Scientific Papers

Endoscopic clip-induced acute appendicitis in a patient on chronic hemodialysis: a case report with literature review | Renal Replacement Therapy

Summary of the case

We diagnosed a case of appendicitis caused by an endoscopic clip in a patient on HD. This endoscopic clip was used for gastric ESD 2 years ago. The patient had been asymptomatic since then. Endoscopic clips are typically blunt in shape with a low risk of gastrointestinal perforation; this may explain why the patient was asymptomatic for 2 years.

Pathophysiology of appendicitis caused by foreign bodies

Approximately 80–93% of ingested foreign bodies pass through the gastrointestinal tract without any event; therefore, foreign bodies in the appendix are rare [3]. Fish bones are the most common foreign body, but rarely, dental prostheses and medical devices such as endoscopic clips may also result in appendicitis [4]. A PubMed search using the terms “acute appendicitis” and “hemostatic clip” yielded one published case in English after the year 2009. Ichushi-Web and google scholar search using the terms “appendicitis” and “endoscopic clips” yielded four cases in both sources. These cases are summarized in Table 1 [5,6,7,8,9]. Endoscopic clips might be covered by fecalith and occlude the appendix for appendicitis to develop; this process may proceed for days to years [4].

Table 1 Summary of five cases of endoscopic clip-induced appendicitis and the present case

Management of appendicitis caused by foreign bodies

Surgical appendectomy is preferred in appendicitis caused by foreign bodies. Although interval appendectomy and conservative treatment prior to surgery are options, most cases of appendicitis caused by foreign bodies are treated with an emergency appendectomy. Dislodging foreign bodies once they are lodged in the appendix is challenging owing to peristalsis toward the tip of the appendix [10]. Prophylactic appendectomy may be performed in such cases. Endoscopic removal of foreign bodies in the appendix has also been reported in the literature as another option [11]. In this case, appendicitis was already complicated by an abscess, and an emergency appendectomy was performed. However, emergency appendectomy is usually recommended for all appendicitis cases caused by foreign bodies, regardless of complications such as abscess formation and perforation. Despite this, if a foreign body is found in the appendix and appendicitis has not developed, the patient may be monitored for 8 weeks to allow the foreign body to be excreted from the appendix [12].

Appendicitis in patients undergoing hemodialysis

The clinical features of appendicitis, one of the most common acute abdominal diseases in HD patients, differ between HD and non-HD patients. The mortality rate of appendicitis is 0.09–0.24% in the general population but 4.0% in HD patients [13, 14]. The risk of perforated appendicitis is also higher in them [15]. The poor outcomes of acute appendicitis in HD patients may be explained by the diseases that leading to HD, (such as diabetes and arteriosclerosis), and hemodynamic instability during HD [15]. Comorbidities such as autonomic dysfunction and compromise immunity in HD patients may also be responsible for these poor outcomes as well as the higher rate of perforated appendicitis in HD patients [16, 17]. A previous study reported that typical symptoms associated with appendicitis, such as nausea, vomiting, right lower quadrant abdominal pain, and leukocytosis, were less common in HD patients [18]. Early diagnosis of appendicitis in HD patients, despite the lack of characteristic symptoms of appendicitis, may be explained by the fact that HD patients regularly visit clinics to receive their treatment. In the present case, the onset of symptom (pain) was on dialysis day, which led to an early diagnosis even though the patient had no fever, nausea, or vomiting. The patient had diabetes mellitus and was at high risk of developing severe appendicitis, but the early diagnosis may have contributed to the uncomplicated course of the disease.

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