An atypical endoscopic diagnosis

A 57-year old man presented to the emergency department with intermittent right lower quadrant pain for the previous two days. No fever on admission. Physical examination revealed discomfort in the right lower quadrant. Abdominal ultrasound revealed thickening of cecum wall with slightly increased diameter of appendix base. Laboratory results show slightly elevated C-reactive protein (CRP 36 mg/dL) and normal leukocyte count (10 000/µL). Liver enzymes, kidney function and electrolytes were normal. Abdominal CT scan was performed and revealed oedematous thickening of cecum wall and local lymphadenopathy. The tip of the appendix appeared normal (Fig. 1). Patient was admitted and observed. To rule out neoplasm or inflammatory bowel disease a total colonoscopy and ileoscopy were performed two days after admission. These revealed an inflammatory cecum with faecal impacted base of the appendix, surrounded by pus (Fig. 2 Panel A). With the use of endoscopic biopsy forceps, the piece of faeces was removed (Fig.2 Panel B).