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CC BY 4.0 · Endoscopy 2024; 56(S 01): E1026-E1027
DOI: 10.1055/a-2462-2098
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Unexpectedly detected appendiceal perforation during endoscopic direct appendicitis therapy despite negative preoperative computed tomography imaging

Authors

  • Jun Cai‡

    1   Department of Gastroenterology, South China Hospital, Medical School, Shenzhen University, Shenzhen, China (Ringgold ID: RIN701237)

  • Yanli Wang‡

    2   Department of Pediatrics, South China Hospital, Medical School, Shenzhen University, Shenzhen, China (Ringgold ID: RIN701237)

  • Silin Huang

    1   Department of Gastroenterology, South China Hospital, Medical School, Shenzhen University, Shenzhen, China (Ringgold ID: RIN701237)

  • Suhuan Liao

    1   Department of Gastroenterology, South China Hospital, Medical School, Shenzhen University, Shenzhen, China (Ringgold ID: RIN701237)

  • Jianzhen Ren

    1   Department of Gastroenterology, South China Hospital, Medical School, Shenzhen University, Shenzhen, China (Ringgold ID: RIN701237)

  • Yitian Guo

    1   Department of Gastroenterology, South China Hospital, Medical School, Shenzhen University, Shenzhen, China (Ringgold ID: RIN701237)

  • Nan Liu

    3   Institute of Environment and Health, South China Hospital, Medical School, Shenzhen University, Shenzhen, China (Ringgold ID: RIN701237)

Supported by: The Clinical Teaching Base Teaching Reform Research Project of School of Medicine in Shenzhen University YXBJG202426
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Endoscopic direct therapy, such as endoscopic direct appendicitis therapy (EDAT) and endoscopic direct diverticulitis therapy (EDDT), are now the preferred treatments for acute uncomplicated appendicitis and diverticulitis [1] [2]. EDAT stands out for its minimal invasiveness, facilitating real-time observation and targeted treatment, while also delivering high definition imaging that enhances diagnostic accuracy [3]. We report a case of appendiceal perforation that was adeptly diagnosed through direct visualization using a 9-Fr cholangioscope (EyeMax; Micro-Tech, Nanjing, China) ([Video 1]).

An appendiceal perforation is unexpectedly detected during endoscopic direct appendicitis therapy despite there having been no evidence of this on preoperative computed tomography.Video 1

A 6-year-old girl presented with lower right quadrant abdominal pain, and a computed tomography (CT) confirmed the diagnosis of acute obstructive appendicitis, but did not initially indicate any signs of perforation ([Fig. 1]). She was subsequently admitted for EDAT to alleviate her condition. During the procedure, the appendiceal orifice was found to be excessively inflamed ([Fig. 2] a). Upon seamless insertion of the cholangioscope into the appendiceal lumen, purulent secretions were observed ([Fig. 2] b), and a perforation was visualized ([Fig. 2] c). The EDAT was promptly aborted, and the patient was swiftly transferred to undergo a laparoscopic appendectomy, which verified the presence of acute appendicitis with appendiceal perforation ([Fig. 3]). The patient has since made an excellent postoperative recovery and has not experienced any subsequent discomfort.

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Fig. 1 Computed tomography scan images showing: a on coronal view, an enlarged appendix (12 mm in diameter), edge-blurred, with no evidence of fluid or gas accumulation; b on sagittal view, significant thickening of the appendix, high density shadows in the lumen, and no evidence of fluid or gas accumulation.
Zoom
Fig. 2 Images during endoscopic direct appendicitis therapy (EDAT) showing: a the cholangioscope passing into the appendiceal lumen; b, c on cholangioscopic view: b congestion, edema, and a small amount of purulent discharge in the appendiceal cavity; c an appendicular perforation.
Zoom
Fig. 3 The postoperative specimen, which confirmed the appendiceal perforation, on: a macroscopic appearance; b histopathologic view, with obvious inflammation, edema, and a large amount of necrotic tissue in the cavity.

Typically, appendiceal perforation is diagnosed through a combination of clinical symptoms, abdominal ultrasound, and especially CT imaging [4], necessitating immediate surgical intervention upon confirmation [5]. In this unique case, the CT scan failed to detect any signs of perforation; however, direct visualization with the cholangioscope did uncover the issue. This timely diagnosis facilitated immediate surgical intervention, thereby averting the escalation to more severe complications. To our knowledge, this represents the first case where appendiceal perforation was diagnosed via direct visualization cholangioscopy, providing an invaluable contribution to the rapid detection of such complications in the management of acute appendicitis.

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Conflict of Interest

The authors declare that they have no conflict of interest.


Correspondence

Silin Huang, MD
Department of Gastroenterology, South China Hospital, Medical School, Shenzhen University
No. 1, Fuxin Road
Longgang District, Shenzhen 518116
P. R. China   

Publication History

Article published online:
22 November 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).

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Zoom
Fig. 1 Computed tomography scan images showing: a on coronal view, an enlarged appendix (12 mm in diameter), edge-blurred, with no evidence of fluid or gas accumulation; b on sagittal view, significant thickening of the appendix, high density shadows in the lumen, and no evidence of fluid or gas accumulation.
Zoom
Fig. 2 Images during endoscopic direct appendicitis therapy (EDAT) showing: a the cholangioscope passing into the appendiceal lumen; b, c on cholangioscopic view: b congestion, edema, and a small amount of purulent discharge in the appendiceal cavity; c an appendicular perforation.
Zoom
Fig. 3 The postoperative specimen, which confirmed the appendiceal perforation, on: a macroscopic appearance; b histopathologic view, with obvious inflammation, edema, and a large amount of necrotic tissue in the cavity.