Case Reports in Gastrointestinal Medicine
Volume 2016 (2016), Article ID 1378046, 6 pages
http://dx.doi.org/10.1155/2016/1378046

Case Report

Diagnostic Colonoscopy Leading to Perforated Appendicitis: A Case Report and Systematic Literature Review

Daniel Paramythiotis, Konstantinia Kofina, Vasileios Papadopoulos, and Antonios Michalopoulos

First Propedeutic Surgical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece

Received 29 July 2016; Revised 10 October 2016; Accepted 18 October 2016

Academic Editor: R. J. L. F. Loffeld

Copyright © 2016 Daniel Paramythiotis et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract.

Introduction. Intestinal perforation is a known complication after colonoscopy. However, appendiceal involvement with inflammation and perforation is extremely rare and only 37 cases of postcolonoscopy appendicitis have been reported so far. We describe a case of perforated appendicitis 24 hours after colonoscopy that was treated successfully in our Department. Case Report. A 60-year-old female patient underwent a colonoscopy during the investigation of nontypical abdominal pain without pathologic findings. 24 hours after the examination she presented gradually increased right lower quadrant abdominal pain and a CT scan was performed, showing an inflammation of the appendiceal area with free peritoneal air. Through laparotomy, perforated appendicitis was diagnosed and an appendectomy was performed. The patient was discharged on the tenth postoperative day in good health condition. Discussion. The characteristics of all cases reported in the literature are described, including our case. Perforated appendicitis soon after a colonoscopy is a rare, but serious complication; therefore, it is crucial to be included in the differential diagnosis of postcolonoscopy acute abdominal pain.

1. Introduction

Colonoscopy is a common procedure used by the gastroenterologists in order to investigate abnormal conditions of the colon and the distal small intestine [1]. Serious complications are not considered as frequent, but they include a wide range of conditions, from pain, bleeding, and inflammation to perforation, cardiopulmonary complications, and even death [2].

Perforation is reported in 0.3% or lower of the cases examined. This complication could be caused by therapeutic interventions, air insufflation, mechanical forces, or movements of the scope [3]. The sigmoid is the most common location of perforation, possibly due to mechanical forces, diverticular disease, polyps, or the thinner colonic wall [4]. Women are considered more prone to perforation because of pelvic surgeries, diverticular disease, or increased colonic length.

Acute appendicitis has been referred to in the literature as a possible complication after a colonoscopy, probably in a higher rate than it was generally considered (until 2007 only 12 cases were reported) [5]. However, according to the ASGE guidelines of 2011, acute appendicitis is only referred to as a possible complication during a couple of cases, while rarer complications are described more thoroughly [6].

We present the case of a female patient that was submitted to diagnostic colonoscopy with normal results but presented with perforated appendicitis 24 hours after the examination. A thorough research of the literature and disclosure of the results has also been performed and recorded.

2. Case Report

A 60-year-old woman was admitted to the Department of Internal Diseases after presenting mild pain at the lower abdomen and the right iliac fossa. The blood laboratory tests showed results within normal limits (WBC: 8.01 K/μL, with 76.3% neutrophils) and imaging control through abdominal X-ray (Figure 1) and ultrasound did not reveal any abnormalities.

Figure 1: Abdominal X-ray on admission. Normal findings.

This initial condition of the patient could reassemble that of mild appendicitis; therefore examination by a surgeon was also realized. However, the patient did not present fever or anorexia, McBurney sign was negative within a couple of hours after the first examination, and tenderness in the lower abdomen had almost disappeared the next day, whereas the laboratory blood tests were still within normal limits.

Therefore, at first, the patient was treated by general practitioners, who considered her present condition as the symptoms of a possible bowel inflammation; this is the reason why they also considered necessary the initial treatment with rehydration and empirical antibiotic administration. Furthermore, the same clinical condition had occurred several times in the past and was treated conservatively with success. Based on this repeated clinical history, the colonoscopy was considered as the examination of choice for further investigation and was programmed immediately, in terms of the same admission. The procedure was uneventful and examination up to 10 cm proximally to the ileocecal valve did not lead to any pathologic findings (Figure 2).

Figure 2: Imaging through colonoscopy. No signs of inflammation until the point of 10 cm proximally to the ileocecal valve.

Mild abdominal pain reoccurred 10 hours after the colonoscopy, increased progressively, and presented as acute abdomen 24 hours after the procedure, especially to the right side, with flatulence, but still without fever or white blood cell count disturbance (WBC: 9.02 K/μL, neutrophils: 78.6%). A new abdominal X-ray was performed, presenting free abdominal gas (Figures 3(a) and 3(b)). Surgical assessment was considered necessary, and imaging through computerized tomography was realized. The abdominal CT scan revealed diffuse inflammation not only in the area of the appendix and free gas in the peritoneal cavity, but also in the retroperitoneal space (Figure 4).

(a)

(b)

Figure 3: Abdominal X-ray after colonoscopy and clinical deterioration. Presence of free abdominal gas.

Figure 4: Abdominal CT scan. Perihepatic collection with free abdominal gas.

Based on the condition and the imaging findings, an exploratory laparotomy was performed, during which perforated appendicitis with peritonitis was revealed (Figures 5(a) and 5(b)). An appendectomy was performed and the cavity was rinsed and drained thoroughly. The time interval between the presence of severe symptoms and surgery included the realization of X-ray and CT imaging and was about six hours. Due to the interference of the colonoscopy, with no abnormal findings until and during its realization, we considered the intraoperative condition as a postcolonoscopy complication. The patient remained hemodynamically stable, still with normal temperature and blood laboratory results, and was discharged on the tenth postoperative day on good health condition.

(a)

(b)

Figure 5: Intraoperative findings. Acute appendicitis with peritonitis. Presence of a fecalith.

3. Discussion

Diagnostic colonoscopy is considered a relatively safe procedure, with a limited range of serious complications. Acute appendicitis following colonoscopy is a rare complication, with a considered incidence of 0.038% [7], according to a research of 2007, either because of underpublication or underrecognition due to simultaneous conservative treatment.

For the review of the literature, we searched only the cases where an uncomplicated classic colonoscopy was performed, without signs of inflammation at the anatomic area of the appendix during the examination. There were no limitations of language or date of publication. An electronic literature search was performed on MEDLINE and manual retrieval of the reference lists of selected papers completed the research. A total of 31 articles were identified in the literature, with a total of 37 cases of postcolonoscopy appendicitis [5, 7–36]. The basic characteristics of these cases, including our own case, are included in Table 1.

Table 1: Presentation of main characteristics of cases described in the literature (ns: not specified).

First author
Year
Sex
Age
Time after colonoscopy
Treatment
Condition

Houghton
1988
Male
35
8 hours
Laparotomy-appendectomy
Acute

Brandt
1989
Female
65
48 hours
Laparotomy-appendectomy
ns

Segawa
1992
Male
49
4 hours
ns
Perforated

Vender
1995
Female
44
Several hours
Laparotomy-appendectomy
ns

Vender
1995
Female
57
Immediate
Laparotomy-appendectomy
Perforated

Vender
1995
Male
55
48 hours
Antibiotics
ns

Hirata
1996
Male
69
12 hours
Laparotomy-appendectomy
Acute

Lipton
1999
Male
69
96 hours
Laparotomy-appendectomy
Gangrenous

de Leusse
1999
Male
71
12 hours
Laparotomy-appendectomy
Perforated

Takagi
2000
Male
56
72 hours
Laparotomy-appendectomy
Phlegmonous

Kapral
2003
Male
79
Same day
ns
Perforated

Srivastava
2004
Male
65
10 days
Laparotomy-appendectomy
Abscess

Rosen
2005
Male
24
48 hours
Laparotomy-appendectomy
ns

Rosen
2005
Male
55
Several hours
Antibiotics
ns

Izzedine
2005
Male
61
1 day
Antibiotics-appendectomy
Perforated

Volchok
2006
Male
60
16 hours
Appendectomy
Nonperforated

Chae
2007
Female
48
Same day
Appendectomy
Nonperforated

Horimatsu
2007
Male
68
1 day
Antibiotics
ns

Pellish
2007
Male
50
Immediate
Laparotomy-appendectomy
Nonperforated

Johnston
2008
Male
55
16 hours
Appendectomy
Perforated

Sheikh
2010
Female
50
4 hours
Laparotomy-appendectomy
Perforated

Moorman
2010
Female
71
Next morning
ns
Perforated

Moorman
2010
Male
47
27 hours
Laparotomy-appendectomy
Perforated

Moorman
2010
Male
84
4 hours
Laparotomy-appendectomy
Acute

Bachir
2010
Male
28
2 days
Appendectomy
Nonperforated

Penkov
2011
Female
50
7 days
Laparotomy-appendectomy
Acute

Rodriguez-Otero
2011
Female
50
6 hours
Laparotomy-appendectomy
Perforated

Aguilar-Shea
2011
Male
34
12 hours
ns
Acute

Louleiro
2011
Male
54
4 hours
Laparotomy-appendectomy
Perforated

Yagnik
2012
Female
35
7 days
Laparotomy-appendectomy
Acute

Musielac
2012
Female
45
4 hours
Laparotomy-appendectomy
Perforated

Musielac
2012
Male
33
6 hours
Laparotomy-appendectomy
Acute

Shaw
2013
Male
67
24 hours
Appendectomy
Acute

April
2013
Male
52
8 hours
Appendectomy
Nonperforated

Kuriyama
2014
Male
83
ns
ns
Acute

Wong
2014
Male
47
13 hours
Laparotomy-appendectomy
Perforated

Nemoto
2015
Female
53
7 hours
Antibiotics
Acute

Paramythiotis
2016
Female
60
24 hours
Laparotomy-appendectomy
Perforated

The sample included 38 patients, 26 males (68.42%) and 12 females (31.58%). Mean age was 54.7 years (55.8 years for males, 52.3 years for females), with a range of 24 to 84 years. The time between the intervention and the presence of symptoms ranged from immediate to ten days after the procedure, with 26 patients (68.42%) showing symptoms within the first 24 hours after colonoscopy. Four patients (10.52%) were treated only conservatively; fifteen (39.47%) were submitted to exploratory laparotomy and appendectomy, seven (18.42%) to open appendectomy through McBurney’s incision, and seven (18.42%) to laparoscopic appendectomy, whereas in five cases the exact treatment was not specified. Intraoperatively, acute appendicitis was diagnosed in ten cases, phlegmonous appendicitis in one case, gangrenous appendicitis also in one case, and perforated appendicitis in fourteen (36.84%), whereas nonspecified inflammation included six cases.

Over 68% of the cases have presented symptoms in a 24-hour period after the procedure, which suggests that there possibly exists an etiologic relationship. Four theoretical mechanisms have been proposed for the development of acute appendicitis after a colonoscopy: preexisting subclinical appendicitis, overinsufflation, impaction of feces or fecalith in the appendix, or direct trauma [15].

In our case, colonoscopy findings from the appendix were normal, so early appendicitis was most probably excluded from the differential diagnosis. Actually, colonoscopy is considered useful even in the diagnosis of appendicitis in cases where imaging studies are not diagnostic [37], so any possible inflammation of the appendix would have been directly shown during this examination.

We support that the causal event was the fecalith that could be introduced into the appendix by the air insufflation. This is suggested by no symptoms prior to the procedure, followed by the finding of impacted stool in the appendix after the open appendectomy. However, the possibility of the presence of the fecalith in the appendix prior to the colonoscopy could not be excluded, as we can also not exclude the fact that perforation could be due to overinsufflation or trauma from the scope. The presence of peritonitis could be explained by the interval of 20 hours from the moment of the presence of mild postcolonoscopy symptoms until the surgical management.

It could be suggested that the presence of fourteen cases of perforation intraoperatively could be due to a delay of diagnosis and deteriorated condition; however, even the immediate diagnosis and treatment [5] show that delayed diagnosis is not always the reason of complicated appendicitis. Even though delayed diagnosis was indeed a characteristic of many cases, immediate surgical procedures after the diagnosis of acute appendicitis could reduce the presence of intraoperative perforation, peritonitis, or any further deterioration of the inflammation.

CT is the examination of choice in order to obtain the optimal preoperative abdominal image, as postcolonoscopy abdominal pain can be generally caused by retained gas, colonic spasm, or postpolypectomy syndrome [7]. Exploratory laparotomy was the main form of operation in cases of diffuse inflammation; however, laparoscopic procedures have relatively recently been introduced and used in cases of perforated appendicitis [23, 27, 31] with good postoperative results.

4. Conclusion

Postcolonoscopy appendicitis may be incidental or the result of the procedure. The mechanism of this complication is still unknown and theoretical. However, acute appendicitis should be always included in the differential diagnosis of postcolonoscopy abdominal pain, in order to avoid a delayed or complicated diagnosis and treatment.

Competing Interests

The authors declare that they have no conflict of interests.

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