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Background: Cecal polyps are challenging insofar as the region represents the highest risk of bleeding and perforation during polypectomy . In addition, polypoid lesions in the cecum may represent a morphologically abnormal ileocecal valve or an inverted appendix. Inadvertent polypectomy in those scenarios would lead to serious sequelae including perforation. Case report: Our patient is a 6-year-old male with a background history of prematurity, lactose intolerance, chronic esophagitis, gastritis, constipation, and painless rectal bleeding. He presented with a acute onset diffuse, severe abdominal pain associated with diarrhea that evolved to include hematochezia. At the time of presentation, he required aggressive resuscitation. His initial hemoglobin was 10mg/dl trending down to 7g/dl over 24 hours. His basic metabolic panel, coagulation panel, infectious stool studies, and calprotectin were negative or within normal limits. The patient stabilized following transfusion and octreotide infusion. Following a negative Meckel’s scan it decided to proceed to endoscopy. Upper endoscopy revealed normal findings whereas colonoscopy showed a pedunculated cecal polypoid lesion estimated at 3 cms diameter, with normal mucosal appearance, streaking erythema with superficial erosions (Fig1) but not actively bleeding. The lesion was recognized as likely protruding from the appendix consistent with appendiceal inversion (Type V; McSwain Classification) . Endoloop assisted appendectomy was not available and urgent surgery consult was obtained. The patient underwent uneventful laparoscopic appendectomy the next day. Histopathology report from the appendix was reported as eosinophilic infiltration with chronic active colitis consistent with presumed ischemic injury. The patient subsequently recovered uneventfully and was discharged home with no residual or recurrent symptoms at 4 month follow up. Discussion: Inversion of the appendix is a rare finding, with an estimated incidence of < 0.01% among all ages . It is theorized that inversion of the appendix may result from appendix peristalsis due to local inflammation or by appendix endometriosis . When symptomatic, inversion presents as abdominal pain, obstruction from intussusception, hematochezia, or diarrhea . Endoscopically an inverted appendix can be easily confused with polyp or neoplasia. Endoscopic removal of inverted appendix, when symptomatic can be achieved safely through endoloop ligation followed by distal (above endoloop) snare polypectomy.
Gastroenterology | Pediatrics
Alatorre-Jimenez, Moises and Attard, Thomas M., "Inverted Appendix Presenting As Abdominal Pain And Lower Gastrointestinal Bleeding" (2022). Posters. 298.