A 38–year–old Caucasian male with a history of gout presented with odynophagia and epigastric pain following a hiking trip. He was diagnosed with gastro esophageal reflux disease likely secondary to NSAID use. Esophogastroduodenoscopy (EGD) confirmed the diagnosis. He was prescribed a proton pump inhibitor. Despite the treatment, his abdominal pain continued. In addition, he began having diarrhea. Diagnostic work–up was negative for infectious causes. He was subsequently diagnosed with irritable bowel syndrome. About one year later, he underwent another EGD and colonoscopy in search for etiology of his continued abdominal pain and diarrhea. No abnormality was found on either study. No biopsies were performed. The following day, the patient presented to emergency room with severe epigastric pain that migrated to umbilical area, radiating to flanks bilaterally. On examination, he exhibited right lower quadrant pain without peritoneal signs. Vitals were stable. Labs showed leukocytosis (WBC 17,000). CT scan of abdomen demonstrated a gaseous appendix with peri–appendiceal inflammation, confirmatory of appendicitis. Laparoscopic appendectomy was performed. Pathology of resected specimen showed severely inflamed appendix with focal area of perforation. No etiology, such as fecolith or foreign body, was found.
Colonoscopy is generally a safe outpatient procedure. Acute appendicitis is a rare complication that may occur following colonoscopy. Post–colonoscopy appendicitis most commonly happens following polyp removal or colonic biopsies (70% of cases). To date, fifteen cases of post–colonoscopy appendicitis have been reported. Five of these fifteen cases involved appendiceal perforation. Further more, only two cases of perforated appendicitis post colonoscopy were reported in which neither polyp removal nor biopsy were performed. More specifically, a rapid progressive perforated appendicitis after colonoscopy without obvious causes – such as fecolith – was reported only once in literature.
This is a rare case presentation of perforated appendicitis following colonoscopy with neither antecedent procedures such as polyp removal or biopsy nor precipitating factors such as fecolith. Though unusual, appendicitis should also be considered in differential diagnosis of abdominal pain following colonoscopy.