Endoscopic Diagnosis of Early Acute Appendicitis in an Asymptomatic Patient

CASE REPORT

A 50-year-old woman with a paternal medical history of colon cancer presented for a routine screening colonoscopy. On presentation, she denied symptoms of abdominal pain, nausea, vomiting, fevers, chills, or anorexia. During the procedure, 5 polyps ranging from 2- to 7-mm were excised from the transverse and sigmoid colon. Evaluation of the cecum revealed a normal mucosa surrounding the base of the appendix and a moderate amount of purulent discharge from the appendiceal orifice (Figure 1). Given these endoscopic findings, which were suggestive of acute appendicitis, she was referred to the emergency department for evaluation and surgical consultation. On initial evaluation, her vital signs were within normal limits, and her abdominal examination was soft, nontender, and without signs of peritonitis. A complete blood count and basic metabolic panel were unremarkable. Abdominal computed tomography showed a 6-mm appendix, mild hyperemia of the appendiceal wall, and lack of intraluminal contrast consistent with acute appendicitis (Figure 2). She was taken for a laparoscopic appendectomy where her appendix and adjacent tissues appeared mildly hyperemic. The appendix was evaluated by a board-certified pathologist, and the final diagnosis was acute appendicitis (Figure 3).

Figure 1.

Appendiceal orifice (black arrow) with purulent discharge and no other significant mucosal changes.

Figure 2.

Computed tomography showing hyperemic and dilated appendix (red arrow) with lack of intraluminal contrast consistent with acute appendicitis.

Figure 3.

Hematoxylin and eosin staining of the appendix mucosa with ulceration and fibrinopurulent exudate (20× magnification).

Appendicitis is a common diagnosis with a well-established clinical course.¹ Despite advances in imaging modalities, we have not seen the expected fall in the rate of negative appendectomies, which highlights the fact that better modalities to aid in the diagnosis of appendicitis may still be needed.² Endoscopy is not currently in the algorithm for the evaluation or treatment of suspected appendicitis and is unlikely to become an effective modality for this disease in the future. However, endoscopists should be aware of the early mucosal changes seen in appendicitis that should prompt further investigation and surgical consultation. Interestingly, there are only 2 previously reported cases of acute appendicitis diagnosed at the time of colonoscopy in patients who were asymptomatic.^3,4 These cases were presented as an account of the earliest mucosal changes seen on endoscopy in appendicitis. In them, mucosal erythema, edema, abscess, and purulent discharge are cited as the earliest findings. This helped the reporting authors corroborate that the pathophysiology of appendicitis begins with luminal obstruction of the appendix and ultimately advances to appendiceal perforation. On the contrary, we argue that the earliest changes in acute appendicitis, even before patients become symptomatic, may not necessarily be luminal obstruction of the appendix. Rather, this obstructive phase of appendicitis may be a secondary change incited by the inflammatory response to an already developing infection.

DISCLOSURES

Author contributions: X. Pereira wrote the manuscript and is the article guarantor. G. Romero-Velez edited the manuscript. G. Dickinson reviewed the manuscript and provided the images. CC Mandujano edited and approved the final version.

Financial disclosure: None to report.

Informed consent could not be obtained for this case report. All identifying information has been removed.