A 63-year-old man presented to the emergency department with 1day history of non-migratory right-sided lower abdominal pain and no other associated symptoms. He had undergone a colonoscopy with banding of haemorrhoids for per rectal bleeding the preceding day. No biopsies or polyps were taken. The procedure itself was uneventful and performed with ease. The bowel preparation was excellent and good visualization of the caecum, identified by appendiceal orifice, ileocaecal valve and palpation. There were no signs of inflammation around the caecum or the appendiceal orifice. He recovered well from the procedure and was discharged home the same day.After 32 h, he presented to the emergency department with abdominal pain and right lower abdominal tenderness with no signs of peritonism. He was afebrile and haemodynamically stable, with an initial white cell count of 11.3 × 10 9 /L with 9 × 10 9 /L neutrophil count. Erect chest X-ray and abdominal X-ray were also normal. He subsequently underwent abdominal computed tomography (CT) imaging, which showed a thickened and oedematous appendix with surrounding fluid and fat stranding in the right iliac fossa (Figs 1,2).The patient was taken to theatre for a laparoscopic appendicectomy 52-h post-colonoscopy. Intraoperative findings were of gangrenous, locally perforated appendix with the presence of intraluminal soft faecal material. The patient made an uneventful recovery and was discharged home 4 days later. Histological examination subsequently confirmed the clinical diagnosis of appendicitis with ulceration, transmural inflammation, and necrosis and peritonitis.
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