Appendiceal Orifice Inflammation and Ulcerative Proctitis

A 14-year-old girl has a 2-month history of vague abdominal discomfort at the time of cheerleading and track activities. She reports hematochezia with the passage of formed to firm stools. Hemogram, erythrocyte sedimentation rate, and chemistry panel were normal. Physical examination was normal including the absence of perianal disease. Digital rectal examination yielded no palpable stool. Endoscopy revealed normal esophagus, stomach, duodenum, terminal ileum (TI), and cecum, but the appendiceal orifice was everted, edematous, and grossly inflamed with mucopus (Figure A). The rectum had asymmetric edema, erythema, and friability. The intervening colon was normal. Because of a concern for appendicitis, a computerized tomography was performed immediately after the endoscopy, which documented the partially everted appendix without appendicitis (Figure B). Biopsy specimens eventually showed no abnormalities in the TI, but biopsy specimens of the appendiceal orifice revealed acute cryptitis and moderate acute and chronic inflammation without granulomas. The rectum showed mild inflammation with cryptitis. These biopsy specimens were compatible with inflammatory bowel disease, specifically, ulcerative colitis (UC). A small-bowel contrast radiograph was normal. The inflammatory bowel disease panel did not reveal increased anti-saccharomyces cerevisiae antibody, anti-outer membrane protein core antibody, or perinuclear antineutrophil cytoplasmic antibody levels.

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