What is the management of acute appendicitis suspected after colonoscopy?

From the Guidelines

The management of acute appendicitis suspected after colonoscopy requires prompt surgical consultation and evaluation, with a focus on reducing morbidity, mortality, and improving quality of life. Patients should be immediately assessed with physical examination, laboratory tests including complete blood count and C-reactive protein, and imaging studies such as CT scan with IV contrast or ultrasound to confirm the diagnosis, as recommended by the World Society of Emergency Surgery (WSES) guidelines 1. While awaiting surgical intervention, patients should be kept NPO (nothing by mouth), given IV fluids for hydration (typically normal saline at 1-2 mL/kg/hr), and started on broad-spectrum antibiotics such as piperacillin-tazobactam 3.375g IV every 6 hours or a combination of ceftriaxone 1-2g IV daily plus metronidazole 500mg IV every 8 hours, in accordance with the WSES guidelines for perioperative antibiotic therapy 1.

Key Considerations

• Pain management with IV analgesics like morphine 0.1 mg/kg or hydromorphone 0.015 mg/kg should be provided to improve patient comfort and reduce stress.
• Definitive treatment is typically laparoscopic appendectomy, though in some cases, conservative management with antibiotics alone may be considered for uncomplicated appendicitis, as suggested by the WSES guidelines 1.
• Post-colonoscopy appendicitis is thought to result from barotrauma during insufflation, direct trauma to the appendiceal orifice, or activation of pre-existing subclinical inflammation, making it a rare but important complication to recognize promptly to prevent perforation and peritonitis.

Management Approach

• The WSES guidelines recommend routine histopathology after appendectomy to identify unexpected disease, with a strong recommendation based on moderate-quality evidence 1.
• Intra-operative grading systems, such as the WSES 2015 grading score or AAST EGS grading score, can help identify homogeneous groups of patients and determine optimal postoperative management, although the evidence is moderate and the recommendation is weak 1.
• Non-operative management with antibiotics and percutaneous drainage may be considered for complicated appendicitis with peri-appendicular abscess, especially in settings where laparoscopic expertise is not available, with a weak recommendation based on moderate-quality evidence 1.

From the Research

Pathogenesis of Acute Appendicitis after Colonoscopy

• Acute appendicitis is a rare complication of colonoscopy, and prompt recognition is essential for early and effective treatment 2.
• The exact mechanism of acute appendicitis after colonoscopy is not well understood, but it may be related to the manipulation of the cecum and appendix during the procedure.

Management of Acute Appendicitis Suspected after Colonoscopy

• The management of acute appendicitis suspected after colonoscopy involves a combination of clinical evaluation, laboratory tests, and imaging studies 3.
• The diagnosis of acute appendicitis is based on history, physical examination, laboratory evaluation, and imaging, and is made in approximately 90% of patients presenting with classic symptoms 3.
• Treatment options for acute appendicitis include laparoscopic appendectomy and broad-spectrum antibiotics, such as piperacillin-tazobactam monotherapy or combination therapy with either cephalosporins or fluoroquinolones with metronidazole 3, 4, 5.
• The choice of treatment depends on the severity of the disease, the presence of complications, and the patient's overall health status 3, 5.
• In patients with uncomplicated acute appendicitis, antibiotics may be considered as first-line therapy, while surgery is recommended for patients with complicated appendicitis or those who are unfit for surgery 3, 5.

Role of Colonoscopy in the Diagnosis of Appendicitis

• Colonoscopy may be useful in the diagnosis of appendicitis when the clinical presentation is atypical for appendicitis and/or imaging studies are nondiagnostic 6.
• Colonoscopic findings in patients with appendicitis include hyperemia, bulging, and mucosal edema at the appendiceal orifice area, and drainage of pus from the appendiceal orifice 6.