Endoscopic retrograde appendicitis therapy for giant periappendiceal abscess with intestinal obstruction

In recent years, endoscopic retrograde appendicitis therapy (ERAT) has been widely used in the treatment of acute uncomplex appendicitis [1]. However, the treatment of a periappendiceal abscess has always been a challenge. Early surgery may cause serious complications such as total peritonitis and postoperative anastomotic leakage [2]. We report a case of acute appendicitis with a giant periappendiceal abscess and intestinal obstruction. Through ERAT, full endoscopic drainage was achieved and the intestinal obstruction was quickly resolved.

A 34-year-old woman presented with abdominal pain, nausea, vomiting, and no anal exhaust defecation for 2 days. Computed tomography (CT) showed acute appendicitis with a giant periappendiceal abscess and intestinal obstruction ([Fig. 1]). After informed consent was given, an ERAT procedure was performed ([Video 1]) with the patient under general anesthesia. The intestine was prepared through colon dialysis. Colonoscopy showed significant protrusion of the mucosa around the appendix. The appendiceal cavity was successfully incised using a duodenal papillary incision knife ([Fig. 2]). Then a guidewire was delivered to the giant periappendiceal abscess, which was clearly visualized by iohexol radiography ([Fig. 3]). After that, a biliary plastic stent was successfully implanted. A large amount of pus flowed out of the stent ([Fig. 4]). The procedure was performed successfully without any adverse events. Postoperative abdominal X-ray indicated no signs of intestinal obstruction. The patient recovered well.

Fig. 1 Before endoscopic retrograde appendicitis therapy, computed tomography (CT) showed acute appendicitis with a giant periappendiceal abscess (9.0 cm × 6.3 cm) and intestinal obstruction.

Video 1 Endoscopic retrograde appendicitis therapy for continuous drainage of giant periappendiceal abscess and the process of removing the stent under colonoscopy.

Fig. 2 Colonoscopy showed protrusion of the mucosa around the appendix. The duodenal papillary incision was used for successful insertion into the appendix cavity.

Fig. 3 The guidewire was delivered to the appendix pus cavity, and then iohexol radiography clearly showed the giant periappendiceal abscess.

Fig. 4 After a plastic biliary stent was implanted into the appendix pus cavity, a large amount of pus flowed out of the stent.

Follow-up CT after 2 months showed that the periappendiceal abscess had fully disappeared ([Fig. 5]). The stent was removed under colonoscopy ([Video 1]). ERAT may be a safe and effective method for adequate drainage of a periappendiceal abscess in the early stage. Further clinical studies with larger samples and long-term follow-up are needed to evaluate this.

Fig. 5 Follow-up CT after 2 months showed that the periappendiceal abscess had fully disappeared and the stent was in place.

Endoscopy_UCTN_Code_CCL_1AD_2AG

Competing interests

The authors declare that they have no conflict of interest.

Acknowledgments

The authors thank the patient involved for permitting the publication of the data regarding his case.

• References

• 1 Ullah S, Ali FS, Shi M. et al. Is it time for global adoption of endoscopic retrograde appendicitis therapy of acute appendicitis?. Clin Res Hepatol Gastroenterol 2022; 46: 102049
• 2 Akingboye AA, Mahmood F, Zaman S. et al. Early versus delayed (interval) appendicectomy for the management of appendicular abscess and phlegmon: a systematic review and meta-analysis. Langenbecks Arch Surg 2021; 406: 1341-1351

Publication History

Article published online:
06 October 2023