Acute appendicitis and cecal diverticulitis are both common causes of acute right-sided
abdominal pain, but it is extremely rare for both to be found in one patient. Acute
appendicitis and diverticulitis are mainly treated through medication and surgical
intervention [1]
[2]. Digital single-operator cholangioscopy (dSOC) has proven effective for managing
inflammation in natural conduits such as the bile duct, pancreatic duct, and appendix
[3]
[4]. Herein, we present endoscopic direct therapy for appendicitis and diverticulitis
in a man with right-sided abdominal pain ([Video 1]).
Initial report on the application of digital single-operator cholangioscopy for endoscopic
direct therapy.Video 1
A 33-year-old man presented with right-sided abdominal pain for 4 days. Abdominal
ultrasonography showed a tubular mass in the right lower quadrant of the abdomen (3.67
× 0.81
cm) and appendicitis was considered ([Fig. 1]
a). Colonoscopy revealed appendicitis and cecal diverticulitis
([Fig. 1]
b). Endoscopic direct appendicitis therapy and endoscopic direct
diverticulitis therapy utilizing dSOC was performed, and a milk-like pus was observed
pouring
out and a substantial volume of fecaliths ([Fig. 2]
a–d). These fecaliths were meticulously fragmented, extracted,
and removed using a disposable basket following repeated lavages with metronidazole
and sodium
chloride ([Fig. 2]
e, f), rendering the mucosa cleansed yet characterized by
roughness and swelling without evidence of perforation ([Fig. 3]
a, b). A 7 Fr pancreatic duct stent was strategically placed to
ensure unobstructed drainage ([Fig. 4]
a, b). The procedure was completed in 165 minutes. The patient’s
abdominal pain was relieved immediately after the procedure. Subsequent computed tomography
revealed fecaliths had been removed completely and the stent discharged ([Fig. 5]). No recurrence or adverse events were noted during the 4-month follow-up.
Fig. 1
a Abdominal ultrasonography showed a tubular mass in the right lower quadrant of the
abdomen (3.67 × 0.81 cm), and appendicitis was considered. b Colonoscopy revealed appendicitis and cecal diverticulitis.
Fig. 2 The process of endoscopic direct therapy. a, b A lot of
milk-like pus was observed pouring out from the appendiceal orifice/cecal diverticulum.
c, d A considerable amount of fecaliths within the diverticular
cavity/appendiceal lumen was visualized using digital single-operator cholangioscopy
(dSOC).
e, f The fecaliths were dissected, extracted, and removed using a
disposable basket under the visual guidance of dSOC.
Fig. 3
a, b Through endoscopic direct therapy, the diverticular
cavity/appendiceal lumen was observed to be clear.
Fig. 4
a, b The stent was strategically placed to ensure unobstructed
drainage.
Fig. 5 Postoperative computed tomography demonstrated fecaliths had been removed completely
and the stent discharged.
As advancements in dSOC continue to evolve, significant innovations in the diagnosis
and management of gastrointestinal diseases have been achieved through endoscopic
direct therapy. This therapy provided a feasible, safe, and effective alternative
approach for diagnosis and management of acute right-sided abdominal pain. To the
best of our knowledge, this is the first reported case of a successful cure of acute
appendicitis combined with diverticulitis with fecalith using endoscopic direct therapy.
This combined approach could reshape the management of acute right-sided abdominal
pain, emphasizing the importance of technological integration in endoscopic practices.
Endoscopy_UCTN_Code_TTT_1AQ_2AF
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