CASO CLINICO

Appendicite: Clinical case
OBSERVATION:Ms. KC was seen in consultation in gynecology for pelvic pain, fever and rectal bleeding lasting for six (6) days. The pain was cramping, without irradiation, late postprandial vomiting and relieved by food. The observed rectal twice the patient was made of blood-streaked stools, fever was accompanied unencrypted or chill or sweat. The patient had presented 5 episodes of pain same in 2 years, which amends all times after treatment with antibiotics, antispasmodics and pest control. The recurrent nature of pain and its location pelvic prompted a consultation in gynecology. She was referred to later in the service of Hepato Gastroenterology.
At the clinic there was an'examen hyperthermia at 38 °, anemia clinic, an oblong mass (40x30 mm), firm, painful, fixed the plane deep in umbilical extending downward to the left iliac fossa and the DRE did not find mass, the blood-stained finger cot returned. The blood count revealed a microcytic anemia with hemoglobin 9 g / 100 ml and a normal leukocyte counts (7000 cells / ml), CRP was 96 mg (N <12mg). The stool examination, the search for Plasmodium and blood culture were objectified any pathogen.
The ultrasound showed a heterogeneous hypodense mass oblong area in umbilical left appendix was not visualized. The liver, spleen, uterus and adnexa were normal and located in their respective boxes. Ultrasound concluded that a mass in the umbilical region to explore by a CT to determine the causative body.
The presence of rectal bleeding had a colonoscopy as the preferred method of exploration in search of a colon tumor. The review performed under conscious sedation (diazepam 5 mg + 5 mg tiemonium SCI) with a colonoscope Olympus Optical CF 30L mounted on a camera OCV 100 of the same brand highlighted an aspect of the mucosa swollen congestive perished - orificielle of Appendix (Figure 1): the diagnosis of appendicitis was mentioned. Exploratory laparotomy found a right colon and caecum float. The caecum was left with a large inflamed appendix attached and adherent to the rectum by the peri appendicular inflammation. An appendectomy was done with favorable postoperative course. The diagnosis of appendicitis was left selected. Pathological examination of the specimen confirmed the diagnosis.The postoperative course was uncomplicated, the patient was seen regularly for dressing the wound and was lost from sight after complete healing.
DISCUSSION:The diagnosis of appendicitis is strongly evoked in the clinic and doubtful cases were receiving an exploratory laparotomy. However, medical imaging currently available and easy to perform to confirm or correct diagnosis of appendicitis reducing the indication for diagnostic laparotomy (3.4). Making a retrospective analysis of colonoscopy in the diagnosis of appendicitis in this new concept, Chang et al [5] showed the performance of this review.
Indeed although the purpose of colonoscopies performed was not the diagnosis of appendicitis, he found a sensitivity of 100%, a specificity of 99%, positive predictive value of 95% and 100% negative. In our case study, the clinical evoked a colon tumors (benign, malignant, amoeboma), an adnexal mass, an inflammatory colitis. The ultrasound had eliminated the diagnosis of adnexal disease. colonoscopy was performed in search of a colonic mass and / or signs of inflammatory colitis: the appearance of the appendix is ​​suggestive of appendicitis, atypical location confirmed at laparoscopy and histology. The significant inflammation of the appendix orifice was certainly responsible for rectal bleeding.
The mass was palpated swelling appendicitis and peri-orificielle. The diagnosis of malformation was asked a laparoscopy. Classically, the diagnosis of appendicitis on the left and the associated malformations are made to medical imaging before signs of the disease on the left [1,2]. The study by Chang et al [5] has clearly shown. Colonoscopy by allowing a direct view is more efficient than CT in the diagnosis of appendicitis in this article colonoscopy allowed the diagnosis in 11 cases confirmed later by laparoscopy and histology or for which the scanner had eliminated appendicitis.
Despite this performance, colonoscopy does not fit the technical level examinations to be performed incase of suspected appendicitis because of its cost and its invasive nature (risk of perforation, poor tolerance of the review). For these reasons, some authors do not recommend the completion of colonoscopy for diagnostic purposes in this disease. Chang et al [5] in their series (the largest published) report no complications. Our review was performed under conscious sedation without significant exacerbation of pain and no complications were reported in the aftermath of the review. Pain is an indicator of risk of developing complications such as perforation, completion of the colonoscopy under conscious sedation may be a method of preventing complications, particularly perforation. It therefore seems to be indicated for sedation colonoscopy for suspected appendicitis.
We believe that in a context like ours, where colonoscopy is more accessible than the scanner, it can be a review of diagnostic confirmation of atypical appendicitis. Furthermore it could be, in case of appendicitis clinically unconfirmed by medical imaging (ultrasound and scanner), the diagnostic test of choice.