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Rodrigues, A., Marques, A., Camarneiro, R., Silva, R., Dias, I., Melo, M. (2018) Apendicite Aguda Perfurada Após Colonoscopia – Um Caso Clínico e Revisão da Literatura, Journal of Aging & Innovation, 7 (3): 12 A., - 18Camarneiro, R., Silva, R., Dias, I., Melo, M. (2018) Estudo de Caso: Rodrigues, A., Marques, Apendicite Aguda Perfurada Após Colonoscopia – Um Caso Clínico e Revisão da Literatura, Journal of Aging & Innovation, 7 (3): 12 - 18

 Estudo de Caso

PERFORATED ACUTE APPENDICITIS AFTER COLONOSCOPY A CASE REPORT AND LITERATURE REVIEW APENDICITE AGUDA PERFURADA APÓS COLONOSCOPIA UM CASO CLÍNICO E REVISÃO DA LITERATURA APENDICITE AGUDA PERFORADA DESPUÉS COLONOSCOPIA UN CASO CLÍNICO Y REVISIÓN DE LA LITERATURA

Ana Rodrigues1, Adriano Marques2, Rita Camarneiro3, Regina Silva4, Isabel Dias5, Margarida Brito e Melo6 1,2,3,4,5,6 MD, General Surgery Department, Centro Hospitalar do Oeste- Portugal Corresponding Author: ana.l.ascenso@gmail.com

Abstract Introduction: Colonoscopy is a widely used fairly safe procedure. Acute appendicitis is a rare complication of colonoscopy, with perforated acute appendicitis being even rarer. A case of acute gangrenous appendicitis with perforation, following a colonoscopy is presented in this study. A systematic literature review is presented. Case report: A case report of a 56-year-old diabetic and hypertensive female with an abdominal pain 12 hours after colonoscopy is presented. She was admitted at the emergency department, after having had pain for 72 hours. She had a generalized abdominal pain. Due to suspicious colon perforation an exploratory laparotomy was done and the diagnosis of perforated acute appendicitis confirmed. Discussion: The physiopathology of acute appendicitis after colonoscopy is not clear. In this case it could be a result of stool accumulation in the appendix due to air insufflation. There are only 23 case reports described in the literature, with a male predominance and the first symptoms occurring within the first 12 hours after colonoscopy in the majority of the cases. Conclusion: Acute perforated appendicitis after colonoscopy is rare and it should be excluded when a right quadrant abdominal pain is present.

Keywords: acute appendicitis, perforation, perforated appendicitis, colonoscopy

Resumo Introdução: A colonoscopia é um procedimento amplamente utilizado e seguro. A apendicite aguda é uma complicação rara da colonoscopia, sendo a apendicite aguda perfurada ainda mais rara. Neste estudo, apresentamos um caso de apendicite aguda gangrenosa com perfuração, após colonoscopia. É realizada uma revisão sistemática sobre os casos de apendicite aguda perfurada. Caso Clínico: É apresentado o caso clínico de uma mulher diabética e hipertensa de 56 anos com dor abdominal com início 12 horas após a realização de colonoscopia.

JOURNAL OF AGING AND INNOVATION, DEZEMBRO, 2018, 7 (3)  ISSN: 2182-696X  http://journalofagingandinnovation.org/

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Estudo de Caso: Rodrigues, A., Marques, A., Camarneiro, R., Silva, R., Dias, I., Melo, M. (2018) Apendicite Aguda Perfurada Após Colonoscopia – Um Caso Clínico e Revisão da Literatura, Journal of Aging & Innovation, 7 (3): 12 - 18 Esta recorreu ao serviço de urgência com dor abdominal com 72 horas de evolução. À entrada no serviço de urgência apresentava dor abdominal generalizada. Devido à suspeita de perfuração cólica foi realizada uma laparotomia exploradora e constatou-se a presença de apendicite aguda perfurada. Discussão: A fisiopatologia da apendicite aguda após colonoscopia não é clara. Neste caso, poderia ser o resultado da impactação de fezes no apêndice devido à insuflação de ar. Existem apenas 23 casos descritos na literatura, com predomínio do sexo masculino, em que os primeiros sintomas se iniciam na maioria dos casos nas primeiras 12 horas após a colonoscopia. Conclusão: A apendicite aguda perfurada após colonoscopia é rara e deve ser excluída sempre que estiver presente dor abdominal nos quadrantes direitos.

Palavras-chave: apendicite aguda, perfuração, apendicite perfurada, colonoscopia

Introduction Colonoscopy is a widely used screening, diagnosis and treatment procedure, with low risk of complications (0.2-3 %) [18, 22]. The most common complications are perforation, bleeding, diverticulitis and postpolipectomy syndrome [22, 15]. A rare complication of colonoscopy is acute appendicitis, with perforated acute appendicitis being even rarer with only a few cases described in the literature. The reason why colonoscopy may lead to appendicitis is not clearly understood [18]. An uncommon case of acute gangrenous appendicitis with perforation, following a colonoscopy is presented in this study. A systematic literature review is elaborated.

Case Report: A 56-year-old diabetic and hypertensive female with dyslipidaemia was subjected to a screening colonoscopy and was asymptomatic before the procedure. The patient had a good mechanical bowel preparation. However, the endoscope was only introduced up to the hepatic flexure of the colon, due to a colon angulation which impaired endoscope progression. A sigmoid polyp was identified and a polypectomy was done without any immediate complications. She started with mild generalized abdominal pain 12 hours after the procedure, which gradually intensified. She was admitted to the emergency department, after having generalized abdominal pain for 72 hours. On examination, she was febrile (temperature=38.4ºC), her blood pressure was 137/61 mmHg with a heart rate of 88 beats per minute. Her abdomen showed tenderness with peritoneal sign. Laboratory tests revealed a hemoglobin of 10,5g/dl, white blood cells of 9x 103/µl with neutrophilia of 88.8% and C-reactive protein level of 31,7mg/dl.

JOURNAL OF AGING AND INNOVATION, DEZEMBRO, 2018, 7 (3)  ISSN: 2182-696X  http://journalofagingandinnovation.org/

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Estudo de Caso: Rodrigues, A., Marques, A., Camarneiro, R., Silva, R., Dias, I., Melo, M. (2018) Apendicite Aguda Perfurada Após Colonoscopia – Um Caso Clínico e Revisão da Literatura, Journal of Aging & Innovation, 7 (3): 12 - 18

An upright abdominal X-ray demonstrated a colonic distension. A subsequent abdominal and pelvic computerized tomography was done, which revealed a colonic distension and small amount of free gas between the transverse colon and the liver. Having a suspicion of a colon perforation, an emergency laparotomy was done. Intraoperatively there was no evidence of colon perforation and a perforated acute gangrenous appendicitis with localized peritonitis was identified. She was subjected to an appendicectomy and the abdominal cavity was washed and drained. The postoperative course was uneventful. The discharge was on the 5 th postoperative

day

when

she

completed

5

days

of

endovenous

antibiotics

(amoxiciline+clavulanic acid and metronidazole) with the switch to oral for a further 3 days. Histological specimens confirmed the clinical diagnosis of gangrenous acute appendicitis with a fecalith.

Figura 1: Polipo da sigmóide

Figure 1: Sigmoid polyp in colonoscopy

Figure 2: upright abdominal X-ray demonstrating a colon distension

Figure 3: Abdominal computed tomography showing colonic distension and small amount of free gas between the transverse colon and the liver

Discussion: The definition of acute appendicitis after colonoscopy is an inflammatory process of the appendix which occurs within the first 72 hours after colonoscopy [18]. The physiopathology of acute appendicitis after colonoscopy is not clear, however, some mechanisms can explain this occurrence [18]. Possible explanations may be: the barotrauma from over insufflation [15, 2, 6, 20]; stool accumulation in the appendix due do air insufflation, which may lead to obstruction and/or inflammation [6, 14, 5]; direct trauma by endoscope progression into the appendix lumen [6, 20]; exacerbation or pre-clinical disease [4]; carbon dioxide insufflation and dilatation of the appendix [3] and inflammation due to glutaraldehyde-type solution, used for cleaning endoscopes [20, 13, 10]. The diagnosis may be challenging due to a similar clinical presentation of colon perforation. Late diagnosis can lead to peritonitis and death [18].

JOURNAL OF AGING AND INNOVATION, DEZEMBRO, 2018, 7 (3)  ISSN: 2182-696X  http://journalofagingandinnovation.org/

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Estudo de Caso: Rodrigues, A., Marques, A., Camarneiro, R., Silva, R., Dias, I., Melo, M. (2018) Apendicite Aguda Perfurada Após Colonoscopia – Um Caso Clínico e Revisão da Literatura, Journal of Aging & Innovation, 7 (3): 12 - 18

In this study, acute appendicitis could be a result of stool accumulation in the appendix due to air insufflation, which may lead to obstruction and/or inflammation. In this particular case report the explanation of direct trauma was excluded, since the colonoscopy did not visualize the right side of the colon. The hypothesis of a pre-existing initial acute appendicitis is unlikely as the patient was asymptomatic before the procedure. The precise diagnose can be challenging and the delay in diagnosis can lead to perforated acute appendicitis. In addition, clinical symptoms may mimic other severe complications such as colon perforation. It is essential to think of acute appendicitis after colonoscopy, when pain is present, particularly in the right quadrants of abdomen. A literature review of perforated acute appendicitis is presented in this study. An electronic literature search was done on MEDLINE. There were no limitations due to language or date of publication. A total of 23 case reports (including ours) were identified in the literature as perforated acute appendicitis after colonoscopy. The basic characteristics of these cases, including our study, are presented in Table 1. Based on cases reported in the literature, perforated appendicitis after colonoscopy seems to be much more common in males (65%). The range of age of patients with this complication varied between 47 and 79. The first symptoms occurred within the first 12 hours after colonoscopy in the majority of the cases, with diagnosis confirmation after 24 hours from the beginning of the pain in 6 cases.

Table 1: Case reports of postcolonoscopy perforated appendicitis First author

Segawa

17

Year

Sex

Age

Time after

Diagnosis

colonoscopy

(time after

(onset)

colonoscopy)

Treatment

1992

M

49

NS

4 hours

Vender20

1995

F

57

Immediate

Immediate

20

2012

M

54

4 hours

<52 hours

1999

M

71

12 hours

1 day

2002

M

71

<12 hours

24 hours

NS

Kapral9

2003

M

79

Same day

NS

NS

Kapral9

2003

M

79

Same day

NS

NS

Izzedine7

2005

M

61

24 hours

24 hours

Vender

le Leusse11 Doohenl

4

NS Laparotomy, appendicectomy NS Antibiotics, appendicectomy

Antibiotics, appendicectomy

JOURNAL OF AGING AND INNOVATION, DEZEMBRO, 2018, 7 (3)  ISSN: 2182-696X  http://journalofagingandinnovation.org/

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Estudo de Caso: Rodrigues, A., Marques, A., Camarneiro, R., Silva, R., Dias, I., Melo, M. (2018) Apendicite Aguda Perfurada Após Colonoscopia – Um Caso Clínico e Revisão da Literatura, Journal of Aging & Innovation, 7 (3): 12 - 18

Laparotomy,

Jonhston8

2008

M

55

5 hours

16 hours

Sheikh15

2010

F

50

NS

4 hours

13

2010

F

71

NS

12 hours

Moorman13

2010

M

47

NS

27 hours

2011

F

50

6 hours

6 hours

Loureiro12

2011

M

54

4 hours

36 hours

Musielak14

2012

F

45

4 hours

<12 hours

19

2012

M

47

27 hours

92 hours

NS

Srivastaval19

2012

M

55

5 hours

<24 hours

NS

22

2012

F

71

24 hours

<33 hours

NS

April1

2012

M

71

0-12 hours

24 hours

NS

Wong21

2014

M

47

13 hours

NS

Paramythiotis3

2016

F

60

10 hours

24 hours

Zhou22

2017

M

73

72 hours

NS

Rodrigues

2018

F

56

12 hours

72 hours

Moorman

RodriguezOtero16

Srivastaval

Srivastaval

appendicectomy Laparotomy, appendicectomy NS Laparotomy, appendicectomy Laparotomy, appendicectomy Laparoscopic appendicectomy Laparoscopic appendicectomy

Laparotomy, appendicectomy Laparotomy, appendicectomy Laparotomy, appendicectomy Laparotomy, appendicectomy

M/F: Male/Female; NS: Not specified

Conclusion: Acute perforated appendicitis after colonoscopy is rare. The diagnosis may be challenging. The clinical presentation may be confused with other complications after colonoscopy such as colon perforation. The late diagnosis can lead to peritonitis and death. It is essencial to exclude acute appendicitis when a patient presents right quadrant abdominal pain after colonoscopy.

References: [1] April M, Simmons J, Nielson A. (2013). An unusual cause of colonoscopy abdominal pain.

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Estudo de Caso: Rodrigues, A., Marques, A., Camarneiro, R., Silva, R., Dias, I., Melo, M. (2018) Apendicite Aguda Perfurada Após Colonoscopia – Um Caso Clínico e Revisão da Literatura, Journal of Aging & Innovation, 7 (3): 12 - 18

American Journal of Emergency Medicine. 31:273.e1-273.e4 [2] Basson MD, Etter L, Panzini LA. (1998). Rates of colonoscopic perforation in current practice. Gastroenterology 114(5):1115 [3] Bildzukewicz NA, Weinstein MS. (2012). Appendicitis following virtual colonoscopy: a case report. J Gastrointest Surg 16: 2291-2293 [4] Doohen RR, Aanning HL. (2002). Appendiceal colic: A rare complication of colonoscopy. S D J Med. 55: 526-527 [5] Gatto NM, Frucht H, Sundararajan V, Jacobson JS, Grann VR, Neugut AI. (2003). Risk of perforation after colonoscopy and sigmoidoscopy: a population-based study. J Natl Cancer Inst. 95: 230-236 [6] Houghton A, Aston N. (1988). Appendicitis complicating colonoscopy. Gastrointest Endosc. 34:489 [7] Izzedine H, Thauvin H, Maisel, Bourry E, Deschamps A. (2005). Postcolonoscopy appendicitis: case report and review of the literature. The American Journal of Gastroenterology. 100:2815–2817 [8] Johnston P, Maa J. (2008). Perforated Appendicitis After Colonoscopy. JSLS.12:335-337 [9] Kapral C, Wewalka F, Kopf C, Aufreiter M, Lenz K. (2003). Acute appendicitis after colonoscopy: causality or coincidence? Zeitschriftfur Gastroenterologie. 41:999–1000 [10] Kuriyama M. (2014). Acute appendicitis as a rare complication after colonoscopy. Clin J Gastroenterol 7:32–5. [11] le Leusse A, Cuillerier E,Marteauetal P. (1999). Acute appendicitis after coloscopy. Gastroenterologie Clinique et Biologique. 23:150–151 [12] Loureiro M, Bonin E, Leiner C, Weigmann S, Fontana A. (2011). Ver. Col. Bras. Cir. 38(5):366-368 [13] Moorman ML, Miller JP, Khanduja KS, et al. (2010). Postcolonoscopy appendicitis. Am Surg. 76:892–895 [14] Musielak M, Patel H, Fegelman E. (2012) Postcolonoscopy appendicitis: laparoscopy a viable option. American Surgeon. 78:1300–1303 [15] Paramythiotis D, Kofina K, Papadopoulos V, Michalopoulos A. (2016). Diagnostic Colonoscopy Leading to Perforated Appendicitis: A Case Report and Systematic Literature Review. Case Reports in Gastrointestinal Medicine. Article ID 1378046 [16] Rodriguez-Otero C, Salas Muñoz J,Targarona EM,Rodriguez Blanco M, Bollo J, Trias M. (2011). Acute appendicitis after colonoscopy: coincidence or cause? Gastroenterologia y Hepatologia. 34:516–517 [17] Segawa T, Suzuki T, Arisawa et al. (1992). A case of acute appendicitis developing after colonoscopy. Gastroenterological Endoscopy. 34:1933–1937

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Estudo de Caso: Rodrigues, A., Marques, A., Camarneiro, R., Silva, R., Dias, I., Melo, M. (2018) Apendicite Aguda Perfurada Após Colonoscopia – Um Caso Clínico e Revisão da Literatura, Journal of Aging & Innovation, 7 (3): 12 - 18

[18] Shaw D, Gallardo G, Basson MD. (2013). Post-colonoscopy appendicitis: A case report and systematic review. World J Gastrointest Surg 5: 259-263 [19] Srivastava V, Pink J, Swarnkar K, Feroz A, Stephenson BM. (2004). Colonoscopically induced appendicitis. Colorectal Dis. 6:124-125 [20] Vender R, Larson J, Garcia J, Topazian M, Ephraim P. (1995) Appendicitis as a complication of colonoscopy. Gastrointest Endosc. 41:514-6 [21] Wong J, Chang J, Alkidady W. (2014). Acute appendicitis postcolonoscopy. ANZ Journal of Surgery. 86:309– 310 [22] Zhou X, Huang C, Dau Y, Huang Z, Lou Z. (2017). Perforated appendicitis after colonoscopy: cause or coincidence? A rare case report and literature review. Medicine 96:46 (e8747)

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