From
http://www.thelancet.com/newlancet/reg/issues/vol351no9101/research495_1.htm
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1-2% of patients with appendicitis have long-term symptoms,1 termed
grumbling appendicitis by Maingot.2 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.1,3 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.4
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
So there!
Chris Burton
GP; Sanquhar Dumfriesshire.
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