Colonoscopic diagnosis of early acute appendicitis

A 62-year-old man with medical history of (1) morbid obesity status post Roun-en Y gastric bypass, (2) chronic obstructive pulmonary disease, (3) cardiac arrest status post pacemaker placement. Due to postprandial diarrhea, general malaise, blood-tinged stool for 1 to 2 weeks, the patient went to our gastroenterology clinic. He denied symptoms of fever, abdominal pain, nausea, vomiting. On initial evaluation, his vital signs were within normal limits, and his abdominal examination was soft, nontender, normal active bowel sound and without signs of peritonitis. A complete blood count and basic biochemical tests were unremarkable. Colonoscopy revealed swollen of appendiceal aperture and a moderate amount of fecalith and purulent discharge from the appendiceal orifice. (Figure 1) Further abdominal computed tomography showed swelling of appendix with perifocal fatty stranding, favor acute appendicitis (Figure 2, arrowhead). He was then admitted for a laparoscopic appendectomy where her appendix and adjacent tissues appeared mildly hyperemic. The appendix was evaluated by an experienced pathologist. Grossly, the external surface of appendix is congested, with pus coating on the serosa. On section, the lumen is filled up with fecal and purulent material. No perforation is found. Microscopically, it shows a picture of acute appendicitis with marked transmural acute inflammation of appendix and peri-appendiceal fat. Acute appendicitis is one of the most common abdominal surgical emergency worldwide. Although advances in imaging modalities, diagnosis of acute appendicitis still has false-negative rate.1 Endoscopy is not the standard for diagnosis and treatment of appendicitis, but there are few reported cases of silent appendicitis diagnosed at the time of colonoscopy. From case reports in recent 2 years, we found purulent discharge,2 bulging, erythematous, edematous of appendiceal orifice were rare endoscopic finding but related to appendicitis. Thus we perform colonoscopy when insert to cecum, we need to take notice of the appendiceal orifice. The authors declare no conflicts of interest. Written informed consent was obtained from the patients.