|Year : 2002 | Volume
| Issue : 2 | Page : 43-52
|Diseases of the appendix recognized during colonoscopy
Fazal Imtiaz Khawaja
Department of Gastroenterology, King Fahad Hospital, Al Madinah Al Munawarrah, Saudi Arabia
Click here for correspondence address and email
|Date of Submission||06-Jun-2001|
|Date of Acceptance||19-Dec-2001|
|How to cite this article:|
Khawaja FI. Diseases of the appendix recognized during colonoscopy. Saudi J Gastroenterol 2002;8:43-52
| Summary|| |
Although the appendiceal orifice is routinely identified during a total colonoscopic examination, there are only a few reports in the English literature describing abnormalities in this region. Many recent case reports have described endoscopic features of various appendiceal pathologies. In order to increase the awareness as well as facilitate the recognition of these uncommon encounters a review of the literature on the endoscopic features of various appendiceal problems is provided. The most frequently reported abnormalities are related to appendiceal neoplasms or intussusception. Interesting observations and new features of appendiceal regional abnormalities in acute appendicitis and ulcerative colitis are being described. Importance of appendiceal involvement in ulcerative colitis is of interest in particular. This may have impact on the disease prognosis and management. The knowledge of the emerging role of colonoscopy in the diagnosis and management of complicated appendicitis might encourage a more aggressive non-operative approach in some of these cases. Recognition of rare entities requires knowledge of their endoscopic appearance. Awareness of these new developments is essential for all endoscopists performing routine colonoscopic examination. In order to detect any abnormality, the appendiceal orifice should be carefully inspected during all routine colonoscopic examinations. This systematic approach may eventually result in more frequent pre-operative diagnosis of appendiceal problems.
| Introduction|| |
Although acute appendicitis is a common clinical problem, other diseases afflicting the appendix are unusual. The pre-operative diagnosis has been difficult. In the past decade more frequent use of US and CT Scan has helped in the recognition of various disease processes involving the appendix , . However the literature on endoscopic features of different appendiceal pathologic conditions has remained scanty. In most of the textbooks and Atlas More Detailses of gastrointestinal endoscopy there is little or no mention about appendiceal pathology ,, . The discussion on this topic is usually limited to the endoscopic recognition of the appendiceal orifice. Occasionally one or two pictures eliciting a pathologic condition are included  . Appendiceal orifice region abnormalities recognized incidentally during colonoscopy are now being reported with increasing frequency. Successful therapeutic applications in some of these unusual cases have also been reported. The current literature on this subject is mostly limited to isolated case reports. The aim of this review is to increase the awareness of these findings and to provide the endoscopists with some insight about the possibility and safety of various therapeutic options available in such situations.
| Normal endoscopic anatomic landmarks|| |
Caecal intubation can be verified with complete certainty by identification of caecal landmarks. Adequate identification of these ceacal landmarks is fundamental to high quality colonoscopy. These landmarks are ileocaecal valve, in particular the ileocaecal valve orifice, the appendiceal orifice and the caecal sling fold (also known as the strap fold) ,,, . Experienced colonoscopists intubate the caecum in more than 90% of cases. In a prospective study the appendiceal orifice was successfully photographed in 98.7% of cases  . The appendiceal orifice lies at the junction of the three taenia coli at the pole of the caecum. In the endoscopic literature this has been referred as " the crow's-foot" appearance of the caecum around the appendiceal orifice ,,,, .
| Colonoscopy and the appendiceal diseases|| |
With the currently available colonoscopes the appendiceal lumen cannot be examined from within. The endoscopic recognition of the appendiceal pathology is therefore limited to the inspection of the appendiceal orifice and the base of the caecum. The most frequently reported abnormalities are related to appendiceal neoplasms or intussusception. Interesting observations of appendiceal region abnormalities in ulcerative colitis are opening new avenues for research. There might be a limited but potentially useful role of therapeutic intervention in selected cases of complicated appendicitis. Awareness of endoscopic features of rare problems will lead to their correct recognition.
| Appendiceal Neoplasms|| |
Neoplasms arising from the vermiform appendix are rare and usually discovered incidentally during surgery or at autopsy , . Clinical features vary from a presentation typical of acute appendicitis or chronic right lower quadrant pain, non-specific symptoms or malena. Occasionally the initial presentation is related to intussusception or a pseudomyxoma peritonei , . Although ninety percent of all appendiceal neoplasms are carcinoids and 90% of all carcnoids arise in the appendix  , the most commonly described lesions described during colonoscopy have been mucoceles ,,,,,,,,,,, followed by benign appendiceal polyps ,,,,,,,, .
Appendiceal mucocele is a descriptive term used to indicate dilatation of the appendiceal lumen by mucous secretions  . It is uncommon and has been observed in only 0.2%-0.3% of appendectomy specimens ,, with a 4:1 preponderance for females and a mean age of 55 years at presentation  . Right lower quadrant pain is the most common symptom. Other symptoms include intermittent colicky pain, gastro-intestinal bleeding associated with intussusception or a palpable abdominal mass. Leukocytosis is usually absent. Early diagnosis of appendiceal mucocele is rare because the symptoms are often absent and are not specific. Diagnosis is however, important, as some of these lesions are malignant. An early detection should also reduce the incidence of pseudomyxoma peritonei and its associated morbidity ,, . Both benign cyst-adenomas and malignant cystadenocarcinoma are characterized by an obstructed mucin-filled appendix displacing the caecum, which may initially be detected as a radiological or endoscopic abnormality  . The use of colonoscopy has resulted in an increase in the reported frequency of this condition ,, . Endoscopically, this lesion appears as a submucosal mound surrounding the appendiceal orifice. The mound is smooth, rounded or hemispheric, covered with a normal but stretched and glossy overlying mucoa and does not flatten out with generous insufflation of air. The appendiceal ostium can be identified as a depression at the top of the mound. A central ulceration containing gelatinous material may be present  . Because the appearance closely resembles a "volcano" this has been labelled as "the volcano sign" , . Sometimes an out-pouring of whitish mucoid material from the appendiceal orifice might be the only clue of an underlying appendiceal mucocele ,, . A colonoscopic biopsy may miss an underlying malignancy  . Because mucocoele of the appendix is a submucosal lesion with a soft consistency and a positive "cushion sign", it may be confused endoscopically with a lipoma or other submucosal lesions of the colon ,,,,,, . EUS is now acknowledged to be the best procedure for the visualization of gastro-intestinal submucosal tumors and determination of their origins. EUS has only recently been shown to be useful in the diagnosis of submucosal tumours of large intestine  . EUS with endoscopically guided ultrasoundprobe can be easily performed during regular colonoscopy without the use of the conventional type echoendoscope. Mizuma et al were the first to report the EUS findings in a case of appendiceal mucocele by using such flexible sonoprobe  . They observed an extra-luminal hypoechoic inhomogenous mass with hyperechoic internal spots. The caecal wall was intact and compressed There were no lymph nodes. These findings suggested a diagnosis of appendiceal mucocele and a laparoscopic appendectomy was successfully performed. If the findings at routine colonoscopy suggest the presence of an appendiceal mucocele, EUS with a miniprobe should be performed for accurate preoperative diagnosis. EUS would also reveal the irregular thickness or the disruption of the cyst wall that are likely to occur with invasion into the stroma. Therefore, in the future, EUS may be able to distinguish the more benign lesions from the more malignant types.
Benign Appendicael Polyps
The reported incidence of benign appendiceal polyps, from various autopsy series, ranges from 0.004%-0.08% , . Lack of careful inspection of the appendiceal lumens by pathologists maybe one of the reasons of such wide fluctuation in the reported incidence. A gross abnormality of the appendix is recognized in 50% of the cases  . Appendiceal polyps are usually located in the proximal appendix and may be solitary or multiple  . Synchronous polyps in the colon have been described in up to 25% of the cases. Multiple appendiceal polyps are well described in familial polyposis and Puetz-Jeghers syndrome  . Histologically mucinous cystadenomas are the most common benign polyps followed by villous adenomas and adenomatous polyps , . The ultimate fate of the asymptomatic appendiceal polyps is not known. However the larger polyps are more likely to be symptomatic because of their tendency to occlude the appendiceal lumen. The risk of carcinoma in these polyps is probably similar to the colonic polyps. Such patients should be subjected to the same surveillance program as those with colonic polyps  .
Benign neoplasms of the appendix have rarely been seen or removed at colonoscopy. The commonest benign appendiceal neoplasm seen during colonoscopy are villous adenomas , .The larger sized villous adenomas are sometimes associated with intussusception of the appendix , or in-situ carcinoma , . Adenomatous polyps of the appendix have also been visualized colonoscopically , . Minute appendiceal adenomas have been identified with the use of magnifying endoscopes , . Bailey et al described a case of a caecal polyp where intussusception of the appendix was suspected during the colonoscopic examination. Surgically resected specimen showed a juvenile polyp, which was originating from the appendix and has resulted in a complete intussusception of the appendix  . Benign appendiceal polyps have been safely removed by colnoscopic polypectomy ,. Weinstock et al removed a three centimeter hamartomatous juvenile polyp with a long stalk coming out of the appendiceal orifice, by using an endoloop and a standard monopolar electrocautery  . Endoscopic removal of an pedunculated adenomatous polyp originating from the appendix has also been reported  .
| Other Appendiceal Neoplasms|| |
Mucinous cystadenoma and primary adenocarcinoma of the appendix causing an intussusception have been described , . Only one case of primary appendiceal-lymphoma appearing as a polypoid mass at the appendiceal orifice has been reported  . Colonoscopic biopsy was diagnostic and surgery revealed lymphoma limited to the appendix. A carcinoid tumor appearing as a nodule occupying the appendiceal orifice  , a few cases of goblet cell carcinoid  and a single case of adeno-carcinoid of the appendix  have also been diagnosed by colonoscopic biopsy.
| Intussusception of the Appendix|| |
Intussusception of the appendix is uncommon  and an accurate pre-operative diagnosis is rare ,,,, . Although there may not be any demonstrable cause for appendiceal intussusception, adenomatous or juvenile polyps, mucinous cystadenoma, adenocarcinoma, carcinoid as well as endometriosis at the appendiceal orifice have all been reported as a cause of the intussusception ,,,,,,,,, . The clinical picture may vary from acute appendicitis, recurrent right iliac fossa pain, intermittent painless rectal bleeding to an asymptomatic finding at laparotomy, barium enema or colonoscopy ,. The diagnosis should be suspected on barium enema when an elongated polypoid lesion at the lower pole of the caecum is noted combined with non-filling of the appendix in any patient without a history of prior appendectomy ,. At colonoscopy it may appear as a sessile or elongated polypoid mass, depending on whether the appendix is partially or completely inverted. Because it can be mistaken for a polyp awareness of such lesions in differential diagnosis is important ,,,,,,, In intussusception the base is typically thinner than the body of this rather tubular polyp. There is no true stalk. The polyp is covered with a normal looking mucosa, which may appear somewhat congested  . Ocassionally a dimple at the tip of the polyp might make it look like "foreskin and the glans". If the dimple get smaller on air insufflation the diagnosis of intussusception can be made with confidence  . Lack of proper diagnosis will lead to complications after endoscopic removal of such "polyps".
| Colonoscopic Appendectomy in Intussusception|| |
Wirtshaffer et al were the first to report a case of colonoscopic appendectomy in 1976  . A caecal polyp after removal histologically proved to bean inverted appendix. The patient developed right lower quadrant pain and leukocytosis in the post polypectomy period however no surgery was needed and the patient was managed conservatively. Since then five more cases have been reported ,,,, .. Gaylord reported an uncomplicated colonoscopic removal of what pathologically proved to be a totally inverted appendix. Fazio et al reported cecal perforation after endoscopic removal of an intussuscepted appendix which was mistaken as a polyp  . Cipolletta et al endoscopically identified a completely inverted appendix as a 2.5 cm cecal polyp  . A standard polypectomy was performed followed by a period of observation. No signs of peritoneal irritation were noted. A small carcinoid tumor was present in the appendix. It is therefore advisable to perform gross examination of all caecal polyps after colonoscopic removal. An inadvertently removed appendix can thus be easily identified. Such a practice will alert the endoscopist to take timely and appropriate actions needed for an expected perforation. Development of endoscopic accessories such as endoloops and endoclips in recent years have enhanced the therapeutic endoscopists ability to prevent, as well as deal with, potential complications of removal of large polyps. Sriram et al reported a case where an inverted appendix was suspected during a colonoscopic examination  . After a prophylactic, endoloop was applied at the base of the appendix, it was removed safely by endoscopic polypectomy. Histologic examination of the appendix revealed an unsuspected endometriosis  .
It is recommended that once there is a suspicion of an inverted appendix, endoscopic removal should be considered because the possibility of an underlying pathology cannot be excluded. Routine use of endoclips or endoloops while resecting such suspected lesions and a period of close observation after polypectomy will minimize the potentially serious complications.
| Surgically Inverted Appendix or Appendiceal Stump|| |
Total inversion of the appendix is an old method of treating non-inflamed appendix. The appendix is supposed to undergo total necrosis after inversion especially if the vascular supply is interrupted by careful suturing. However remnants of appendix may exist long after total inversion. A report from Finland described endoscopic features in six cases of inverted appendix  . Typical appearance is that of a smooth 3-5 cm long polyp in the area of the appendix. The lesion is freely mobile in the lumen and is covered with normal mucosa. The endoscopic appearance is quite uniform. Therefore a similar endoscopic appearance and a history of inversion of the appendix should justify the diagnosis  . Surgically inverted appendix has been removed safely during colonoscopy ,, . Endoscopic removal of such "inverted appendiceal polyp" should be safe since the serosal orifice has been closed surgically. Sometimes after an appendectomy the remaining stump is inverted into the caecum. Healthy invaginated appendiceal stump following appendectomy can lead to an erroneous diagnosis as a polyp at the cecal pole at subsequent colonoscopy . In such cases the stump appears as a small protrubrance covered with a smooth normal colonic mucosa. The appendiceal orifice is easily identified in the center of this protrubrance  . Irregularity of this area should be carefully evaluated as a case of adenocarcinoma arising from the appendiceal stump has been described  . Ulcerations of the appendiceal stump have resulted in massive lower intestinal haemmorhage many years after the appendectomy  . The reason of this delayed ulceration is not clear. Mass et al were able to safely remove an appendiceal stump ulcerated with a fungal infection one year after the appendectomy  .
| Appendix and Inflammatory Bowel Disease|| |
The aetiology of ulcerative colitis is unknown. However, much interest has been devoted recently to the relationship between appendectomy and ulcerative colitis (UC). Appendectomy appears to have a protective effect and reduces the chance of developing UC ,, . Appendix is frequently inflammed in resected colon specimens from patients with pan-colitis  . It has also been noted that the appendix can be involved as a skip lesion in patients with left sided ulcerative colitis, separated from the involved distal segment by macroscopically and microscopically uninvolved mucosa , . The clinical significance of this finding is starting to emerge. Appendicitis may be the initial manifestation of Crohns disease  . Some 20-25% patients with Crohns appendicitis have concurrent Crohns disease elsewhere in the gastrointestinal tract. Crohns disease develops elsewhere in the gut in about 10% of patients after resection of isolated Crohns appendicitis. Although appendectomy is more frequent but it is not proven to be a risk factor in Crohns disease  .
| Appendiceal orifice inflammation (AOI), Appendectomy and Ulcerative Colitis|| |
Appendiceal orifice inflammation (AOI) as a skip lesion in ulcerative colitis might be quite common. The AOI consists of mucosal erythema, friability, granularity and presence of mucopus, erosions or ulcerations at the appendiceal orifice without any mucosal changes in the caecum or ascending colon. It is unlikely to be a pseudo-skip lesion due to segmental healing of colitis from previous medical therapy. Yang et al did not find even a single case of lesion similar to AOI in more than 3500 colonoscopies, although the appendiceal orifice area was carefully observed  . They suggest that the appendiceal skip lesion favours the diagnosis of ulcerative colitis. Although the clinical significance of this finding remains uncertain at present, there are some very interesting emerging facts. There is an evidence to suggest that appendectomy might be protective against the development of ulcerative colitis , . In a recent large population study, Andersson et al confirmed the inverse relationship between appendectomy and the development of ulcerative colitis  . They demonstrated that ulcerative colitis developed less frequently in persons who have undergone an appendectomy before the age of 20 years, particularly when this appendectomy was performed for acute inflammatory disease of the appendix. Does it mean that the appendiceal inflammation is a "source" of continued inflammatory activity more distally? It also has certain consequences for diagnosis. At least in one study patients with an AOI at initial examination suffered from a more aggressive disease course and had more frequent relapses  . This raises an interesting question. Should all patients with left sided colitis, or at least the ones with severe disease, have total colonocscopy and a careful look of the periappendiceal region? It may also be important for treatment, because topical therapy is often inadequate in these patients  . Okazaki et al were the first to document that an appendectomy resulted in marked reduction in the inflammatory activity and clinical improvement in a patient with left sided colitis  . They demonstrated an increase in the ratio of CD4 to CD8 lymphocytes from the appendix as well as the rectum of their patient, After the appendectomy they were able to document a significant reduction in the production of interferon gamma by the rectal lymphocytes. They concluded that removal of the appendix altered the T-helper (Thl/Th2) balance, and this lead to reduction in the inflammatory process and improvement in the patient's colitis. Will laparoscopic appendectomy become an important modality of treatment in refractory left sided colitis? This interesting issue has been addressed in a study reporting laparoscopic appendectomies in patients with refractory ulcerative colitis  . More studies are needed to shed more light on this interesting observation.
| Acute appendicitis|| |
Is there any role of colonoscopy in acute appendicitis and its complications? Some interesting observations have been reported over the past decade. Although most of these were incidental findings during colonoscopy some useful information can be obtained. More recently therapeutic applications in abscess and fistulas have been reported. For the purpose of discussion the available endoscopic data on this issue is reviewed. (a) Endoscopic findings in acute appendicitis and peri-appendiceal abscess:
Ohtaka et al reported a case of pericaecal appendiceal abscess presenting as a submucosal caecal mass  . An area of ulceration was seen which on biopsy resulted in drainage of pus into the caecal lumen. They also summarized five more cases where the abscess was recognized during colonoscopy and pus was drained into the caecum  . Uehara et al described a case where pus was seen coming out of the appendiceal orifice  . Although the patient was asymptomatic at the time of colonoscopic examination, subsequent surgery confirmed an acutely inflammed appendix. (b) Appendicitis as a complication of colonoscopy: There have been reports of acute appendicitis occurring after colonoscopic examinations for unrelated causes ,, . Potential etiologic mechanisms for the development of appendicitis following colonoscopy include: a) pre-existing sub-clinical appendicitis, b) baro-trauma caused by over inflation, c) introduction of an appendicolith inside the appendix, d) traumatic intubations of the appendix, and e) gluteraldehyde induced appendicitis resulting from the influx of residual glutaraldehyde into the appendix during washing of the cecum , . Colonoscopy may promote the development and progression of inflammation including possible perforation during acute phase of Appendicitis  .
(c) Appendicolith disimpaction and Prevention of acute appendicitis:
Obstruction of the appendiceal lumen by a faecolith with subsequent bacterial proliferation and invasion of hypoxic mucosa is thought to be implicated in acute appendicitis  . Nadler and Tanger reported a case, with nice photographic documentation, of an appendicolith impacted in the appendiceal orifice  . An open biopsy forceps was used to "scoop" the appendicolith free from the orifice. The patient had no symptoms related to the appendix. Disimpaction of all appendicoliths identified during colonoscopy is recommended even if the patient is asymptomatic. Because appendicoliths have been found in 77% of gangrenous appendicitis and 42% of patients with appendiceal abscess  . It is probable that removing these appendicoliths will prevent subsequent appendicitis and its complications.
(d) Appendiceal-cutaneous fistulas: colonoscopic management?
Lee and Jeong described two patients with fecal fistula that has developed after surgery for perforated appendicitis  . In both cases the fistulous opening was identified in the caecum during colonoscopy. Multiple endoclips were applied to close the caecal orifices of the fistulas. This resulted in complete healing of the fistulas. This interventional endoscopic approach is recommended as an early option for the treatment of fecal fistula. It may become the preferred method of treatment because of its simplicity and safety as compared with the surgical approach and because it is likely to reduce hospital stay.
(e) Acute appendicitis as a sign of colo-rectal carcinoma:
Rarely acute appendicitis can be an initial manifestation of colo-rectal malignancy. Arnbjornsson found an unusually high incidence of colon carcinoma in patients over age 40 presenting with appendicitis  . It is suggested that any patient over age 40 be carefully checked for colonic cancer following an episode of acute appendicitis, regardless of how it was treated. In cases of appendiceal mass colonoscopy should be done when the appendiceal mass has settled in patients over 40 to exclude colon carcinoma.
Under what conditions should colonoscopy be performed in cases of acute appendicitis or pericecal abscess? There is no clear answer at present. It is recommended that colonoscopy should only be performed in a highly selected group of patients with atypical appendicitis or the patients with uncertain diagnosis of appendiceal perforation. In such situations colonoscopy may be helpful in diagnosis of other conditions which may be clinically confused with appendicitis. In future endo-sonographic information with EUS and EUS guided FNA might greatly enhance the diagnostic and therapeutic benefits of an endoscopic approach in this situation.
| Unusual and miscellaneous problems|| |
(a) Acute lower gastrointestinal bleeding from the appendix:
The endoscopic visualization of bleeding from the appendiceal orifice from any cause is extremely rare. Bleeding from isolated Crohn's of the appendix  , vascular ectasia of the appendix  and appendiceal endometriosis  have been reported. These patients presented as massive lower gastrointestinal bleeding. The bleeding was endoscopically identified to be originating from within the appendiceal orifice at the time of urgent colonoscopy for hematochezia. All cases were successfully treated with laparoscopic appendectomy and major colonic resection was thus avoided. Appendiceal bleeding should be suspected when fresh blood is visualized in the caecal area but no obvious lesion is seen in the caecum or terminal ileum. Vigorous washing and careful observation along with a high index of suspicion in such cases may lead to correct diagnosis.
(b) Foreign Bodies in the Appendix:
Foreign bodies can be caught in the appendiceal orifice. Meltzer et al reported a case of obstruction of the appendix simulating colon carcinoma  . At colonoscopy a toothpick embedded in the appendix was found. The free end of the wooden toothpick was protruding from the appendiceal orifice and was intermittently scratching the opposite wall of the caecum. This was grasped by a biopsy forceps and simply pulled out without any complications. It was a 7cm wooden toothpick with pointed both ends. In another case a nail stuck in the appendiceal orifice was removed endoscopically  . A few cases have also been reported where a dental drill or its broken fragment has lodged in the appendiceal orifice  . Goenka et al reported a patient with right iliac fossa pain where an ascaris was seen emerging from the appendiceal orifice  . This was caught with a snare and removed. Ascaris is known to enter the appendix and cause appendiceal perforation in endemic areas. Similarly entrobius vermicularis has been seen coming in and out of the appendiceal orifice (Personal observation).
(c) Appendiceal fistula and penetration into the colon:
Fistula formation between the vermiform appendix and the sigmoid colon has been reported and most cases have resulted from appendicitis or diverticulitis ,. Kurakawa et al reported a case where the appendix had penetrated the sigmoid colon without a fistula and was seen as a large sessile polyp on colonoscopy  . Fortunately no endoscopic attempt was made to remove this polyp. At surgery the tip of the appendix was seen protruding into the sigmoid colon. Histologically the appendix had penetrated the serosa and muscle layer and was only covered by a thin layer of colonic mucosa. Keating et al recently reported as cases of appendiceal carcinoma penetrating the rectum and presenting as a sessile villous adenoma  . The orifice of an appendiculo-ileo-vesical fistula  and an aorto-appendiceal fistula  has been identified during colonoscopy.
(c) Rare inflammatory conditions:
Gastrointestinal tuberculosis, seen in endemic regions, affects most commonly the ileo-cecal area. Involvement of appendix alone is rare. Singh et al described 17 cases of isolated tuberculosis of the appendix  . A button like elevation of the inverted appendiceal orifice in the caecum due to inflammatory infiltration by actinomycosis has been reported  .
(e) Miscellaneous Problems:
Colonoscopic appendicography, by injecting soluble contrast material in the appendiceal lumen during colonoscopy, has been proposed as a simple diagnostic measure for surveying the position and anatomical qualities of the appendix  . It maybe complementary to ileo-colonoscopy in evaluating appendiceal diseases.
| Future directions|| |
US and CT scan finding pointing towards an appendiceal pathology are being recognized more often. Attempts will be made to reach a more accurate preoperative diagnosis and to provide a less invasive therapuetic alternative. Although colonoscopy has its limitations, its role in such clinical situations is being emphasized. EUS, and fine intraluminal sonoprobes in particular, might prove more useful in defining accuracy. Miniscopes and catheter scopes provide an interesting avenue to visualize the appendiceal lumen from within. Currently it appears to be of academic interest only, but opens an interesting area of early diagnosis of asymptomatic pathology. Technical developments might add new insight and open some interesting avenues for future research.
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Fazal Imtiaz Khawaja
Consultant Gastroenterologist, P. 0. Box 1925, Al Madinah AI Munawarrah
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