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Colonoscopic diagnosis of grumbling appendicitis
RESEARCH LETTERS
Research letters
Colonoscopic diagnosis of grumbling appendicitis Toby R Johnson, Jerome J DeCosse
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. 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.5 Here we show that clinical suspicion can be strengthened by colonoscopy. Timely use may help silence some grumblers. 1
2 3 4
5
Mattei P, Sola JE, Yeo CJ. Chronic and recurrent appendicitis are uncommon entities often misdiagnosed. J Am Coll Surg 1994; 178: 385–89. Ellis H. Appendix. In: Schwartz SI, Ellis H, eds. Maingot’s abdominal operations. 9th edn. Norwalk, CT: Appleton & Lange, 1989: 972. Barber MD, McLaren J, Rainey JB. Recurrent appendicitis. Br J Surg 1997; 84: 110–12. Said M, Ledochowski M, Dietze O, Simader H. Colonoscopic diagnosis and treatment of acute appendicitis. Eur J Gastroenterol Hepatol 1995; 7: 569–71. Hoffmann J, Rasmussen O. Aids in the diagnosis of acute appendicitis. Br J Surg 1989; 76: 774–79.
Department of Surgery, New York Hospital and Cornell University Medical College, New York, NY 10021, USA (J J DeCosse)
Isolation of measles virus below 4 months of age during an outbreak in Pune, India N S Wairagkar, N J Shaikh, P Udavant, K Banerjee
Appendiceal orifice
THE LANCET • Vol 351 • February 14, 1998
The recommended age for measles vaccination under the Expanded Programme of Immunisation in India is 9–15 months. However, clinical and subclinical measles in infants below 6 months of age has been reported from India1 and from other parts of the world.2–4 We report the isolation of measles virus from infants below 4 months of age during an outbreak in an orphanage at Pune, India in June, 1996. This orphanage caters to the needs of abandoned children below 5 years of age. Six of 24 inmates showed clinical manifestations of measles. Of these, four were 4 months of age or less and the other two were 7 and 11 months old. None were immunised against measles. Bronchopneumonia and weight loss were the main complications. One baby (3 months old) had postmeasles encephalitis; none died. Throat swabs, skin scrapings, and blood samples were collected from all the inmates and processed for virus isolation in Vero-cell
495
Research letters
Colonoscopic diagnosis of grumbling appendicitis Toby R Johnson, Jerome J DeCosse
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. 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.5 Here we show that clinical suspicion can be strengthened by colonoscopy. Timely use may help silence some grumblers. 1
2 3 4
5
Mattei P, Sola JE, Yeo CJ. Chronic and recurrent appendicitis are uncommon entities often misdiagnosed. J Am Coll Surg 1994; 178: 385–89. Ellis H. Appendix. In: Schwartz SI, Ellis H, eds. Maingot’s abdominal operations. 9th edn. Norwalk, CT: Appleton & Lange, 1989: 972. Barber MD, McLaren J, Rainey JB. Recurrent appendicitis. Br J Surg 1997; 84: 110–12. Said M, Ledochowski M, Dietze O, Simader H. Colonoscopic diagnosis and treatment of acute appendicitis. Eur J Gastroenterol Hepatol 1995; 7: 569–71. Hoffmann J, Rasmussen O. Aids in the diagnosis of acute appendicitis. Br J Surg 1989; 76: 774–79.
Department of Surgery, New York Hospital and Cornell University Medical College, New York, NY 10021, USA (J J DeCosse)
Isolation of measles virus below 4 months of age during an outbreak in Pune, India N S Wairagkar, N J Shaikh, P Udavant, K Banerjee
Appendiceal orifice
THE LANCET • Vol 351 • February 14, 1998
The recommended age for measles vaccination under the Expanded Programme of Immunisation in India is 9–15 months. However, clinical and subclinical measles in infants below 6 months of age has been reported from India1 and from other parts of the world.2–4 We report the isolation of measles virus from infants below 4 months of age during an outbreak in an orphanage at Pune, India in June, 1996. This orphanage caters to the needs of abandoned children below 5 years of age. Six of 24 inmates showed clinical manifestations of measles. Of these, four were 4 months of age or less and the other two were 7 and 11 months old. None were immunised against measles. Bronchopneumonia and weight loss were the main complications. One baby (3 months old) had postmeasles encephalitis; none died. Throat swabs, skin scrapings, and blood samples were collected from all the inmates and processed for virus isolation in Vero-cell
495