REVIEW ARTICLE
Postcolonoscopy Appendicitis: A Review of 57 Cases
Hytham K.S. Hamid, MRCSEd,* Amjed Y. Ahmed, MBBS,*
and Joshua R. Simmons, MD†
Abstract: The purpose of this study is to review the cases of post-
colonoscopy appendicitis (PCA) reported in the literature. A com-
prehensive search using PubMed, EMBASE, Scopus, and Google
Scholar identified 57 cases. The median age at presentations of PCA
was 55 years. PCAs typically occurred during the first 24 hours after
Downloaded from http://journals.lww.com/surgical-laparoscopy by BhDMf5ePHKbH4TTImqenVL56SvJs3yjmwDKJIf6KMSyFcSBbysK62EW/NeKfWIlZNJhXudoMa90= on 10/05/2020
colonoscopy, and the majority developed after diagnostic colono-
scopy. Clinical presentations were similar to those with common
acute appendicitis, though with a high perforation rate. Most
patients were correctly diagnosed using ultrasound or computed
tomography scan. Treatment included open appendicectomy, lap-
aroscopic appendicectomy or cecotomy, radiologic drainage of the
abscess, nonoperative treatment with antibiotics. In addition to
barotrauma, fecalith impaction into the appendiceal lumen, direct
trauma to the appendiceal orifice, and underlying ulcerative colitis,
a pre-existing subclinical disease of the appendix seems to play an
important role in the pathogenesis. For PCA, timely diagnosis and
management are crucial to attain a satisfactory outcome.
Key Words: appendicitis, postcolonoscopy, complications, perfo-
ration, management
(Surg Laparosc Endosc Percutan Tech 2019;29:328–334)
O ptical colonoscopy is a widely performed procedure
with diagnostic and therapeutic intent in a broad range
of gastrointestinal (GI) diseases. Although up to one third of
patients report at least 1 minor transient GI symptom after
colonoscopy,1 serious complications are uncommon. Both
infectious and noninfectious complications have been
described after colonoscopy, and the rates of these compli-
cations increase if a biopsy or polypectomy is performed
during the procedure.2,3 Noninfectious complications
include colonic perforation, bleeding, splenic injury, post-
polypectomy syndrome (PPS), and cardiopulmonary
adverse events. Fortunately, most are minor and easily
managed. However, serious noninfectious complications
such as major colonic perforation are associated with high
morbidity and mortality, requirement for surgical inter-
vention, and potential postoperative complications, such as
wound infection and anastomotic leak.4 Infectious compli-
cations include bacteremia, diverticulitis, cholecystitis, and
appendicitis.5–7
Acute appendicitis after lower GI endoscopy is well
recognized. Its estimated incidence runs between 3.8 and 4.9
per 10,000 colonoscopies, and represents 13.4% of all lower
GI endoscopy-related infections.7,8 Moreover, it was shown
that the incidence rate of acute appendicitis is significantly
Received for publication March 20, 2019; accepted July 23, 2019.
From the *Department of Surgery, Soba University Hospital, Khartoum,
Sudan; and †Department of Emergency Medicine, San Antonio
Uniformed Services, San Antonio, TX.
The authors declare no conflicts of interest.
Reprints: Hytham K.S. Hamid, MRCSEd, Department of Surgery, Soba
University Hospital, Khartoum, Sudan (e-mail: kujali2@gmail.com).
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
328 | www.surgical-laparoscopy.com Surg Laparosc Endosc Percutan Tech  Volume 29, Number 5, October 2019
Copyright r 2019 Wolters Kluwer Health, Inc. All rights reserved.
higher in the first week after colonoscopy compared with the
subsequent 51 weeks, indicating that colonoscopy predis-
poses to appendicitis within 1 week.9
The first case of postcolonoscopy appendicitis (PCA)
was reported by Houghton and Aston in 1988.10 Nonethe-
less, despite the increasing number of colonoscopy being
performed annually, PCA remains rare. The current study
reviewed the literature and presents the clinical features and
management outcomes of 57 cases of PCA.
METHODS
The literature search was conducted to identify published
articles on PCA using 3 search strategies. The initial search
strategy involved searches through the “PubMed,” “EMBASE,”
and “Scopus” databases using the keywords “appendicitis after/
appendicitis following/appendicitis caused by, and colonoscopy,”
“colonoscopy induced appendicitis” and “postcolonoscopy
appendicitis.” No publication date restriction was applied. The
second strategy involved using the “Google Scholar” search
engine using the same search string. After removal of duplicate
articles, review of titles and abstracts was performed independ-
ently by 2 investigators (H.K.S.H. and A.Y.A.), both of whom
had to agree the article was eligible for inclusion. Articles
describing acute appendicitis, defined as an appendix with radi-
ologic and/or histologic evidence of inflammation, after optical
colonoscopy procedure were included. Articles describing
chronic appendicitis after colonoscopy or appendicitis after vir-
tual colonoscopy were excluded. Finally, we reviewed the refer-
ences for further relevant articles on PCA cited by relevant
publications identified through the first 2 strategies.
Overall, 48 publications reporting 59 cases were
identified from the 3 search strategies (Fig. 1). Thirty-four
publications were retrieved from “PubMed,” “EMBASE,”
and “Scopus,”11–45 and further 10 publications from “Google
scholar” which were not indexed in either “PubMed,”
“EMBASE” or “Scopus.”46–55 Four additional articles were
identified through manual search.8,10,46,56
The total number of publications and cases reported
are shown in Figure 2. The majority of publications had
originated from North America (n = 17, 35.4%), followed by
Europe (n = 15, 31.2%) and Asia (n = 13, 27.1%). Three
publications originated from Australia (n = 3, 6.3%). A
majority of the publications reported a single case and 7
reported multiple cases (4 reported 2 cases; 2 report 3 cases;
and 1 reported 4 cases).
Attempts were made to retrieve all the identified pub-
lications. In cases where full articles were not available, the
abstracts that had been published in English were carefully
reviewed. Overall, 2 publications that had reported a total
of 2 cases provided inadequate details and were excluded,
leaving 57 cases for the review.44,45 For the articles published
in non-English journals and where full publication articles
were available, full translations were obtained through inter-
preters. All available publications were carefully analyzed.
Surg Laparosc Endosc Percutan Tech  Volume 29, Number 5, October 2019 Postcolonoscopy Appendicitis

Records identified through Additional records identified

database searching (“Pubmed”, through “Google scholar” and
“Embase”, and “Scopus”) other sources

Identification
(n = 203) (n = 13)

Records after duplicates removed

(n = 155)
Screening

Records screened Records excluded

(n = 155) (n = 105)

Full-text articles excluded

Eligibility

Abstract/Full-text articles Acute appendicitis after virtual

assessed for eligibility colonoscopy 1
(n = 50) No histological evidence of acute
appendicitis 1

Eligible articles reporting

Articles with inadequate
Included

postcolonoscopy acute
information
appendicitis
(n = 2)
(n = 48)

Articles included in the

review
(n = 46)

FIGURE 1. Flow diagram of literature search.

Furthermore, the corresponding authors were contacted to of symptoms (defined as the time from onset of symptoms to
ascertain details about clinical presentation and management. hospital presentation), indications and procedure details
Clinical data were collected on demographics (age and sex), (diagnostic or therapeutic: polypectomy or none), time to
clinical features, time to onset of clinical symptoms, duration surgery (defined as the time from onset of symptoms to

FIGURE 2. The numbers of publications in 5-year blocks (dark columns) and the number of cases reported (lighter columns).

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Hamid et al Surg Laparosc Endosc Percutan Tech  Volume 29, Number 5, October 2019

surgery), and type of appendicitis (uncomplicated or compli-

cated). On the basis of radiologic, operative, and histologic TABLE 2. Clinical Presentation and Diagnoses of Patients With
Postcolonoscopy Appendicitis
findings, complicated appendicitis was defined as appendicitis
with perforation, mass, or abscess formation. Data on the n (%)
primary treatment provided (open surgery, laparoscopy, and Clinical finding
nonoperative), outcomes, and laboratory and imaging inves- RLQ pain 29 (50.9)
tigations were also retrieved. Diffuse pain 24 (42.1)
Shifting pain to RLQ 4 (7)
Nausea or vomiting 22 (38.6)
RESULTS Fever 25 (43.9)
The median age at presentations was 55 years (range, Peritonism 32 (57.1)
24 to 84 y) with more male individuals being affected RLQ mass 3 (5.3)
(n = 37, 64.9%). The duration of symptoms ranged between Others 12 (21.1)
0 and 9 days. Admitting diagnoses
Most patients underwent diagnostic colonoscopy, Acute appendicitis 44 (77.1)
whereas 9 had primary therapeutic procedures: 5 endoscopic Colonic perforation 6 (10.5)
mucosal resections (EMR), 3 polypectomies, and 1 epi- Postpolypectomy syndrome 3 (5.2)
Acute diverticulitis 1 (1.8)
nephrine injection and coagulation for a bleeding poly-
Crohn disease 1 (1.8)
pectomy site. Overall, 47.4% of patients had a colonoscopy Intestinal obstruction 1 (1.8)
with additional procedures. Details of indications and types of Intra-abdominal abscess 1 (1.8)
procedures carried out are shown in Table 1. The median time
from colonoscopy to the clinical presentation of symptoms Percentages presented in brackets do not add up to 100% because of
related to PCA was 10 hours (range, 2 h to 10 mo); 63% overlapping as some patients had multiple symptoms.
RLQ indicates right lower quadrant.
presented <24 hours after colonoscopy, and 35% presented
between 24 hours and 5 days. Only 1 case of PCA presented
after 5 days, manifesting 10 months after colonoscopy, and
this was attributed to stricture formation at the appendicular (n = 6, 10.5%), introduction of a fecalith into the appendi-
orifice after EMR. Reported clinical features and admitting ceal lumen causing obstruction and subsequently inflam-
diagnoses of PCA are shown in Table 2. The most common mation (n = 21, 36.8%), direct trauma to the appendiceal
clinical presentations were right lower quadrant or diffuse orifice because of polyp removal (n = 6, 10.5%), underlying
pain, fever, and peritonism (rebound tenderness and/or ulcerative colitis (n = 5, 8.8%), and a pre-existing subclinical
guarding). At presentations, acute appendicitis was the most disease of the appendix which was reported in 1 (1.8%) case.
common admitting diagnosis (n = 44, 77.1%), whereas diag- In 2 of these cases, > 1 mechanism was suggested. In other
nosis was initially missed in other 13 cases for colonic perfo- 21 (36.8%), the mechanism was unknown.
ration, PPS, acute diverticulitis, small bowel obstruction, The majority of patients (n = 37, 78.7%) had raised
intra-abdominal abscess, and Crohn disease. Twenty-two white cell count. The computed tomographic scan was done
(38.6%) had complicated appendicitis. This rate was similar in 45 (78.9%) patients and confirmed the diagnosis of
regardless of time to presentation or type of colonoscopy appendicitis in 36, with a diagnostic accuracy of 80%.
procedure. Four patients concurrently had other colonoscopy- Ultrasound confirmed the diagnosis in other 5 patients.
related complications: colonic perforation (n = 2) and intesti- Imaging findings included fat stranding, dilated bowel
nal obstruction (n = 2). loops, free abdominal gas and fluids, ileocecal wall thick-
The postulated mechanisms that contributed to PCA ening, intra-abdominal abscess, and a thick-walled appendix
included: barotrauma resulting from air overinsufflation with or without intraluminal air or fecalith (Fig. 3).

TABLE 1. Details of Colonoscopy Indications and Types of Management

Additional Procedures Overall, of the 57 cases of PCA, 29 (50.9%) were suc-
Details n (%) cessfully treated with open surgery, 17 (29.8%) with lapa-
roscopic appendicectomy, 1 (1.8%) had concomitant intes-
Indications tinal obstruction and was treated with radiologic drainage of
Screening* 33 (57.8) abscess, and 8 (14%) were successfully treated non-
Polyp removal† 8 (14)
UC surveillance 3 (5.3)
operatively with antibiotics. One patient underwent lapa-
Polyp surveillance 9 (15.8) roscopic cecotomy because of suspicion of associated
Cancer surveillance 2 (3.5) residual tumor after previous EMR for a high-grade dys-
Bleeding 1 (1.8) plastic adenoma. The histologic findings of 48 patients who
Pretransplant evaluation 1 (1.8) had appendicectomy were as follow: 29 simple appendicitis,
Type of additional procedures‡ 2 gangrenous nonperforated appendicitis, and 17 perforated
Polypectomy 20 (74.1) appendicitis.
EMR 6 (22.2) Laparoscopic appendicectomy was attempted in 19
Coagulation & epinephrine injection 1 (3.7) patients and was successful in 17 (89.5%). This included 2
*This includes 2 cases, 1 screened for recurrent abdominal pain, and patients who had a conversion to open appendicectomy
another one had endoscopic evidence of inflammation in the appendicular because of difficult dissection or suspicion of right colonic
orifice. injury. Thirty patients had open appendicectomy with a
†This includes 6 cases of cecal polyps and 2 cases of sigmoid polyps.
‡Additional procedures were performed in a total of 27 patients.
success rate of 96.7%. Twenty-five patients had open
EMR indicates endoscopic mucosal resection; UC, ulcerative colitis. appendicectomy as the initial interventions, whereas the
remainder (n = 5) had open appendicectomy after failed

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Surg Laparosc Endosc Percutan Tech  Volume 29, Number 5, October 2019
FIGURE 3. Computed tomography image of a 52-year-old man
with postcolonoscopy appendicitis showing a thick-walled
appendix with intraluminal fecalith. Permission to use Figure 3 has
been obtained from the publisher.33
nonoperative/laparoscopic treatments. Of these patients, 12
had clinical or radiologic evidence of perforated appendicitis
or abscess formation.
Sixteen patients had attempted nonoperative treatment
with or without antibiotics and only 8 were successful (50%).
Reasons for choosing nonoperative approach as the initial
treatment were: appendiceal mass (n = 2), minimal signs of
peritoneal irritation (n = 4), patient refusal of surgical treat-
ment (n = 1), suspected other diagnoses such as Crohn disease
(n = 1), PPS (n = 2), acute diverticulitis (n = 1), and intestinal
obstruction (n = 1), and trial of antibiotic treatment for
uncomplicated appendicitis (n = 4). Of the 8 patients who were
successfully treated nonoperatively, 2 underwent interval
appendicectomy 1 and 4 months later. Meanwhile, the other 7
who failed initial nonoperative treatment had either laparo-
scopic appendicectomy (n = 4), open appendicectomy (n = 3),
or radiologic drainage of abscess (n = 1).
Overall, the median time to surgical intervention was
1 day (range, 0 to 5 d). Time to surgery was longer for com-
plicated appendicitis compared with uncomplicated appendi-
citis, though no statistically significant (P = 0.099, Mann-
Whitney test). Meanwhile, no difference was noted in the time
to surgery between patients who had a colonoscopy with or
without additional procedure (P = 0.56, Mann-Whitney test).
Perioperative morbidity and mortality directly related to PCA
occurred in 1 (2.1%) patient. This patient had failed primary
open surgical intervention for a pelvic appendiceal abscess
and subsequently developed postoperative intestinal obstruc-
tion. Repeated laparotomy did not show any further
abdominal pathology. The patient deteriorated and eventually
succumbed despite aggressive multiorgan support measures.
No other patients required reintervention.
DISCUSSION
This review showed that PCA is uncommon despite a
large number of colonoscopies carried out annually. The
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Postcolonoscopy Appendicitis
majority of the published reports had originated from the 3
major continents (North America, Europe, and Asia),
reflecting a large number of colonoscopies performed in
these regions. The number of reported PCA in the literature
increased steadily over the last 2 decades, particularly dur-
ing the period of 2004 to 2018, and this correlated with the
implementation of the national colorectal cancer screening
programs in many countries.57 This also reflects the
increased awareness of this rather uncommon complication
and corroborates previous observations made by Houghton
and Aston in suggesting that PCA is under-reported and will
be a more common complication in the future.10
The peak incidence of acute appendicitis is in the sec-
ond and third decades of life. Although among teenagers
and young adults, acute appendicitis is slightly more com-
mon in males than in female individuals, sex distribution is
equal beyond these age groups.58,59 In stark contrast, the
median age for PCA was 55 years, and male individuals
were almost twice as likely affected as female individuals.
These age and sex predilections for PCA probably reflect the
population characteristics of patients undergoing colono-
scopy which is more commonly performed in male indi-
viduals and the older age group.60–62 The clinical manifes-
tations of PCA were not different from common acute
appendicitis. Most of the patients presented with typical
symptoms of acute appendicitis. It is of note, however, that
perforated appendicitis was encountered in more than one
third of patients with PCA in our study. This could partially
be ascribable to the high percentage of older patients who
have a significantly increased risk of perforation compared
with their younger counterparts.63 Moreover, the non-
specific symptoms and findings on plain abdominal films of
PCA are often attributed to more common colonoscopy-
related complications such as PPS and colonic perforation,
which causes a delay in management and further increases
perforation rates.11,15,37 Ultrasound and computed tomog-
raphy scan are often required to distinguish between PCA
and other complications after colonoscopy.
The management of PCA is similar to that of common
acute appendicitis. On the basis of current evidence, laparo-
scopy should be the modality of choice, which is superior to
open surgery in terms of lower wound infection rates, faster
postoperative recovery, and better cosmesis, whereas in cases
of generalized peritonitis or lacking availability of expertise
and equipment, open surgery remains a safe and fast
alternative.64,65 Open appendicectomies were utilized for PCA
management in the earlier period as the laparoscopic
approach was still at its infancy and facilities were not widely
available. This is highlighted by the cases where open surgery
was chosen as the intervention to deal with both complicated
and uncompleted PCA.8,10–17,56 Overall, open surgical inter-
ventions had a success rate of 96.7%. The only case that had
failed open surgical intervention was mainly because of failure
to early diagnose PCA before surgery.16
Laparoscopy became the modality of choice in the later
period, notably the last 15 years, with a success rate of
89.5%. This is comparable with the success rates reported
for common acute appendicitis in adult patients.66 In most
cases, laparoscopy was used as the initial treatment, whereas
it was required in other 4 cases as a rescue procedure after
the failure of nonoperative treatment.26,28,40,51
Recently, there has been a growing interest in non-
operative management of acute appendicitis, and the dictum
that surgical removal of the appendix is necessary has been
largely challenged.67 For image-proven uncomplicated
www.surgical-laparoscopy.com | 331
Hamid et al Surg Laparosc Endosc Percutan Tech
appendicitis, nonoperative treatment was shown to be fea-
sible and confers the advantages of lower postintervention
complication rate and cost compared with surgical
treatment.68 A trial of nonoperative treatment with anti-
biotics was used in a total of 8 patients with uncomplicated
PCA; all but 2 responded well and did not require surgery
resulting in a success rate of 75%. Only 1 patient had a
perforation. This is consistent with the success and perfo-
ration rates reported for uncomplicated appendicitis.68 On
the contrary, all patients who were initially misdiagnosed
and treated nonoperatively eventually required surgery with
a peroration rate of 60%. This perhaps emphasizes the
importance of early diagnosis and management of PCA.
The exact etiopathogenesis of PCA is not well under-
stood but is likely to involve complex sets of events occur-
ring simultaneously as previously reported.8 The underlying
pathogenesis probably shares some similarities to the etio-
logical basis of postcolonoscopy diverticulitis.8 The process
involves the initial obstruction of the appendiceal lumen and
later followed by inflammation. This obstruction may occur
during colonoscopy or during the preparation phase in
response to aggressive catharsis.56
There are many factors that contribute to the obstruction
of the appendiceal lumen. These include barotraumas because
of overinsuffiation, fecalith impaction into the appendiceal
lumen, and direct trauma to the appendiceal orifice after
polyp removal or accidental intubation of the appendiceal
lumen, with resultant edema and obstruction.8,21,23,40 Never-
theless, the presence of intraluminal fecalith and removal of
polyp adjacent to the appendiceal orifice were reported only in
half of the cases. In addition, considering that most colono-
scopy procedures in this study were performed with ease and
were uneventful, barotrauma is less likely to be a key etio-
logical factor. A more important mechanism which has been
suggested is an exacerbation of a pre-existing subclinical dis-
ease of the appendix. This can lead to early manifestations
and probably account for those cases of early presentations
soon after the colonoscopy. Indeed, in support of this
hypothesis, the high perforation rate was encountered in
patients who developed clinical symptoms of PCA in the first
24 hours. Furthermore, 1 case had evidence of inflammation
in the appendix during a colonoscopy which can be attributed
to the phase of catharsis before the actual procedure.56 The
presence of glutaraldehyde residues in the endoscope after
disinfection can also be a causative factor of PCA, particularly
after polypectomy.8,69 Previous studies have shown that direct
contact of glutaraldehyde with colonic mucosa can produce
an allergic and chemical reaction, resulting in self-limiting
colitis.70 In addition, ulcerative colitis is another potential
cause, which has been reported in 5 cases.17,24,27,47 Appendi-
ceal orifice inflammation may occur in the context of estab-
lished ulcerative colitis or may precede the onset of the
disease.71
To reduce the risk of PCA, all the modifiable factors
need to be considered and avoided. This includes adequate
bowel preparation before colonoscopy, minimizing air
insufflation during the procedure, and proper washing of
endoscopes after chemical disinfection. Routine antibiotic
prophylaxis for infections before colonoscopy is not sug-
gested by the current guidelines and is only recommended in
patients receiving peritoneal dialysis.72,73 For infective
endocarditis prophylaxis, antibiotics should only be given
before colonoscopy in patients with high-risk cardiac con-
ditions and those with established GI tract infections, pos-
sibly involving enterococci.72–74 Given the different
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 Volume 29, Number 5, October 2019
underlying mechanisms of infection, we believe that anti-
biotic prophylaxis would have a minor role in reducing the
risk of PCA.
As technology advances, newer and more efficient
techniques are being developed and adapted to improve
pain and polyp detection during the colonoscopic exami-
nation. These include the use of CO2 insufflation, and water
immersion and exchange colonoscopy.75 In fact, such
modalities have been shown to be feasible for colonic eval-
uation and are already being used in some centers.76,77
Therefore, it will be interesting to see if these newer
modalities will reduce the number of complications related
to colonoscopy, particularly infections such as PCA.
Overall, PCA is rare. However, it is possible that the true
incidence of PCA is underestimated. First, the infection may
go unnoticed as the symptoms of PCA are nonspecific and
spontaneous resolution of infection may occur. Second, it is
possible that additional publications, particularly in the non-
indexed, non-English journals, might have been missed.
Finally, cases of PCA might have gone unreported or have
been included as part of other types of publications.7 How-
ever, the overall number of missed cases is likely to be small.
In conclusion, although rare, PCA needs to be consid-
ered in the differential diagnosis for patients presenting with
acute abdominal pain immediately after colonoscopy. The
clinical manifestations are similar to that of common acute
appendicitis with a high rate of perforation. Laparoscopic
appendicectomy is currently the treatment of choice, whereas
nonoperative treatment may be successful in uncomplicated
cases. The recent number of reported cases of PCA has shown
a rising trend. As the number of colonoscopies performed
annually is increasing steadily because of the continued rec-
ommendation for colorectal cancer screening given by many
experts and clinical guidelines, the number of colonoscopy-
related infections, including PCA, is expected to further
increase. Further studies are warranted to better estimate the
incidence and understand the pathogenesis of PCA, and to
assess the impact of preventive measures in reducing the
incidence of postcolonoscopy infections.
ACKNOWLEDGMENTS
The authors would like to acknowledge the assistance of
Mr Mohamed Sallam and Mr Manhal Alhamo for retrieving
some of the identified publications, and Dr Bogdan Socea and
Dr Abhijeet Waghray for sharing their cases and experience.
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