Endoscopic ultrasound-guided transduodenal drainage using forward-viewing echoendoscope for appendiceal abscess

Appendiceal abscesses sometimes require percutaneous drainage [1]. Recently, endoscopic ultrasound (EUS)-guided drainage through the intestinal tract has become possible, even in cases of pelvic or intra-abdominal abscesses resulting from lower gastrointestinal tract disease. However, this approach is usually performed through the rectum or sigmoid colon [2] [3] [4] [5], and its use is challenging for appendiceal abscesses because of their location. Herein, we report a case of appendiceal abscess successfully treated by EUS-guided transduodenal drainage using a forward-viewing echoendoscope.

A 93-year-old woman presented to our hospital with high fever and abdominal pain. Computed tomography (CT) showed appendiceal swelling with surrounding inflammation, prompting initial conservative treatment with antibiotics. However, CT on hospital Day 10 showed a 10-cm appendiceal abscess extending around the transverse part of the duodenum ([Fig. 1]). Percutaneous drainage was challenging due to the surrounding organs. Although the abscess was due to appendicitis, it was in proximity to the duodenum. Therefore, we attempted EUS-guided transduodenal drainage ([Video 1]).

Fig. 1 Computed tomography on hospital Day 10 showing a 10-cm appendiceal abscess extending around the transverse part of the duodenum.

Video 1 Endoscopic ultrasound-guided transduodenal drainage using a forward-viewing echoendoscope for appendiceal abscess.

In order to puncture the abscess from the deeper part of the duodenum, we used a forward-viewing echoendoscope (TGF-UC260J; Olympus Medical Systems, Tokyo, Japan). The abscess was visualized from the inferior duodenal angle before being punctured with a 22-gauge needle under EUS guidance ([Fig. 2]). Contrast medium was injected to confirm that it was an abscess and its extent. A 0.018-inch guidewire (Fielder 0.018; Olympus Medical Systems) was advanced into the abscess ([Fig. 3]). A catheter was inserted over the guidewire to dilate the needle tract and aspirate pus. However, minimal specimen was aspirated due to its high viscosity. A 7-Fr double-pigtail plastic stent was then placed, which subsequently drained the pus ([Fig. 4]). The patient quickly recovered and was discharged 6 days after the procedure. Outpatient CT on postprocedural Day 9 showed a remarkable reduction of the abscess cavity volume ([Fig. 5]).

Fig. 2 Endoscopic ultrasound image. The appendiceal abscess is punctured by a 22-gauge needle through the inferior duodenum angle using a forward-viewing echoendoscope.

Fig. 3 Fluoroscopic image. The appendiceal abscess is confirmed fluoroscopically by injection of contrast medium. A 0.018-inch guidewire is advanced into the abscess, and a catheter is inserted over the guidewire to dilate the puncture site and aspirate pus.

Fig. 4 A 7-Fr double-pigtail plastic stent is placed using a forward-viewing echoendoscope, and effective pus drainage is observed.

Fig. 5 Outpatient computed tomography on postprocedural Day 9 shows a remarkable reduction of the abscess cavity volume.

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Publikationsverlauf

Artikel online veröffentlicht:
31. Januar 2023

• References

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