Colonoscopically placed hemoclips as treatment for massive appendiceal stump bleeding

Massive bleeding from an appendiceal stump is a rare but occasionally seen severe complication. The bleeding may drain into the abdominal cavity, the retroperitoneum, or the digestive tract. Gastrointestinal hemorrhage may occur early or even years after appendectomy. The typical management includes ligation of the bleeding vessel or cecal resection done by either emergency laparotomy or laparoscopy. An alternative treatment option would be an angiographic embolization of the bleeding vessel. We report on a 33-year-old woman with severe lower gastrointestinal hemorrhage 1 day after an apparently uncomplicated appendectomy for acute phlegmonous appendicitis with ligation and invagination of the appendiceal stump. Hemoglobin level dropped to 6.3 g/dl and made blood transfusion necessary. The cause of bleeding was a small intramural branch of the appendiceal artery at the appendiceal stump, which was diagnosed by emergency colonoscopy. The hemorrhage could be controlled endoscopically by placing hemoclips on the distinct vessel in combination with a biological tissue adhesive. The patient recovered thereafter without further intervention. Endoscopic clipping for the treatment of appendiceal stump bleeding is a novel, effective, and safe procedure. Thereby, conventional emergency laparotomy or laparoscopy or angiographic embolization can be avoided.