A 20-year-old female presented with recurrent episodes of abdominal pain. She had
previously received antitubercular therapy for a diagnosis of gastrointestinal tuberculosis
on the basis of abdominal lymph node cytology showing granuloma with acid-fast bacilli.
She underwent a colonoscopy for suspected post-tubercular intestinal stricture. Just
beyond the hepatic flexure, an appendix-like structure was identified ([Fig. 1A] and [B]). However, because of nonvisualization ileocecal valve and intubation of the terminal
ileum, we applied suction, which showed a flow of fluid (bowel preparation) from this
opening. A wire-guided controlled radial expansion balloon was passed across this
narrowing completely (CRE, Microvasive, Boston Scientific Co., Natick, MA, United
States), and dilatation was performed up to 12 mm diameter for 30 seconds. The colonoscopy
was not negotiated across post-dilatation ([Fig. 1C] and [D]). The patient became asymptomatic after a single dilatation procedure and was advised
to follow up.
Fig. 1 (A) Colonoscopic image showing appendix-like structure just beyond hepatic flexure.
(B) Opening better visualized on air insufflation and closer view. (C) Passage of wire-guided balloon. (D) Dilatation using controlled radial expansion balloon.
The case has two important lessons. The identification of the cecum on colonoscopy
is usually based on the visualization of one of two structures: the appendix or the
intubation of the terminal ileum.[1] Cecum may also be identified by the tri-radiate folds formed by the fusion of the
three tenia coli around the appendix. However, here, the stricture had the appearance
of a normal appendix, and only because of strong suspicion, was the stricture suspected.
Even transillumination may not correctly identify the cecum in such patients because
of pulling up and contraction. Secondly, tubercular involvement of the ileocecal area
can result in strictures, which can present even after the completion of therapy and
healing of ileal ulcers.[2] Therefore, continuing symptoms even after antitubercular therapy may suggest the
presence of sequelae such as strictures.[3]
