Open Access
Open Peer Review

This article has Open Peer Review reports available.

How does Open Peer Review work?

A therapeutic barium enema is a practical option to control bleeding from the appendix

  • Youkou Konno1,
  • Mikihiro Fujiya2Email author,
  • Kazuyuki Tanaka1,
  • Aki Sakatani1,
  • Mizue Shimoda1,
  • Akihiro Hayashi1,
  • Momotaro Muto1,
  • Mitutaka Inoue1,
  • Jun Sakamoto3,
  • Kensuke Oikawa4,
  • Nobuhiro Ueno2,
  • Yuhei Inaba2,
  • Kentaro Moriichi2 and
  • Yutaka Kohgo2
BMC Gastroenterology201313:152

DOI: 10.1186/1471-230X-13-152

Received: 18 June 2012

Accepted: 17 October 2013

Published: 25 October 2013

Abstract

Background

Acute lower gastrointestinal hemorrhage originating from the appendix is rare and often intractable, because it is almost impossible to approach the bleeding point by endoscopy. We herein describe the first case of bleeding from the appendix, which was successively controlled by a therapeutic barium enema administered into the appendix.

Case presentation

A 71-year-old male visited our hospital because of melena. He has been receiving an anti-coagulation drug, ticlopidine hydrochloride, for 10 years. By an emergency colonoscopy, a hemorrhage was detected in the appendix, and the lesion responsible for the bleeding was regarded to exist in the appendix. Two hundred milliliters of 50 W/V% barium was sprayed into the orifice of the appendix using a spraying tube. The bleeding could thus be immediately stopped, and a radiological examination revealed the accumulation of barium at the cecum and the orifice of the appendix. The barium accumulation disappeared by the next day, and no obvious anal bleeding was observed. Two weeks after stopping the bleeding from the appendix, an appendectomy was performed to prevent any further refractory hemorrhaging. The patient has had no complaints of any abdominal symptoms or anal bleeding for 10 months.

Conclusions

A therapeutic barium enema is a useful procedure to control bleeding from the appendix and to avoid emergency surgery, such as partial cecectomy and hemicolectomy.

Keywords

Appendix bleeding Barium enema Intestinal hemorrhage Appendicitis

Background

Acute lower gastrointestinal hemorrhage originating from the appendix is rare and often intractable [122], because it is very difficult to approach the bleeding point in the appendix by endoscopy. Therefore, in most cases with bleeding from the appendix, an emergency operation was necessary [113, 1522]. We herein report the first case of the bleeding associated with the appendix ulcer which was successively controlled by the administration of a therapeutic barium enema into the appendix.

Case presentation

A 71-year-old male visited our hospital because of melena. He was suffering from diabetes mellitus and the sequelae of a cerebral infarction. He has been receiving oral diabetic drugs and an anti-coagulation drug, ticlopidine hydrochloride for 10 years. His blood pressure was 150/83 mmHg and the pulse rate was 105/minute. A blood examination revealed a high level of blood sugar at 162 mg/dL, and hemoglobin A1c of 6.6%, but neither a decrease in red blood cells nor hemoglobin. A computed tomography scan in the abdomen detected a high density fluid of ascites, but no inflammatory changes in any organs, including the intestinal tract. By an emergency colonoscopy, the fresh blood in the entire colon, but not in the ileum, and the blood and coagula in the orifice of the appendix were observed (Figure 1A). After washing the orifice with water, a hemorrhage was detected in the appendix (Figure 1B), and the lesion responsible for bleeding was regarded to exist in the appendix. After obtaining the patient’s informed consent, 200 ml of 50 W/V% barium was sprayed into the orifice of the appendix using a spraying tube (Figure 1C), because a therapeutic barium enema has been shown to be a useful procedure to control bleeding from a diverticulum [23, 24]. The bleeding could be immediately stopped, and a radiological examination revealed the accumulation of barium at the cecum and the orifice of the appendix (Figure 2A). The barium accumulation disappeared by the next day (Figure 2B) and no obvious anal bleeding was observed in the patient. Two weeks after stopping the bleeding from the appendix, an appendectomy was performed to prevent further refractory hemorrhage from the appendix. A gross specimen showed ulceration, but no tumorous lesions, at the tip of the appendix (Figure 3A). A severe infiltration of neutrophils and lymphocytes within a shallow ulcer was histologically observed (Figure 3B). The administration of the anti-coagulant ticlopidine hydrochloride, was restarted two weeks after the operation. The patient has had no complaints of any abdominal symptoms, including anal bleeding, for 10 months.
https://static-content.springer.com/image/art%3A10.1186%2F1471-230X-13-152/MediaObjects/12876_2012_Article_1014_Fig1_HTML.jpg
Figure 1

The findings of emergency endoscopy. Blood and coagula were observed in the cecum (A). After washing with water, a hemorrhage from the appendix was detected (B). Two hundred ml of 50 W/V% barium was sprayed into the orifice of the appendix through a spraying tube (C).

https://static-content.springer.com/image/art%3A10.1186%2F1471-230X-13-152/MediaObjects/12876_2012_Article_1014_Fig2_HTML.jpg
Figure 2

Radiological examinations of the abdomen. A radiological examination showed the accumulation of the barium at the cecum and orifice of the appendix (A). By the next day, the accumulation had almost completely disappeared (B).

https://static-content.springer.com/image/art%3A10.1186%2F1471-230X-13-152/MediaObjects/12876_2012_Article_1014_Fig3_HTML.jpg
Figure 3

Histological features of the surgical specimen. A gross surgical specimen showed an ulcer in the tip of the appendix with no tumorous lesion (A). The histological sections revealed a severe infiltration of neutrophils and lymphocytes within a shallow ulcer (Hematoxilin eosin staining, ×40) (B).

Discussion and conclusion

This report presented the first case of bleeding from an appendix ulcer that was successfully controlled with therapeutic barium enema. To date, 23 cases of bleeding from the appendix have been reported [122] (Table 1). The age of the patients with bleeding from the appendix ranged from 9 to 76 years of age. Sixteen patients were male, while the others were female. The causes of the bleeding included diverticulitis [1], Crohn’s disease [2, 4, 16], a mucinous cyst [6], aorta-appendix fistula [15], ectopic uterus mucosa [10], angiodysplasia [11, 14], intussusceptions [3, 8, 9, 13], gastrointestinal stromal tumor [20] and intestinal tuberculosis [21]. Anti-coagulation drugs were administered in 4 cases [5, 17, 20]. In the present case, the administration of the anti-coagulation drug, ticlopidine hydrochloride, was thought to aggravate the bleeding from the appendix, while the cause of the ulceration itself of the appendix remains unclear. The therapeutic barium enema is thought to have stopped the acute bleeding from the appendix, and the suspension of the administration of the anti-coagulant helped to prevent re-bleeding. In many of the reported cases, the appendix bleeding has been diagnosed via colonoscopy.
Table 1

The reported cases and our case of bleeding from appendix

Authors

Age

Sex

  Administration of anti-coagulation drugs

Method of diagnosis

Treatment

Histopathologic findings

Tamvakopoulos (1969) [1]

40

M

 

Not described

Conventional appendectomy

Diverticulitis

Tamvakopoulos (1969) [1]

43

F

 

Barium enema

Conventional appendectomy

Diverticulitis

Geerken and Gibbons (1974) [2]

17

M

 

Barium enema

Conventional appendectomy

Crohn’s disease

Brewer and Wangensteen (1974) [3]

24

F

 

Barium enema

Ileocecal resection

Intussusception

Brown and Peter (1976) [4]

19

M

 

Barium enema

Right hemicolectomy

Crohn’s disease

Milewski (1977) [5]

14

M

  Aspirin tablet taken on the night of admission

Not described

Ileocecal resection

Appendicitis, abscess

Mullen (1979) [6]

63

M

 

Barium enema

Right hemicolectomy

Diverticulum, mucocele

Norman et al (1980) [7]

48

M

 

Angiography

Conventional appendectomy

Diverticulum

McIntosh et al (1990) [8]

18

F

 

CF, CT

Conventional appendectomy

Intussusception

Jevon et al (1992) [9]

32

F

 

CF

Partial cecectomy

Intussusception

Shome et al (1995) [10]

33

F

 

CF

Ileocecal resection

Endometriosis

So et al (1995) [11]

42

M

 

CF

Laparoscopic appendectomy

Angiodysplasia

Morales et al (1997) [12]

60

M

 

CF

Laparoscopic appendectomy

Appendicitis

Gupta et al (2000) [13]

9

M

 

CF

Partial cecectomy

Intussusception

Kyokane et al (2001) [14]

76

F

 

Angiography

Transcatheter arterial embolization, conventional appendectomy

Angiodysplasia

Monaghan and Cogbill (2002) [15]

66

M

 

US, CT

Conventional appendectomy, AAAresection

Primary aortoappendiceal fistula, appendicitis

Lima et al (2004) [16]

16

M

  Aspirin 200mg/day

CF

Conventional appendectomy

Crohn’s disease

Rivera-Irigoin et al (2005) [17]

51

M

 

CF

Conventional appendectomy

Aspirin-induced ulcer

Yamazaki et al (2006) [18]

53

F

 

CF, CT

Laparoscopic appendectomy

Appendicitis

Ogi et al (2006) [19]

44

M

 

CF

Laparoscopic appendectomy

Hematoma

Kim et al (2007) [20]

56

M

  Few tablets of NSAID

CF

Right hemicolectomy

GIST

Kuntanapreeda (2008) [21]

20

M

 

CF

Conventional appendectomy, partial cecectomy

Tuberculosis

Baek (2010) [22]

42

M

 

CT, CF

Laparoscopic appendectomy

Mucosal erosion

Our case

71

M

  Ticlopidine hydrochloride

CT, CF

Therapeutic barium enema, laparoscopic appendectomy

Ulcer

Up to now, an emergency operation, including partial cecectomy and hemicolectomy, is generally conducted to control the bleeding in most cases, but no non-operative therapeutic strategy for bleeding from the appendix has yet been established. Only one case of the embolization of the responsible artery has so far been reported [14]. As the therapeutic use of a barium enema has recently been shown to be a useful procedure to treat diverticular bleeding [23, 24], we thought that the use of a therapeutic barium enema could also be a practical and less invasive option for controlling such intractable appendix bleeding. In fact, the present case is the first reported case in which a therapeutic barium enema successfully controlled such bleeding.

The mechanism underlying this effect was speculated to be protection of the intestinal epithelia, compression of the blood vessels, coagulating action and the production of a thrombus by the barium itself. In the current case, such functions of the barium enema appeared to be effective for controlling the bleeding from the appendix. From this perspective, the therapeutic barium enema is thought to be useful for the treatment of appendiceal bleeding caused by erosions or ulcers in the appendix, as well as that caused by other disorders, such as diverticulitis and angiodysplasia. We were apprehensive that the therapeutic barium enema might cause the obstruction of the appendix, leading to severe appendicitis. However, the accumulation of barium was almost completely eliminated by the next day, and an appendectomy was successfully performed. An appendectomy is a routine laparoscopic procedure that poses much less risk and less invasive for the patient than an emergency operation, such as cecectomy and hemicolectomy, and arterial embolization. Therefore, the use of a therapeutic barium enema is thought to be a practical and safe procedure to control bleeding from the appendix and to avoid an emergency operation.

Consent

The patient has given their consent for the case report to be published. Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Declarations

Authors’ Affiliations

(1)
Department of Internal Medicine, Engaru-Kosei general Hospital
(2)
Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University
(3)
Department of Gastroenterology, Sapporo Higashi Tokushukai Hospital
(4)
Department of pathology, Asahikawa-Kosei general Hospital

References

  1. Tamvakopoulos SK: Clinical observation on diverticulosis-diverticulitis of the appendix rectal bleeding in association with symptoms of acute appendicitis suggests diagnosis. R I Med J. 1969, 52: 443-444.PubMedGoogle Scholar
  2. Geerken RG, Gibons RB: Isolated Crohn’s disease of the appendix: case report. Mil Med. 1974, 139: 215-217.PubMedGoogle Scholar
  3. Brewer RJ, Wangensteen SL: Appendiceal intussusception: an unusual cause of painless rectal bleeding. Am Surg. 1974, 40: 319-320.PubMedGoogle Scholar
  4. Brown WK, Peters RW: Crohn’s Disease of the appendix presenting as lower intestinal hemorrhage and cecal mass. Am J Gastroenterol. 1976, 65: 349-352.PubMedGoogle Scholar
  5. Milewski PJ: Appendix abscess with intestinal haemorrhage. Br Med J. 1977, 1: 147-View ArticlePubMedPubMed CentralGoogle Scholar
  6. Mullen JT: Mucocele of the appendix associated with hematochezia. South Med J. 1979, 72: 766-767.View ArticlePubMedGoogle Scholar
  7. Normann DA, Morisson EB, Meyers WM: Massive gastrointestinal hemorrhage from a diverticulum of the appendix. Dig Dis Sci. 1980, 25: 145-147.View ArticleGoogle Scholar
  8. McIntosh JC, Mroczek EC, Baldwin C, et al: Intussusception of the appendix in a patient with cystic fibrosis. J Pediatr Gastroenterol Nutr. 1990, 11: 542-544.View ArticlePubMedGoogle Scholar
  9. Jevon GP, Daya D, Qizilbash AH: Intussusception of the appendix a report of four cases and review of the literature. Arch Pathol Lab Med. 1992, 116: 960-964.PubMedGoogle Scholar
  10. Shome GP, Nagaraju M, Munis A, et al: Appendicecal endometoriosis presenting as massive lower intestinal hemorrhage. Am J Gastroenterol. 1995, 90: 1881-1883.PubMedGoogle Scholar
  11. So JB, Alexander DJ, Chong AP, et al: Laparoscopic appendectomy in the management of the acute lower gastrointestinal bleeding. Gastrointest Endosc. 1995, 42: 488-489.View ArticlePubMedGoogle Scholar
  12. Morales TG, Yalam J, Dinning JP, et al: Acute lower gastrointestinal bleeding from the appendix. Gastrointest Endosc. 1997, 46: 458-460.View ArticlePubMedGoogle Scholar
  13. Gupta P, Chwals W, Guandalini S: Intussusception of the appendix: another poorly recognized cause of rectal bleeding. J Pediatr Gastroenterol Nutr. 2000, 30: 320-323.View ArticlePubMedGoogle Scholar
  14. Kyokane T, Akita Y, Katayama M, et al: Angiodysplasia of the appendix. Am J Gastroenterol. 2001, 96: 242-243.View ArticlePubMedGoogle Scholar
  15. Monaghan K, Cogbill TH: Primary aortoappendiceal fistula: case report and review of the literature. J Vasc Surg. 2002, 35: 1284-1286.View ArticlePubMedGoogle Scholar
  16. Lima SE, Speranzini MB, Guiro MP: Isolated Crohn’s disease of the appendix as a source of enterorrhagia. Arq Gastroenterol. 2004, 41: 60-63.View ArticlePubMedGoogle Scholar
  17. Rivera-Irigoín R, De Sola-Earle C, Palma-Carazo F, et al: Active lower gastrointestinal bleeding due to appendiceal ulcer. Gastroenterol Hepatol. 2005, 28: 445-446.View ArticlePubMedGoogle Scholar
  18. Yamazaki K, Nakao K, Tsunoda A, et al: Successful laparoscopic treatment of hemorrhage from the appendix with phlegmonous acute appendicitis: a case report and review of the literature. Gastrointest Endosc. 2006, 63: 877-880.View ArticlePubMedGoogle Scholar
  19. Ogi M, Kawamura KJ, Konishi F, et al: Idiopathic hemorrhage from appendix. Jichi Medical University Journal. 2006, 29: 217-221.Google Scholar
  20. Kim KJ, Moon W, Park MI, et al: Gastrointestinal stromal tumor of appendix incidentally diagnosed by appendiceal hemorrhage. World J Gastroenterol. 2007, 13: 3265-3267.View ArticlePubMedPubMed CentralGoogle Scholar
  21. Kuntanapreeda K: Tuberculous appendicitis presenting with lower gastrointestinal hemorrhage- a case report and review of the literature. J Med Assoc Thai. 2008, 91: 937-942.PubMedGoogle Scholar
  22. Baek SK, Kim YH, Kim SP: Acute lower gastrointestinal bleeding due to appendiceal mucosal erosion. Surg Laparosc Endosc Percutan Tech. 2010, 20: 110-113.View ArticleGoogle Scholar
  23. Chorost MI, Fruchter G, Kantor AM, et al: The therapeutic barium enema revisited. Clin Radiol. 2001, 56: 856-858.View ArticlePubMedGoogle Scholar
  24. Iwamoto J, Mizokami Y, Shimokobe K, et al: Therapeutic barium enema for bleeding colonic diverticula: four case series and review of the literature. World J Gastroenterol. 2008, 14: 6413-6417.View ArticlePubMedPubMed CentralGoogle Scholar
  25. Pre-publication history

    1. The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-230X/13/152/prepub

Copyright

© Konno et al.; licensee BioMed Central Ltd. 2013

This article is published under license to BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Advertisement