsy of the mucosa at the base of the appendix demonstrated
mild nonspecific chronic and focal acute inflammation.
The general surgeon on call was notified and observed the
appendiceal findings at colonoscopy. The patient’s generally
benign condition and the duration of the symptoms were
taken into consideration, as was the interesting finding of freely
flowing pus from the appendiceal orifice. The surgeon elected to
observe the patient over the weekend and repeat a CT scan if his
symptoms persisted.
The patient remained symptomatic and underwent a repeat CT
scan. The radiologist noted that this scan was similar in appearance
to the patient’s previous studies and that the appendix was fluidfilled,
although the walls were not thickened and there were no
inflammatory changes. The remainder of the abdomen and pelvis
appeared normal.
The following day, the patient underwent laparoscopic
appendectomy. Intraoperative findings included an enlarged,
inflamed appendix and mild mesenteric scarring around the
CoLonoSCopiC diAGnoSiS of AppendiCitiS
terminal ileum. No signs of active Crohn disease or ulcerative colitis
were identified. No signs of a Meckel diverticulum were present.
Routine pathologic evaluation of the appendix later confirmed the
diagnosis of acute suppurative appendicitis with benign lymphoid
hyperplasia. The patient was discharged home after a brief and
benign recovery.
Just over a month later, the patient was seen in the emergency
department for recurrent abdominal pain, which quickly resolved
without intervention. His postoperative course had been benign
until that point, with the exception of a knee joint effusion, possibly
related to trauma from playing basketball. Since that episode 24
months ago, the patient has reported no abdominal pain.
To our knowledge, this is the first report of colonoscopic
diagnosis of appendicitis in a patient with known ulcerative colitis
and possible Crohn disease, which significantly confounded the
evaluation.
diSCuSSion
In 1994, Said et al reported a case of atypical appendicitis that
was diagnosed by colonoscopy. The patient had experienced
abdominal pain and fever for 2 weeks and was hospitalized and
treated nonoperatively. The results of laboratory studies were
consistent with inflammation. Workup included ultrasonography
and upper endoscopy. On the third day after admission,
colonoscopy was performed, pus was aspirated from the
appendiceal orifice, and the patient’s symptoms resolved within
a day. Interval appendectomy was performed 5 months later and
confirmed a previous diagnosis of appendicitis. 14
figure 2. Colonoscopy demonstrates pus from the appendiceal os,
slight inflammation near the base of the appendix.
Gundersen Lutheran Medical Journal • Volume 6, Number 1, June 2009 15