A wolf in sheep’s clothing: concomitant appendicitis with occult cecal adenocarcinoma

We present the case of an 89-years-old female with an atypical presentation of an obstructive acute appendicitis secondary to a cecal carcinoma. The physical exam revealed a distended abdomen with bilateral lower quadrants tenderness without rebound or rigidity. CT scan demonstrated distal small bowel obstruction and ruptured acute appendicitis. Patient was treated conservatively with nasogastric decompression, intravenous fluids, and antibiotics. She later underwent CT guided drainage of a rim-enhancing fluid collection and her symptoms eventually resolved. She returned a week later and a CT imaging showed high grade distal small bowel obstruction, and findings were a 4.5 cm diameter cecal mass. She underwent an exploratory laparotomy and modified right hemicolectomy with ileostomy for. She had an uneventful postoperative course. Pathology revealed poorly differentiated adenocarcinoma of the cecum stage III T4N1Mx. Appendectomy for appendicitis is the most commonly performed emergency operation in the world. Appendicitis are often rare in elderly, with atypical or delayed presentation and expanded differential diagnosis, making preoperative diagnosis challenging. With the increase overall risk of cancer in this age group, occult colonic carcinoma should be high in the differential diagnosis. Three mechanisms potentially leading to obstruction of the appendiceal lumen by the tumor includes: immediate proximity to the lumen, inflammatory changes from the tumor, back pressure on the cecum causing obstruction of the appendix. Despite advances in imaging, local inflammation, collections, and masses may be misleading. The diagnostic accuracy of CT scan reportedly can be as low as 54% for cecal tumors.

P324 Deep enteroscopy after balloon dilatation for differential diagnosis of small bowel stricture

Background Use of non-steroidal anti-inflammatory drugs (NSAIDs) and low-dose aspirin may result in gastrointestinal complications including ulceration, bleeding, and stricture. Chronic fibrosis and chronic ulcerations form bowel stricture which is the most severe stage of NSAIDs induced enteropathy. Capsule endoscopy and balloon enteroscopy may provide detailed information of small bowel mucosal lesions such as longitudinal ulceration suggesting Crohn’s disease. However, more distal or proximal evaluation above stricture is impossible due to severe stricture. Nowadays, balloon dilatation through the enterosope is available and can dilate stricture site by expanding force. This technique allows enteroscope to pass of stricture site and provides accurate evaluation of more proximal or distal small bowel above the stricture. We report our experience of small bowel evaluation after balloon dilatation. Methods Nine patients with small bowel stricture and history of NSAIDs between 2012 February and 2019 October were analysed. All patients with small bowel stricture had symptoms including abdominal pain, abdominal fullness, or vomiting and enteroscope could not pass the stricture site. Balloon dilatations were performed with through the scope balloon from 8 mm to 15 mm diameter in these patients. After adequate dilation, enteroscope passage could pass the stricture site. Detailed mucosal evaluation of more proximal or distal small bowel above the stricture was performed. Results Successful and adequate balloon dilation of small bowel stricture was achieved in 9 of 9 patients. Additional deep and longitudinal ulceration suggesting Crohn’s disease was found after successful passage of enteroscope in 3 of 9 patients. In 6 of 9 patients, additional chronic shallow ulcerative lesions without deep and longitudinal ulceration was found after eneteroscope passage. Deep enteroscopy after balloon dilatation provided important diagnostic clue and treatment strategy in 3 of 9 patients. Conclusion Deep small bowel evaluation above the stricture after balloon dilatation may provide additional and detailed information for differential diagnosis of small bowel stricture.