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]
