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Massive lower gastrointestinal bleeding from the appendix.
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MedLine Citation:
PMID:  21814607     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Abstract/OtherAbstract:
Massive rectal bleeding from the appendix, considered a rare case of lower gastrointestinal bleeding, is not easily recognized by various diagnostic modalities. A multidisciplinary approach for both a diagnosis and a differential diagnosis is important because the identification of the bleeding site is crucial to proceed to a proper intervention and there are various causes of appendiceal bleeding. Because early colonoscopy plays an important role in the diagnosis and management of lower gastrointestinal hemorrhage, we report a case of a life threatening massive rectal bleeding from the appendix diagnosed by colonoscopy. We also present a review of the literature.
Authors:
Kyu Sung Chung; Jian Peng Gao
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Publication Detail:
Type:  Journal Article     Date:  2011-06-28
Journal Detail:
Title:  Gut and liver     Volume:  5     ISSN:  2005-1212     ISO Abbreviation:  Gut Liver     Publication Date:  2011 Jun 
Date Detail:
Created Date:  2011-08-04     Completed Date:  2011-11-10     Revised Date:  2013-11-13    
Medline Journal Info:
Nlm Unique ID:  101316452     Medline TA:  Gut Liver     Country:  Korea (South)    
Other Details:
Languages:  eng     Pagination:  234-7     Citation Subset:  -    
Affiliation:
Department of Gastroenterology, The Affiliated YanAn Hospital of Kunming Medical College, Kunming, Yunnan, China.
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Journal Information
Journal ID (nlm-ta): Gut Liver
Journal ID (publisher-id): GNL
ISSN: 1976-2283
ISSN: 2005-1212
Publisher: The Korean Society of Gastroenterology; the Korean Society of Gastrointestinal Endoscopy; the Korean Association for the Study of the Liver; the Korean Society of Neurogastroenterology and Motility; Korean Association for the Study of Intestinal Diseases; Korean College of Helicobacter and Upper Gastrointestinal Research; Korean Society of Pancreatobiliary Diseases
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Copyright © 2011 The Korean Society of Gastroenterology, the Korean Society of Gastrointestinal Endoscopy, the Korean Society of Neurogastroenterology and Motility, Korean College of Helicobacter and Upper Gastrointestinal Research, the Korean Association for the Study of Intestinal Diseases, Korean Association for the Study of the Liver and Korean Society of Pancreatobiliary Diseases
open-access:
Received Day: 11 Month: 3 Year: 2010
Accepted Day: 12 Month: 4 Year: 2010
Print publication date: Month: 6 Year: 2011
Electronic publication date: Day: 28 Month: 6 Year: 2011
Volume: 5 Issue: 2
First Page: 234 Last Page: 237
ID: 3140672
PubMed Id: 21814607
DOI: 10.5009/gnl.2011.5.2.234

Massive Lower Gastrointestinal Bleeding from the Appendix
Kyu Sung ChungA1
Jian Peng GaoA1
Department of Gastroenterology, The Affiliated YanAn Hospital of Kunming Medical College, Kunming, Yunnan, China.
Correspondence: Correspondence to: Jian Peng Gao. Department of Gastroenterology, The Affiliated YanAn Hospital of Kunming Medical College, 245 East Renmin Road, Kunming, Yunnan, China. Tel: +86-13648716327, gaojianpeng@medmail.com.cn

INTRODUCTION

An appendiceal origin of the lower gastrointestinal bleeding (LGIB) is extremely rare.1 To obtain its proper diagnosis, though a various diagnostic modalities have been approached, like angiography,2 radionuclide scintigraphy,3 multi-detector computed tomography (MDCT),4 or colonoscopy, it is still difficult to make an accurate diagnosis with further interventions. In particular, unlike some promising reports regarding the use of colonoscopy, prospective studies are needed to determine the efficacy of this approach on outcomes because it is not always effective if it has severe bleeding or a non-active bleeding status.3 The object of this study was to report a case of a massive rectal bleeding from the appendix and to discuss causes, useful diagnostic modalities, and treatment through a computer-assisted search of the English-language literature and cross-checks from other review articles.


CASE REPORT

We describe a 33-year-old man who presented a painless massive amount of bright reddish and burgundy rectal bleeding for 3 consecutive days. The patient had neither fever nor abdominal pain. He denied previous digestive tract related medical history as well as taking any of current medicine history, like nonsteroid anti-inflammatory drug. On admission the patient had an acute ill looking appearance and no altered mental status. Resting tachycardia was observed, but his blood pressure was in a normal range. In the second day of admission, he was referred to the endoscopic center where we gauzed the systolic blood pressure just less than 100 mm Hg and he complained dizziness. There were no other specific abnormalities, such as abnormal bowel sound, tender abdomen, or hepatosplenomegaly. The initial hemoglobin level was 12.3 g/dL which subsequently dropped to 9.9 g/dL the next day. Other laboratory exams, like hematologic profiles, were within normal range. The patient was first resuscitated with intravenous saline solution and followed by digestive endoscopies accordingly. An emergency esophagogastroduodenoscopy did not claim any specific lesion, but the colonoscopy disclosed fresh blood at the appendiceal orifice (Fig. 1). Interestingly, after we performed a large amount of water irrigation and removed blood contained liquids, we could not see any fresh blood, implying that the bleeding source did not seem to be around the cecum. Further, following ileoscopy illustrated that the terminal ileum was not evident for any current bleeding episode from the upper level of the tract. However, getting back to the cecum, as the scope entered the appendiceal orifice and after irrigating a small amount of water, it allowed us to corroborate appendiceal intraluminal bleeding in real-time image (Fig. 2). An emergency appendectomy eliminated the bleeding source successfully. On surgery, the appendix, about 8 cm long, had grossly normal appearance except much blood filled in. An eroded focal mucosal lesion was observed at the distal portion of inner part of the vermiform appendix. The histopathological examination revealed a case of appendiceal mucosal erosion (Fig. 3). Although relatively rare, benign appendiceal lesions, such as ulcer or erosion, should be considered a possible cause in patient who present with LGIB. Colonoscopy could reveal the location as well as the characteristics of the affected lesions, whether it provides clinicians with any suspicious source that bleeding takes place.


DISCUSSION

Appendiceal ulcer or erosion is made up a very small portion of cause of the LGIB.5,6 Acute bleeding from the vermiform appendix is thought to be one of the least common causes of LGIB. The causes have been reported diversely as diverticulitis,7 diverticulum,8 acute appendicitis,9,10 endometriosis,11 angiodysplasia,2,12 Crohn's disease,13,14 aortoappendiceal fistula,15 intussusceptions,16-19 Henoch-Schonlein purpura,20,21 gastrointestinal stromal tumor,22 ulcer,5 and erosion.6 Our search has found 20 cases that had all presented with LGIB in English-language literature. Only one ulcer and one erosion were reported, whereas intussusception was relatively frequently reported. Most reported cases manifest acute or chronic recurrent rectal bleeding than mimic acute appendicitis. In other words, appendiceal bleeding should be suspicious when acute of chronic recurrent LGIB.2,10 Like other origins of LGIB, appendiceal origin bleedings also need various diagnostic modalities. Because colonoscopy has replaced barium enema, in most cases since 1990s, colonoscopy has played major role in a diagnosis.17,18 Currently, a prospective randomized study compared urgent colonoscopy group to standard care group in patients with hematochezia and concluded the group of standard care that put radionuclide scintigraphy first position has similar outcome from the group of urgent colonoscopy.3 However, none of 20 cases has gotten the diagnosis through scintigraphy. Though radionuclide scanning has its advantage of noninvasive nature, no bowel preparation needed and easily repeated, as its variable accuracy may delay other therapeutic procedures, we also did not choose it prioritized as the patient was suspicious in hemodynamic instability.1 Mesenteric artery angiography could make an appropriate documentation of the site to those who bleed faster than 0.5 mL/min.1 A study tried to embolize the vessels of appendiceal bleeding; but it reoccurred and failed to stop bleeding.2 Some of unsuccessful angiographic treatment led to fatal myocardial infarction and intestinal infarction during intra-arterial infusion of vasopressin or transcatheter embolization in some patients of LGIB. In addition to this, there was a report regarding the potential danger that ileocecal arterial embolization tends to have more chances of intestinal ischemia, infarction, and stenosis than other branches of mesenteric artery embolization.23,24 Indeed, only 2 cases has successfully gotten definitive diagnosis through mesenteric angiography.2,8 Early diagnostic colonoscopy has an accepted role in the management of persistent or recurrent LGIB. Despite of its promising benefit, it is often hard to find out the exact bleeding site if colonoscopy is done in a situation of a large amount of acute bleeding. Besides, it is also hard to find the site if it bleeds intermittently, slowly, or even if it stops temporarily. In our case, as it bled intermittently, we had almost failed to document the origin of bleeding until the scope entered the orifice of the vermiform appendix. Since, nevertheless, endoscopic intervention can result in decreased resource utilization in terms of length of hospital stay, blood transfusion requirements, and cost, the case has also benefited to be sent to an operation with only 300 mL of blood transfusion right after the colonoscopy.25 MDCT has a good accuracy for localization of acute GI bleeding. In particular, arterial phase multi-detector row CT is likely accurate for the depiction and localization of sites of bleeding in patients with acute massive gastrointestinal bleeding.4,6 Thus, MDCT is theoretically available to those bleeding patients who are suspicious of vascular origin, but they should not be severe in hemodynamic compromised status because it requires relatively long period of time. We did conduct merely non enhanced CT right after this colonoscopy as his vital sign was getting deteriorated and there was only one concern whether it was any tumor like condition morphologically as surgeons would like to decide on the range of surgery. The size and nature of appendix looked normal; yet the histologic examination revealed hemorrhagic findings with several erosive lesions and surrounding inflammatory infiltrates mostly at mucosal layer without transmural inflammations. A review has revealed that the pathological finding of superficial mucosal ulcerative lesion is frequently observed among the patients who underwent appendectomy after acute appendicitis, suggesting that pathomorphologically, this kind of erosion and ulcer could be found in early stage of acute appendicitis without appendiceal hypertrophy.26 Currently, a laparoscopic appendectomy tends to the treatment of choice of appendiceal bleeding as it has an advantage of minimal invasive surgery.

We present a case of severe LGIB due to appendiceal mucosal erosion. In a hemodynamic deteriorated status, an urgent colonoscopy described characteristics of the source of bleeding and also identified the location during the acute occurrence, letting effective handling in the course of simple appendectomy to be carried out. Hence, it is conceivably postulated for unresolved LGIB that clinicians may take time to let colonoscopy enter the vermiform appendix for diagnosing appendix origin pathologies. Though the chance of appendiceal origin massive bleeding is rare, as it is vital to diagnose it at an early stage for the most favorable treatment of this disease, colonoscopy would be one of the essential tools for its accuracy, convenience, and therapeutic potentiality.


References
1. Strate LL. Lower GI bleeding: epidemiology and diagnosisGastroenterol Clin North AmYear: 20053464366416303575
2. Kyokane T,Akita Y,Katayama M,et al. Angiodysplasia of the appendixAm J GastroenterolYear: 20019624224411197261
3. Green BT,Rockey DC,Portwood G,et al. Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trialAm J GastroenterolYear: 20051002395240216279891
4. Yoon W,Jeong YY,Shin SS,et al. Acute massive gastrointestinal bleeding: detection and localization with arterial phase multidetector row helical CTRadiologyYear: 200623916016716484350
5. Morales TG,Yalam J,Dinning JP,Mills M. Acute lower gastrointestinal bleeding from the appendixGastrointest EndoscYear: 1997464584609402124
6. Baek SK,Kim YH,Kim SP. Acute lower gastrointestinal bleeding due to appendiceal mucosal erosionSurg Laparosc Endosc Percutan TechYear: 200919e211e21419851256
7. Tamvakopoulos SK. Clinical observations on diverticulosis-diverticulitis of the appendix. Rectal bleeding in association with symptoms of acute appendicitis suggests diagnosisR I Med JYear: 196952443444 passim4979423
8. Norman DA,Morrison EB,Meyers WM Jr. Massive gastrointestinal hemorrhage from a diverticulum of the appendixDig Dis SciYear: 1980251451476766375
9. Milewski PJ. Appendix abscess with intestinal haemorrhageBr Med JYear: 19771147299823
10. Yamazaki K,Nakao K,Tsunoda A,et al. Successful laparoscopic treatment of hemorrhage from the appendix with phlegmonous acute appendicitis: a case report and review of the literatureGastrointest EndoscYear: 20066387788016650567
11. Shome GP,Nagaraju M,Munis A,Wiese D. Appendiceal endometriosis presenting as massive lower intestinal hemorrhageAm J GastroenterolYear: 199590188118837572915
12. So JB,Alexander DJ,Chong AP,Goh PM. Laparoscopic appendicectomy in the management of acute lower gastrointestinal bleedingGastrointest EndoscYear: 1995424884898566644
13. Geerken RG,Gibbons RB. Isolated Crohn's disease of the appendix: case reportMil MedYear: 19741392152174206171
14. Brown WK,Peters RW. Crohn's disease of the appendix presenting as lower intestinal hemorrhage and cecal massAm J GastroenterolYear: 1976653493521084689
15. Monaghan K,Cogbill TH. Primary aortoappendiceal fistula: case report and review of the literatureJ Vasc SurgYear: 2002351284128612075600
16. Brewer RJ,Wangensteen SL. Appendiceal intussusception: an unusual cause of painless rectal bleedingAm SurgYear: 1974403193204544976
17. McIntosh JC,Mroczek EC,Baldwin C,Mestre J. Intussusception of the appendix in a patient with cystic fibrosisJ Pediatr Gastroenterol NutrYear: 1990115425442262843
18. Jevon GP,Daya D,Qizilbash AH. Intussusception of the appendix. A report of four cases and review of the literatureArch Pathol Lab MedYear: 19921169609641524463
19. Gupta P,Chwals W,Guandalini S. Intussusception of the appendix: another poorly recognized cause of rectal bleedingJ Pediatr Gastroenterol NutrYear: 20003032032310749420
20. Kim CJ,Chung HY,Kim SY,et al. Acute appendicitis in Henoch-Schönlein purpura: a case reportJ Korean Med SciYear: 20052089990016224172
21. Jangjoo A,Amouzeshi A,Jalali AN. Gangrenous appendicitis in a child with Henoch-Schonlein purpuraJ Pediatr SurgYear: 200843e33e3518970918
22. Kim KJ,Moon W,Park MI,Park SJ,Lee SH,Chun BK. Gastrointestinal stromal tumor of appendix incidentally diagnosed by appendiceal hemorrhageWorld J GastroenterolYear: 2007133265326717589911
23. Leitman IM,Paull DE,Shires GT 3rd. Evaluation and management of massive lower gastrointestinal hemorrhageAnn SurgYear: 19892091751802783842
24. Gerlock AJ Jr,Muhletaler CA,Berger JL,Halter SA,O'Leary JP,Avant GR. Infarction after embolization of the ileocolic arteryCardiovasc Intervent RadiolYear: 198142022056974595
25. Strate LL,Syngal S. Timing of colonoscopy: impact on length of hospital stay in patients with acute lower intestinal bleedingAm J GastroenterolYear: 20039831732212591048
26. Sisson RG,Ahlvin RC,Harlow MC. Superficial mucosal ulceration and the pathogenesis of acute appendicitisAm J SurgYear: 19711223783805570610

Article Categories:
  • Case Report

Keywords: Appendiceal bleeding, Acute appendicitis, Colonoscopy.

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