Case Study in Gastroenterology & Hepatology

Telciane S. Vesa, MD, Pegah Hosseini-Carroll, MD, Kenneth Manas, MD

Gastroenterology & Hepatology

June 2014, Volume 10, Issue 6

Diverticular Hemorrhage of the Appendix

Telciane S. Vesa, MD, Pegah Hosseini-Carroll, MD, Kenneth Manas, MD

Department of Medicine, Division of Gastroenterology and Hepatology, Louisiana State University Health Sciences Center, Shreveport, Louisiana

A 44-year-old man presented to the emergency department with a 24-hour history of maroon-colored stools followed by a syncopal episode. He had stable vital signs on presentation and a benign abdominal examination. His initial hemoglobin level was 10.9 g/dL and white blood cell count was 11.87 × 109/L. An esophagogastroduodenoscopy revealed only mild gastritis. The following day, the patient underwent a colonoscopy, which showed old and fresh blood throughout the entire colon, 3 small diverticula in the ascending colon, and one 0.8-cm × 1.2-cm sessile polyp in the cecum. Interestingly, intermittent, active bleeding from the appendiceal orifice also was observed (Figure 1). Malignancy, such as lymphoma or carcinoid, led the differential diagnosis. A computed tomography scan of the abdomen and pelvis demonstrated a thickened appendix without fat stranding and thickened proximal colon without obstruction (Figure 2). There were isolated proximal colonic diverticula, fatty liver, and an incidental 2-cm hypervascular lesion in the left kidney that was suspicious for renal cell carcinoma.

As the patient continued to have maroon-colored stools, his hemoglobin level continued to decline despite blood transfusion (7.4 g/dL by the third day of hospitalization). He received 6 units of packed red blood cells by the fourth hospital day. A red blood cell nuclear scan failed to identify the bleeding source, likely due to the fact that the bleed was noted to be slow and intermittent during colonoscopy. The patient underwent an uneventful right hemicolectomy, with removal of the ileocecal valve and
4 cm of terminal ileum. During the perioperative period, the patient received an additional 3 units of packed red blood cells. Pathology studies of the surgical specimen revealed an appendix with 3 diverticula and evidence of diverticulitis (Figure 3). The cecum polyp was a tubular adenoma. The remainder of the colon and small bowel was unremarkable. The patient had an excellent postoperative recovery and was discharged home on the tenth hospital day. He underwent curative left nephrectomy a few months later for the incidentally found renal cell carcinoma.


The literature contains numerous, separate case reports of appendiceal diverticulitis1-4 and appendiceal hemorrhage,5-13 with the latter including a wide variety of etiologies, including benign erosions, ulcers, carcinoids, lymphomas, angiodysplasia, endometriosis, appendicitis, inflammatory bowel disease, aortoappendiceal fistulae, and postappendectomy stump bleeding. Lower gastrointestinal hemorrhage secondary to appendiceal diverticulosis is extremely rare, with only 1 case reported in the literature by Norman and colleagues in 1980.14 

In the current case, diverticulitis was identified only in the postsurgical specimen without clinical manifestations, as the patient did not have abdominal discomfort, fever, or leukocytosis. There was no active bleeding from the terminal ileum or from the few scattered diverticula in the ascending colon. Video recordings and endoscopic pictures served to document fresh blood intermittently flowing from the appendiceal orifice.

Colonic diverticulosis is the most common cause of brisk lower gastrointestinal bleed.15,16 In clinical practice, when facing the rarity of appendiceal bleed and the concomitant endoscopic findings of diverticular disease in the surrounding colon, it is reasonable to suspect the latter as the most likely source of bleeding. It is such thought that led to surgical resection of the right colon rather than a simple appendectomy.


This case illustrates the potential for overly aggressive surgical intervention in the circumstance of a rare endoscopic finding. When an appendiceal bleed is diagnosed by colonoscopy, it should promptly be followed by surgical resection as definitive treatment, preferably with a minimally invasive appendectomy unless otherwise indicated by clinical or surgical findings.


1. Trollope ML, Lindenauer SM. Diverticulosis of the appendix: a collective review. Dis Colon Rectum. 1974;17(2):200-218.

2. Heffernan DS, Saqib N, Terry M. A case of appendiceal diverticulitis, and a review of the literature. Ir J Med Sci. 2009;178(4):519-521.

3. Lee KH, Lee HS, Park SH, et al. Appendiceal diverticulitis: diagnosis and differentiation from usual acute appendicitis using computed tomography. J Comput Assist Tomogr. 2007;31(5):763-769.

4. Yamana I, Kawamoto S, Inada K, et al. Clinical characteristics of 12 cases of appendiceal diverticulitis: a comparison with 378 cases of acute appendicitis. Surg Today. 2012;42(4):363-637.

5. Chiang CC, Tu CW, Liao CS, et al. Appendiceal hemorrhage—an uncommon cause of lower gastrointestinal bleeding. J Chin Med Assoc. 2011;74(6):277-279.

6. Baek SK, Kim YH, Kim SP. Acute lower gastrointestinal bleeding due to appendiceal mucosal erosion. Surg Laparosc Endosc Percutan Tech. 2010;20(3):110-113.

7. Kim KJ, Moon W, Park MI, et al. Gastrointestinal stromal tumor of appendix incidentally diagnosed by appendiceal hemorrhage. World J Gastroenterol. 2007;13(23):3265-3267.

8. Kecmanovic DM, Bulajic MM, Pavlov MJ, et al. Recurrent rectal bleeding from an appendiceal stump granuloma: a rare late complication of appendectomy. Endoscopy. 2005;37(11):1161.

9. Koornstra JJ, Schot BW, Dijkstra G. Mantle cell lymphoma involving the appendiceal orifice as an unusual cause of lower gastrointestinal bleeding. Int J Colorectal Dis. 2007;22(1):99-100.

10. Ooi CW, Usatoff V. Aorto-appendiceal fistula presenting with bleeding per rectum. ANZ J Surg. 2004;74(10):913.

11. Shome GP, Nagaraju M, Munis A, et al. Appendiceal endometriosis presenting as massive lower intestinal hemorrhage. Am J Gastroenterol. 1995;90(10):1881-1883.

12. Brewer RJ, Wangensteen SL. Appendiceal intussusception: an unusual cause of painless rectal bleeding. Am Surg. 1974;40(5):319-320.

13. Foster JH, Morgan CV, Therlkell JB, et al. Vascular malformation of the appendiceal stump. A rare cause of massive hemorrhage. JAMA. 1971;215(4):636-638.

14. Norman DA, Morrison EB, Myers WM. Massive gastrointestinal hemorrhage from diverticulum of the appendix. Dig Dis Sci. 1980;25(2):145-147.

15. Gostout CJ, Wang KK, Ahlquist DA, et al. Acute gastrointestinal bleeding. Experience of a specialized management team. J Clin Gastroenterol. 1992;14(3):260-267.

16. Gayer C, Chino A, Lucas C, et al. Acute lower gastrointestinal bleeding in 1,112 patients admitted to an urban emergency medical center. Surgery. 2009;146(4):600-606.

Millennium Medical Publishing, Inc