A Rare Case of Acute Appendicitis Associated with Endoscopic Mucosal Resection (EMR) of A Large Cecal Polyp
Annie Shergill*, Humberto Rios and Luis Nasiff
Larkin Community Hospital, Palm Springs Campus, Hialeah, FL, USA
*Corresponding author
Annie Shergill, Larkin Community Hospital, Palm Springs Campus, Hialeah, FL, USA.
Introduction
Appendicitis is an extremely rare complication of diagnostic and therapeutic colonoscopy. The exact underlying mechanism of this complication is not known. We present a rare case of acute appendicitis associated with EMR of a large cecal polyp.
Case Description
A 53 year-old female with past medical history of hypertension underwent a screening colonoscopy. Colonoscopy showed mild sigmoid diverticulosis and a cecal polyp measuring approximately 15 mm (Figure 1 A). Polyp was found to be in close proximity of the appendiceal orifice (Figure 1 A). Polyp was removed with EMR using an OVESCO traction polypectomy snare (Figure 1 B&C). Minimal bleeding was noted from the post-polypectomy site which resolved spontaneously. Patient recovered uneventfully from the procedure and was discharged home. The next day, patient presented to the ED with excruciating right lower quadrant abdominal pain. Patient was notable febrile but hemodynamically stable. Labs were remarkable for an elevated WBC count of 18,000. CT abdomen and pelvis without contrast showed fluid-filled enlarged appendix with peri-appendiceal fat stranding consistent with acute appendicitis. Patient underwent emergent appendectomy with laparoscopic approach and received IV antibiotics. Patient’s symptoms resolved postoperatively. Given the temporal relationship between the EMR and presentation with acute appendicitis, it was determined that the appendicitis was very likely incited by the cecal EMR.
Discussion
Sub-acute abdominal pain post-colonoscopy immediately raises suspicion for a colonic perforation. Our case highlights the occurrence of a rare post-colonoscopy complication like acute appendicitis, which in this case was particularly associated with cecal EMR. EMR is an endoscopic resection technique to remove mucosal and superficial sub-mucosal lesions. Utilization of EMR has nearly eliminated the need for surgical intervention for such lesions. It is associated with some common complications such as bleeding and perforation. However, we must be aware of lesser known complications as seen in our case to develop a low diagnostic threshold and timely management of these issues. While there is no clear understanding of the development of acute appendicitis post cecal EMR- a postulated hypothesis is that mucosal or even some sub-mucosal injury that results from EMR, can further induce bacterial translocation and serve as a nidus for bacterial entry considering close proximity to the appendiceal orifice. While there is no current recommendation in regards to using antibiotic prophylaxis in such cases, our case necessitates the need to study and evaluate this prospectively in the future.
