Endoscopic direct therapy for appendicitis and diverticulitis in one patient with right-sided abdominal pain

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.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Talan DA, Di Saverio S. Treatment of acute uncomplicated appendicitis. N Engl J Med 2021; 385: 1116-1123
• 2 Sartelli M, Weber DG, Kluger Y. et al. 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting. World J Emerg Surg 2020; 15: 32
• 3 Gerges C, Beyna T, Tang RSY. et al. Digital single-operator peroral cholangioscopy-guided biopsy sampling versus ERCP-guided brushing for indeterminate biliary strictures: a prospective, randomized, multicenter trial (with video). Gastrointest Endosc 2020; 91: 1105-1113
• 4 Kong LJ, Liu D, Zhang JY. et al. Digital single-operator cholangioscope for endoscopic retrograde appendicitis therapy. Endoscopy 2022; 54: 396-400

Publication History

Article published online:
07 August 2024