ACADEMIA Letters

Post-colonoscopy appendicitis: a rare complication of

colonoscopy
Kostas Tepelenis, Department of Surgery, University Hospital of Ioannina
Nikolaos Tepelenis, Department of Pathology, Agia Sofia Children’s Hospital
Maria Alexandra Kefala, Pediatrician
Konstantinos Vlachos, Department of Surgery, University Hospital of Ioannina

Colonoscopy is a widely used endoscopic procedure for both diagnostic and therapeutic pur-
poses in various colorectal diseases. It is considered a safe procedure, though complications
might occur rarely. The most typical complications encompass perforation with a reported in-
cidence of 0.016-0.8% for diagnostic colonoscopy and up to 5% for therapeutic colonoscopy,
and bleeding, which happens in 2.4 cases per1000 colonoscopies. Other rare complications
include post-polypectomy syndrome, appendicitis, cecal volvulus, splenic injury, small bowel
perforation, cholecystitis, pancreatitis, and mesenteric ischemia (1, 2).
Post-colonoscopy appendicitis is an extremely rare complication (3) with an estimated
incidence of 0.038% (4, 5). Houghton and Aston first described it in 1988 (6). It usually
affects males (male to female ratio 2:1) with a median age of 55 years (range 24-84 years).
Although colonoscopy is usually carried out for screening, most patients have undergone an
additional procedure during colonoscopy like polypectomy or endoscopic mucosal resection
(EMR). The time of diagnosis varies from few hours to ten days after colonoscopy, with the
majority of patients being diagnosed within the first two days post-colonoscopy (7, 8).
We have previously published the case of a 56-year-old female who visited our hospi-
tal’s emergency department with diffuse abdominal pain and nausea 8 hours after a screening
colonoscopy. The initial diagnosis was acute appendicitis, and the patient underwent a la-
paroscopic appendectomy. Histopathology report evinced the diagnosis of acute appendicitis
(3). According to our knowledge, 57 case reports have been published in the literature until

Academia Letters, August 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Kostas Tepelenis, [email protected]

Citation: Tepelenis, K., Tepelenis, N., Kefala, M.A., Vlachos, K. (2021). Post-colonoscopy appendicitis: a rare
complication of colonoscopy. Academia Letters, Article 3269. https://doi.org/10.20935/AL3269.

1
now.
For many years, there was a dilemma concerning post-colonoscopy appendicitis: coin-
cidence or complication? It seems that post-colonoscopy appendicitis is an infrequent com-
plication of colonoscopy. Worth noting that the identified case reports in the last decade are
quadruple compared to those in the first decade, which might reflect the greater awareness
of this potential sequela (7). Although the exact mechanism by which colonoscopy induces
appendicitis remains obscure, several theories have been proposed to elucidate its pathogene-
sis. These theories encompass the introduction or propagation of a fecalith into the appendix,
barotrauma resulting from increased airway pressure, direct trauma, or exposure of the mucosa
to the residual glutaraldehyde type of solution for cleaning the endoscope (4, 8, 9-11). Cases
in which acute appendicitis was diagnosed during colonoscopy may represent the reason for
colonoscopy, and therefore can’t be attributed as a sequel to colonoscopy (7).
The clinical manifestation of post-colonoscopy appendicitis is the same as acute appen-
dicitis. The typical symptoms are right lower quadrant pain (more often) or diffuse abdom-
inal pain in conjunction with anorexia, nausea, vomiting, and fever. The presence of fever,
tachycardia, and peritonism (rebound tenderness, guarding, and rigidity) indicates sepsis and
peritonitis (3). In a literature review, Hamid et al. reported that perforated appendicitis was
found in 33% of patients with post-colonoscopy appendicitis. The high incidence of perfo-
rated appendicitis is probably attributed to the high percentage of older patients who have a
significantly increased risk of perforation compared to younger patients (8). Perforation is
more frequent in youths or individuals older than 50 years, and it is linked with higher mortal-
ity and morbidity (12). The main problem is that other complications like bowel perforation
and post-polypectomy syndrome might mimic its presentation (3).
Imaging modalities are the critical elements for distinguishing between post-colonoscopy
appendicitis and other complications after colonoscopy. Computed tomography of the ab-
domen is the gold standard for the diagnosis of post-colonoscopy appendicitis. Abdominal
ultrasound might also help differentiate post-colonoscopy appendicitis from other complica-
tions (3, 8).
The management of post-colonoscopy appendicitis is the same as acute appendicitis. In
a literature review of 57 cases with post-colonoscopy appendicitis, 52.6% of the cases were
treated with open appendectomy, 29.8% with laparoscopic appendectomy, and 14% conser-
vatively with antibiotics. One patient (1.8%) was treated with radiologic drainage of an ap-
pendiceal abscess. In comparison, one other patient (1.8%) underwent laparoscopic resection
of the caecum due to suspicion of residual tumor after endoscopic mucosal resection (EMR)
for a high-grade dysplastic adenoma (8).
Although open appendectomy is the cornerstone of surgical intervention, laparoscopic ap-

Academia Letters, August 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Kostas Tepelenis, [email protected]

Citation: Tepelenis, K., Tepelenis, N., Kefala, M.A., Vlachos, K. (2021). Post-colonoscopy appendicitis: a rare
complication of colonoscopy. Academia Letters, Article 3269. https://doi.org/10.20935/AL3269.

2
pendectomy has gained much popularity and has become the preferred approach for uncom-
plicated and complicated appendicitis. Advantages of laparoscopic appendectomy include a
shorter hospital stay, earlier return to normal activities, less postoperative pain, an earlier start
of oral intake, and lower wound infections (12). Another benefit of laparoscopy is the rapid
examination of the abdomen for evidence of bowel perforation. If present, bowel perforation
can be managed either laparoscopically or through conversion to open laparotomy, depending
on the surgeon’s skill. In lacking equipment or skilled surgeons, open appendectomy remains
a safe and efficient alternative (3).
To sum up, post-colonoscopy appendicitis is an extremely rare complication of colonoscopy,
with an estimated incidence of 0.038%. The exact pathogenesis is not well-documented. The
clinical manifestation of post-colonoscopy appendicitis is not different from acute appendici-
tis. Imaging modalities, especially abdominal computed tomography, are crucial for differen-
tiating post-colonoscopy appendicitis from other complications. Nowadays, the treatment of
choice is laparoscopic appendectomy.

Acknowledgements: None.

Financial Support / Funding: This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.

Ethical approval: Not required.

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Academia Letters, August 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Kostas Tepelenis, [email protected]

Citation: Tepelenis, K., Tepelenis, N., Kefala, M.A., Vlachos, K. (2021). Post-colonoscopy appendicitis: a rare
complication of colonoscopy. Academia Letters, Article 3269. https://doi.org/10.20935/AL3269.

3
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Academia Letters, August 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Kostas Tepelenis, [email protected]

Citation: Tepelenis, K., Tepelenis, N., Kefala, M.A., Vlachos, K. (2021). Post-colonoscopy appendicitis: a rare
complication of colonoscopy. Academia Letters, Article 3269. https://doi.org/10.20935/AL3269.