Dig Dis Sci (2016) 61:3099–3101

DOI 10.1007/s10620-016-4299-7

EDITORIAL

ERAT: A New ERA for Appendicitis Therapy?

Published online: 21 September 2016

Appendicitis, a common cause of acute abdomen, usually unnecessary when the clinical diagnosis is nearly certain,
occurs in the 2nd or 3rd decade of life with an incidence of with less diagnostic certainty, the treatment plan is altered
233/100,000 [1]. Its pathophysiology is thought to result in *60 % of suspected cases.
from appendiceal obstruction due to fecal material, undi- The ‘gold standard’ for treatment of acute appendicitis is
gested food, foreign body, enlarged lymphoid follicles, open or laparoscopic surgical appendectomy. Despite
stenosis, or twisting of the organ. Initial clinical manifes- higher cost, laparoscopic appendectomy has gained popu-
tations include right lower quadrant abdominal pain, nau- larity due to a lower rate of wound infection, less postop-
sea, vomiting, and low-grade fever. Classic physical erative pain, shorter hospital stays, and lowered morbidity
findings such as tenderness at McBurney’s point (1.5–2 in. [4, 5]. A non-operative approach to acute appendicitis has
from the anterior superior iliac spine [ASIS] on a straight also been suggested: In a randomized controlled trial
line from the ASIS to the umbilicus), psoas sign (right comparing antibiotics alone versus appendectomy
lower quadrant pain with passive right hip extension), and (n = 243), the complication rate was lower with antibiotics
Rovsing’s sign (pain in the right lower quadrant with pal- (4.9 vs. 8.4 %) but the recurrence rate was 26 % within a
pation of left lower quadrant) either may not be present year [6].
early in the disease course or are difficult to elicit in an Endoscopic retrograde appendicitis therapy (ERAT) is a
acute abdomen. Leukocytosis is the only consistently new and minimally invasive technique for the diagnosis
abnormal routine laboratory abnormality [2]. and treatment of acute appendicitis patterned after the
Imaging modalities such as computed tomography (CT) success that endoscopic retrograde cholangiopancreatog-
(sensitivity, 94–100 %; specificity, 93–100 %) and ultra- raphy (ERCP) achieved in the treatment of acute cholan-
sonography (sensitivity, 74–100 %; specificity, 88–99 %) gitis. For ERAT, a colonoscope is used to access the
are increasingly used to confirm acute appendicitis and appendiceal orifice and inspect the area for signs of acute
decrease the rate of negative appendectomy [3]. Although appendicitis such as hyperemia, edema, pus, or impacted
preoperative CT scanning reduces the negative appendec- appendicolith. A transparent cap attached to the tip of the
tomy rate by *20 %, it involves ionizing radiation and colonoscope improves visualization of the appendiceal
may delay surgery. Although diagnostic imaging may be orifice by flattening folds when pressed against the mucosa.
The appendiceal lumen is cannulated with a 0.035-in. in
diameter ERCP guidewire to facilitate dye injection for
& Doumit S. BouHaidar fluoroscopic imaging and to obtain access for therapy.
doumit.bouhaidar@vcuhealth.org Definitive treatment includes irrigation, appendicolith
1
removal, and plastic stent placement for appendiceal orifice
Department of Internal Medicine, Division of
stenosis. The bowel can be prepared for the procedure with
Gastroenterology, Virginia Commonwealth University,
1200 E Broad Street, P.O. Box 980341, Richmond, 500 ml of a normal saline solution delivered as a low-
VA 23298-03411, USA pressure enema.
2
Division of Gastroenterology, McGuire VAMC, The initial report of appendicitis diagnosed and treated
Richmond, VA, USA with ERAT was in 1995 [7]. In 2012, a small pilot study

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3100 Dig Dis Sci (2016) 61:3099–3101

from China was published [8]; the same Chinese group resection. Since the appendix may serve a beneficial
published, in 2015, a multicenter retrospective study of 41 immunologic function and support the gut microbiome by
patients with suspected acute uncomplicated appendicitis helping recolonize the colon with commensal flora, its
managed with ERAT. Of 34 patients (83 %) diagnosed preservation appears to be desirable [12].
with acute appendicitis, 97 % were successfully treated How should a patient with suspected acute appendicitis
with ERAT [9]. be managed currently? Initially, routine measures such as
In this issue of Digestive Diseases and Sciences, Li et al. obtaining a careful history and performing a physical
[10] report retrospectively on 21 patients who underwent examination, and obtaining routine laboratory tests and
ERAT to diagnose and treat acute appendicitis. The radiologic imaging (CT and/or ultrasound) are required. In
patients underwent colonoscopic direct visualization of the light of the initial data obtained, alternative diagnoses
appendiceal orifice as well as endoscopic retrograde should be considered such as acute diverticulitis, Crohn’s
appendicography (ERA), the latter involving injection of a disease, pelvic inflammatory disease, ectopic pregnancy,
soluble contrast agent with fluoroscopic guidance into the ureteral stone, and endometriosis. Although surgery
appendix to evaluate for radiographic features of appen- remains the ‘gold standard’ against which all other inter-
dicitis such as irregular contour, enlarged appendiceal ventions should be compared, available studies suggest that
lumen (C5 mm), appendicolith, and luminal stenosis. ERAT, in those experienced with the procedure, is a safe
The authors are to be commended for reporting a rela- and effective diagnostic and therapeutic procedure with a
tively large case series illustrating the utility of ERAT to reported complication rate of *5 % with no need for
diagnose and treat acute appendicitis. The sample size is emergent surgical appendectomy in cases amenable to
sufficient to serve as a basis for the design of a prospective endoscopic treatment. Successful completion of a
randomized study. The diagnosis of acute appendicitis was prospective, randomized, controlled trial comparing sur-
confirmed in 20 of 21 (95 %) patients—15 (75 %) by gery versus ERAT is needed in order to determine whether
endoscopic inspection and 5 (25 %) by ERA. The reason ERAT will supplant existing interventions in the treatment
the five patients diagnosed by ERA had no endoscopic of acute appendicitis.
abnormalities is unknown, but it is possible that inflam-
mation was limited to the tip or the body of the appendix.
Fluoroscopy also enabled therapy to be tailored to the
findings, for instance placing a plastic stent for appendiceal References
orifice stenosis.
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