Appendiceal Crohn's disease presenting with urinary symptoms: a case report

There is limited pediatric data describing the presentation and management of Crohn's disease of the appendix. Although appendectomies are common pediatric procedures, there is a paucity of literature regarding appendiceal Crohn's disease in pediatric patients. A 15-year-old male presented with six months of chronic right lower quadrant pain, intermittent low-grade fevers, dysuria, and gross hematuria without urinary frequency. Laboratory studies revealed sterile pyuria, elevated CRP, and elevated fecal calprotectin. Endoscopic histopathology suggested celiac disease, and celiac serologies were positive. A computed tomography scan with intravenous contrast of the abdomen and pelvis (CT) showed a dilated, thick-walled appendix with mild surrounding inflammation, an appendicolith, and asymmetric thickening of the right posterolateral bladder wall with possible fistulous connection. Diagnostic laparoscopy revealed a thickened appendiceal base densely adherent to the posterior bladder wall. He underwent an open ileocecectomy and cystoscopy. Cystoscopy showed posterior bladder inflammation. Pathology demonstrated transmural inflammation, ulceration, and noncaseating granulomas consistent with Crohn's disease. The patient was discharged on postoperative day three. Seven days later, he presented with pain, nausea, and fever. A CT revealed a small pelvic fluid collection, which was aspirated. He was treated with IV antibiotics and started on infliximab before discharge. At his one-year follow-up appointment, the patient remains well on infliximab and a gluten-free diet with resolution of symptoms. Crohn's disease of the appendix can cause chronic abdominal pain and urinary symptoms such as dysuria and hematuria.