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Gastrointestinal: Colonoscopic features of acute appendicitis

In 1990, the lifetime risk of acute appendicitis in the USA was estimated at 8.6% for men and 6.7% for women. However, the incidence of acute appendicitis has been falling in many Western countries for several decades and lower lifetime risks may well apply in the future. In Asia and Africa, lifetime risks for acute appendicitis are substantially lower than those in Western countries. The disease may occur at any age but the peak incidence is between 15 and 19 years. Fortunately, most patients with acute appendicitis have typical symptoms and physical findings. Indeed, the diagnostic accuracy of clinical evaluation ranges from 78% to 92% in men and from 58% to 85% in women. Furthermore, the diagnosis is often supported by results from simple blood tests, such as an elevated white cell count and elevated levels of C-reactive protein. In relation to imaging, investigations such as ultrasonography and computed tomography can increase the diagnostic accuracy to a range that varies from 71% to 98%. They are of particular value when patients have atypical presentations. The images shown below were from patients who were diagnosed with acute appendicitis at the time of colonoscopy. The image shown in Figure 1 was from a woman, aged 54 years, who was investigated by colonoscopy because of the possibility of inflammatory bowel disease. There was bulging of the appendiceal orifice into the cecal lumen, as well as marked inflammation in the region. The image shown in Figure 2 was from a male, aged 44 years with suspected cecal cancer. He described a short history of fluctuating pain in the right iliac fossa and had thickening of the cecum on an ultrasound study. At colonoscopy, the appendiceal orifice was red and markedly edematous. In both patients, the diagnosis of acute appendicitis was confirmed at the time of surgery. Colonoscopy can assist with the diagnosis of acute appendicitis although use of this investigation is likely to be restricted to occasional patients with atypical presentations.