A 66-year-old man presented with recurrent abdominal pain for half a month. He wrongly
thought it was acute gastritis, without initially paying any attention to it; however,
as the pain became aggravating, he came to our hospital. An abdominal computed tomography
(CT) scan revealed a peri-appendiceal abscess ([Fig. 1]). Endoscopic retrograde appendicitis therapy (ERAT) was then performed.
Fig. 1 Abdominal contrast-enhanced computed tomography scan showing an irregular mass with
a size of 5.5 × 4.5 cm located in the ileocecal area (red arrowheads).
At colonoscopy, the cecum, including the ileocecal valve, was seen to be severely
swollen and enlarged. A transparent cap fixed to the colonoscope was used to detect
the appendiceal orifice. Milk-like pus was observed pouring out from the folded mucosa,
which was presumed to be where the appendiceal orifice was situated. When this was
successfully cannulated with an endoscopic retrograde cholangiopancreatography (ERCP)
sphincterotome, a considerable quantity of pus poured out from the appendiceal cavity.
The abscess cavity was shown on fluoroscopy to be 5.0 × 4.5 cm in size. Irrigation
with metronidazole was performed until the drainage fluid was clear. Finally, a 6-Fr × 6-cm
pancreatic stent was introduced into the appendiceal cavity over a guidewire ([Fig. 2]; [Video 1]). The patient recovered uneventfully after the procedure.
Fig. 2 Images of endoscopic retrograde appendicitis therapy (ERAT) being performed in a
patient with an appendiceal abscess showing: a severe swelling and enlargement of the cecum, including the ileocecal valve; b cannulation of the appendiceal orifice being performed with an endoscopic retrograde
cholangiopancreatography sphincterotome; c pus flowing out, with decompression of the intra-appendiceal pressure; d the irregularly shaped cavity of the peri-appendiceal abscess (5.0 × 4.5 cm in size)
clearly displayed on fluoroscopy; e a 6-Fr × 6-cm pancreatic stent that was placed into the appendiceal cavity over a
guidewire to provide continuous drainage; f the correctly positioned stent on radiographic imaging.
Video 1 Endoscopic drainage of a peri-appendiceal abscess with endoscopic retrograde appendicitis
therapy (ERAT) in a 66-year-old man.
A peri-appendiceal abscess is a condition of worsening acute appendicitis, with an
incidence rate of approximately 4 %–20 % in patients with acute appendicitis [1]. Percutaneous drainage is recommended by the World Society of Emergency Surgery
as the first-line treatment for the condition [2]. However, the minimally invasive procedure is also associated with several complications,
such as bleeding, fistula formation, or injury to adjacent organs [1]
[2].
ERAT is an emerging technique that is used to manage acute appendicitis [3]. As experience has accumulated, we attempted to use ERAT to manage an appendiceal
abscess. Between April 2020 and February 2021, nine patients with an appendiceal abscess
underwent ERAT in our center. All of the patients had good outcomes, without the need
for surgery. Within this small sample, ERAT seems to be promising in the treatment
of appendiceal abscess; however, further research should be carried out.
Endoscopy_UCTN_Code_CPL_1AJ_2AF
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