Colonoscopic diagnosis of grumbling appendicitis
Authors: Toby R Johnson, Jerome J DeCosse
Journal: The Lancet (1998)

1–2% of patients with appendicitis have long-term symptoms,1Mattei P Sola JE Yeo CJ Chronic and recurrent appendicitis are uncommon entities often misdiagnosed.J Am Coll Surg. 1994; 178: 385-389PubMed Google Scholar termed grumbling appendicitis by Maingot.2Ellis H Appendix.in: Schwartz SI Ellis H Maingot's abdominal operations. 9th edn. Appleton & Lange, Norwalk, CT1989: 972Google Scholar A timely diagnosis is often clouded by atypical presentation leading to other diagnoses, particularly Crohn's disease or, in women, gynaecological disease. Patients with chronic appendicitis should be distinguished from the 6·5–10% of patients who have a short history of episodic acute abdominal pain, a pattern termed recurrent appendicitis.1Mattei P Sola JE Yeo CJ Chronic and recurrent appendicitis are uncommon entities often misdiagnosed.J Am Coll Surg. 1994; 178: 385-389PubMed Google Scholar, 3Barber MD McLaren J Rainey JB Recurrent appendicitis.Br J Surg. 1997; 84: 110-112Crossref PubMed Scopus (54) Google Scholar We describe two patients in whom colonoscopy illuminated a long history of appendicitis and could have led to an earlier diagnosis. We also found one case report where colonoscopy was useful in the diagnosis of acute appendicitis.4Said M Ledochowski M Dietze O Simader H Colonoscopic diagnosis and treatment of acute appendicitis.Eur J Gastroenterol Hepatol. 1995; 7: 569-571PubMed Google ScholarIn May, 1994, a 39-year-old woman with intermittent lower abdominal discomfort and low-grade fever had a colonoscopy because she had a family history of colon cancer. A biopsy was taken from an inflamed appendiceal orifice and interpreted as active colitis. A tentative diagnosis of Crohn's disease was made. Small-bowel radiographs were normal. Ultrasonography and magnetic resonance imaging showed a right adnexal mass. Lower abdominal pain and intermittent fever persisted, then intensified and localised: at operation 4 months after the colonoscopy, a necrotic appendix with a periappendiceal abscess was removed with complete relief of symptoms.In July, 1997, a 23-year-old man with a 7-month history of recurrent lower abdominal pain and diarrhoea had a colonoscopy that showed isolated inflammation confined to the caecum at the appendiceal orifice. A biopsy specimen showed non-specific active colitis. Oral steroids were initiated without benefit. Computed tomographic scan and a small-bowel radiography were normal. In October, a repeat colonoscopy showed similar visual (figure) and histological findings. Lower abdominal pain and diarrhoea persisted without anorexia or fever. In November, 4 months after the first colonoscopy and 11 months after the onset of disease, a periappendiceal mass was removed. Intra-abdominal examination showed no other disease. The specimen showed an obliterated appendix, a chronic inflammatory infiltrate, and focal reactive fibrotic tissue without granulomas. The patient is symptom-free.Clear distinctions among acute, recurrent, and chronic appendicitis are lacking. The histopathology of acute and recurrent appendicitis is identical, whereas chronic appendicitis should show evidence of chronic inflammation, not found in the first patient. In these patients, the unusually long duration of symptoms and the colonoscopic findings suggest that some with appendicitis will have only prolonged intramural inflammation without the serositis that would induce localisation of pain and tenderness. If recognised early, broad-spectrum antibiotic therapy might achieve resolution.In acute appendicitis, clinical awareness can be heightened by barium enema, ultrasonography, computed tomographic scan, magnetic resonance imaging, and even laparoscopy.5Hoffmann J Rasmussen O Aids in the diagnosis of acute appendicitis.Br J Surg. 1989; 76: 774-779Crossref PubMed Scopus (180) Google Scholar Here we show that clinical suspicion can be strengthened by colonoscopy. Timely use may help silence some grumblers. 1–2% of patients with appendicitis have long-term symptoms,1Mattei P Sola JE Yeo CJ Chronic and recurrent appendicitis are uncommon entities often misdiagnosed.J Am Coll Surg. 1994; 178: 385-389PubMed Google Scholar termed grumbling appendicitis by Maingot.2Ellis H Appendix.in: Schwartz SI Ellis H Maingot's abdominal operations. 9th edn. Appleton & Lange, Norwalk, CT1989: 972Google Scholar A timely diagnosis is often clouded by atypical presentation leading to other diagnoses, particularly Crohn's disease or, in women, gynaecological disease. Patients with chronic appendicitis should be distinguished from the 6·5–10% of patients who have a short history of episodic acute abdominal pain, a pattern termed recurrent appendicitis.1Mattei P Sola JE Yeo CJ Chronic and recurrent appendicitis are uncommon entities often misdiagnosed.J Am Coll Surg. 1994; 178: 385-389PubMed Google Scholar, 3Barber MD McLaren J Rainey JB Recurrent appendicitis.Br J Surg. 1997; 84: 110-112Crossref PubMed Scopus (54) Google Scholar We describe two patients in whom colonoscopy illuminated a long history of appendicitis and could have led to an earlier diagnosis. We also found one case report where colonoscopy was useful in the diagnosis of acute appendicitis.4Said M Ledochowski M Dietze O Simader H Colonoscopic diagnosis and treatment of acute appendicitis.Eur J Gastroenterol Hepatol. 1995; 7: 569-571PubMed Google Scholar In May, 1994, a 39-year-old woman with intermittent lower abdominal discomfort and low-grade fever had a colonoscopy because she had a family history of colon cancer. A biopsy was taken from an inflamed appendiceal orifice and interpreted as active colitis. A tentative diagnosis of Crohn's disease was made. Small-bowel radiographs were normal. Ultrasonography and magnetic resonance imaging showed a right adnexal mass. Lower abdominal pain and intermittent fever persisted, then intensified and localised: at operation 4 months after the colonoscopy, a necrotic appendix with a periappendiceal abscess was removed with complete relief of symptoms. In July, 1997, a 23-year-old man with a 7-month history of recurrent lower abdominal pain and diarrhoea had a colonoscopy that showed isolated inflammation confined to the caecum at the appendiceal orifice. A biopsy specimen showed non-specific active colitis. Oral steroids were initiated without benefit. Computed tomographic scan and a small-bowel radiography were normal. In October, a repeat colonoscopy showed similar visual (figure) and histological findings. Lower abdominal pain and diarrhoea persisted without anorexia or fever. In November, 4 months after the first colonoscopy and 11 months after the onset of disease, a periappendiceal mass was removed. Intra-abdominal examination showed no other disease. The specimen showed an obliterated appendix, a chronic inflammatory infiltrate, and focal reactive fibrotic tissue without granulomas. The patient is symptom-free. Clear distinctions among acute, recurrent, and chronic appendicitis are lacking. The histopathology of acute and recurrent appendicitis is identical, whereas chronic appendicitis should show evidence of chronic inflammation, not found in the first patient. In these patients, the unusually long duration of symptoms and the colonoscopic findings suggest that some with appendicitis will have only prolonged intramural inflammation without the serositis that would induce localisation of pain and tenderness. If recognised early, broad-spectrum antibiotic therapy might achieve resolution. In acute appendicitis, clinical awareness can be heightened by barium enema, ultrasonography, computed tomographic scan, magnetic resonance imaging, and even laparoscopy.5Hoffmann J Rasmussen O Aids in the diagnosis of acute appendicitis.Br J Surg. 1989; 76: 774-779Crossref PubMed Scopus (180) Google Scholar Here we show that clinical suspicion can be strengthened by colonoscopy. Timely use may help silence some grumblers.