LAUSR

Appendicitis remains one of the most common indications requiring emergent surgical intervention. Lifetime risk has been reported as 8.6% in men and 6.7% in women. The pathophysiology of appendicitis is not entirely understood, however the most commonly accepted theory is that luminal obstruction leads increased intraluminal pressure which can progress to ischaemia, necrosis and perforation if not treated. This luminal obstruction is generally secondary to faecolith, impacted stool, lymphoid hyperplasia or neoplasm. We report a case of ischaemia as the precipitating aetiology of acute appendicitis. A 70-year-old man with a past medical history significant for hypertension, hyperlipidemia, and transient ischaemic attack, was admitted to our facility for lower gastrointestinal bleed. He recently had undergone colonoscopy with polypectomy in which two 5-6 mm polyps, pathologically confirmed as a tubular and serrated adenoma, of the caecum were removed using hot snare and without hemostatic clips. Additionally, he had just restarted clopidogrel that had been withheld for 1 week after polypectomy. The patient presented transiently hypotensive requiring transfusion of blood products. Subsequent computed tomography (CT) of the abdomen/ pelvis revealed active extravasation in the caecum (Fig. 1(a)); he underwent immediate selective coil embolization of branches of the ileocolic and right colic arteries (Fig. 1(b) and (c)). On post-procedure day two, he began to have severe right lower quadrant abdominal pain. He was febrile, tachycardic and had a new onset leukocytosis (12.7 10/L). A repeat CT was concerning for possible acute appendicitis (Fig. 2(a)). Due to his recent procedure, there was concern that the aetiology of his pain and imaging findings were secondary to progressive colonic ischaemia as a consequence of angioembolization. The patient underwent diagnostic laparoscopy; the distal two-thirds of the appendix appeared