Endoscopic Management of Complicated Appendicitis: Expanding Horizon of Therapeutic Endoscopy

Case Description

A 35-year-old male presented with acute-onset right lower abdominal pain, high-grade fever, and chills. He had tachycardia, localized guarding in the right iliac fossa, and leucocytosis (total leucocyte count 13,200/mm³). Ultrasound of abdomen showed a thickened and inflamed appendix and an ill-defined pelvic collection. Contrast-enhanced computed tomography (CECT) showed inflamed and distended appendix with appendicolith, and a pelvic collection (6 × 8 cm) ([Fig. 1A, B]). Due to obesity (body mass index 36.4), percutaneous drainage of pelvic collection was deemed difficult. Hence, the patient was planned for surgery, which he refused. So, he was taken up for EUS-guided pelvic collection drainage and endoscopic retrograde appendicitis therapy (ERAT) after informed consent. The pelvic collection was identified at 15 cm from the anal verge and was punctured using 19-G EUS-FNA needle and frank pus was aspirated. After dilatation using a 6-mm Hurricane balloon (Boston Scientific, USA), two 7 Fr × 5 cm double pigtail plastic stents were placed and free flow of pus was noted. The patient became afebrile after 24 hours. After stabilization, colonoscopy was performed for ERAT under CO₂ insufflation. On colonoscopy, the swollen and bulky appendicular opening was identified. The orifice was cannulated using a standard endoscopic retrograde cholangiography (ERC) cannula, and a retrograde appendicogram showed no obvious communication with the peritoneal cavity, and a small appendicolith near the appendicular orifice ([Fig. 2A, B]). Pus and appendicolith were extracted using a biliary extraction balloon. He was discharged after 5 days. Repeat CECT showed complete resolution of pelvic collection and spontaneous external migration of the plastic stents ([Fig. 3A, B]). On follow-up till 3 months, the patient remained asymptomatic ([Supplementary Video 1]).

Video herunterladen

Video 1 Showing Endoscopic Management of Complicated Appendicitis

Fig. 1 Preintervention CT. (A) Axial contrast-enhanced CT at the level of the base of the cecum showing an appendicolith (arrow) with a thickened appendix (short arrow). Also note extensive fat stranding. (B) Axial contrast-enhanced CT at a lower level showing a large pelvic collection suggestive of appendicular perforation.

Fig. 2 (A, B) Endoscopic retrograde appendicogram showing contrast-filled normal-sized appendix without any contrast extravasation (yellow arrow), and presence of small appendicolith (green arrow).

Fig. 3 Post-intervention CT. (A) Axial contrast-enhanced CT at the same level (as in [Fig. 1]) showing no appendicolith (arrow). The appendicular thickening (short arrow) and fat stranding have resolved. (B) Follow-up CT showing almost complete resolution of the pelvic collection along with spontaneous external migration of the stents.

Practical Implications for Endoscopists

• Although antibiotic therapy has been found to be non-inferior to appendicectomy, it has been associated with high recurrence rate especially in the presence of appendicolith.[1] [2]

• In recent years, ERAT has emerged as a minimally invasive treatment for acute appendicitis with faster recovery and shorter hospital stay with high clinical success rate (>95%), low adverse event rates (<1%), and acceptable recurrence rates (6%).[3] [4]

• Although the majority of studies on ERAT have been mainly focused on uncomplicated appendicitis, a few cases have also been published on its usefulness in complicated appendicitis.

• The index patient had a complicated appendicitis with the presence of appendicolith and pelvic collection. In this patient, we used both modalities, EUS-guided drainage of pelvic collection along with ERAT with removal of appendicolith to reduce the chances of recurrent appendicitis. This case highlights a unique scenario in which ERAT can be combined with therapeutic EUS to have an optimal outcome in the presence of adequate expertise.

• References

• 1 Scheijmans JCG, Haijanen J, Flum DR. et al. Antibiotic treatment versus appendicectomy for acute appendicitis in adults: an individual patient data meta-analysis. Lancet Gastroenterol Hepatol 2025; 10 (03) 222-233
• 2 Bertrand MM, Lefrant JY, Prudhomme M. A randomized trial comparing antibiotics with appendectomy for appendicitis. N Engl J Med 2021; 384 (09) 880-881
• 3 Dhindsa B, Naga Y, Praus A. et al. Endoscopic retrograde appendicitis therapy for acute appendicitis: a systematic review and meta-analysis. Endosc Int Open 2022; 10 (07) E1014-E1019
• 4 Zhang A, Fan N, Zhang X. et al. Endoscopic retrograde appendicitis therapy. Therap Adv Gastroenterol 2024; 17: 17 562848241275314