Appendiceal bleeding caused by angiodysplasia: A case report and review of literature

Abstract

BACKGROUND

Lower gastrointestinal bleeding is a common clinical presentation. However, appendiceal bleeding is exceedingly rare and often results in diagnostic delay or misdiagnosis.

CASE SUMMARY

We report the case of a 28-year-old man presenting with a two-day history of intermittent hematochezia. A colonoscopy revealed continuous fresh blood exuding from the appendiceal orifice. Computed tomography angiography demonstrated active bleeding from the appendix. An immediate laparoscopic appendectomy was performed. Pathological examination indicated that the bleeding originated from vascular dysplasia of the appendix. Postoperatively, no recurrence of bleeding or complications occurred, and the patient was discharged home on postoperative day 3.

CONCLUSION

Appendiceal bleeding is rare. Its cause remains obscure, challenging diagnosis. Colonoscopy is the primary diagnostic tool; appendectomy provides definitive treatment.

Key Words: Appendiceal bleeding; Colonoscopy; Computed tomography angiography; Angiodysplasia; Appendectomy; Case report

Core Tip: Appendiceal bleeding is extremely rare. We reported a case of a young man with hematochezia diagnosed with appendiceal bleeding via colonoscopy and computed tomography angiography. Laparoscopic appendectomy confirmed vascular malformation as the cause. Through literature review, we summarized clinical manifestations, causes, and treatment options, aiming to provide references for clinicians. Endoscopic hemostasis is feasible but carries a risk of appendicitis. Appendectomy is considered the definitive and reliable treatment, especially after failure of conservative treatment or endoscopic management, as it prevents recurrence.

INTRODUCTION

Lower gastrointestinal bleeding (GIB) accounts for 20%-50% of all GIB cases[1]. It most commonly originates from the colon, rectum, and terminal ileum. Appendiceal bleeding is exceedingly rare, accounting for only 0.014% of all GIB cases. Because of its anatomical position and structure, the appendix is difficult to visualize during colonoscopy[2]. In addition, appendiceal bleeding may not be visible at the time of colonoscopy. Hence, in many cases, appendiceal bleeding may be misdiagnosed as obscure GIB. Here, we report a rare case of appendiceal bleeding in a male patient successfully managed with laparoscopic appendectomy. Additionally, we conducted a detailed literature review to discuss the causes, optimal diagnostic approaches, and management strategies for appendicular bleeding.

CASE PRESENTATION

Chief complaints

A 28-year-old man presented to the gastroenterology department with a 48-hour history of intermittent hematochezia.

History of present illness

The patient developed intermittent hematochezia (1-2 times/day) with approximately 5-10 mL of dark red blood accompanying each bowel movement. He denied abdominal pain, fever, or dizziness.

Physical examination upon admission

Vital signs were stable, and the abdomen was soft and non-tender. The patient showed no signs of anemia.

Laboratory examinations

The routine blood examination showed a hemoglobin level of 134 g/L. Routine coagulation parameters were within normal limits.

Imaging examinations

On January 7, 2025, colonoscopy was performed after bowel preparation which revealed a small amount of dark red blood in the colon and minimal bright red blood in the terminal ileum. After repeated water flushing, the mucosa of the terminal ileum appeared smooth, with no blood in the proximal intestinal lumen. On careful examination, fresh bleeding was noted from the appendiceal orifice (Figure 1). Following colonoscopy, emergent computed tomography angiography (CTA) was performed, which demonstrated active bleeding at the appendiceal orifice (Figure 2).

Figure 1 Colonoscopic examination shows bright red blood in the ileocecal region, and a blood clot and blood flowing from the appendix orifice. A: Blood clot at the appendiceal orifice (arrow); B: Extravasation of blood from the orifice of the appendix after flushing (arrow).

Figure 2 Abdominal computed tomography angiography reveals active appendiceal bleeding. A: Computed tomography scan without contrast showing no abnormalities (arrow); B: The arterial phase showing an active contrast leak in the appendix (arrow); C: The venous phase showing progressive enlargement of the contrast leak (arrow).

FINAL DIAGNOSIS

The final diagnosis was appendiceal bleeding.

TREATMENT

The preoperative routine blood test showed that the hemoglobin level was 114 g/L. The patient underwent an emergency laparoscopic appendectomy. Intraoperatively, the resected appendix measured 5 cm and showed no evidence of gangrene or perforation. There was no blood, fluid or pus in the pelvic cavity. Postoperatively, analgesic and nutritional medications were administered. Histopathological examination of the resected appendix revealed abnormal veins penetrating the muscular layers of the appendix (Figure 3).

Figure 3 The histopathology of the resected specimen. Abnormal veins piercing the muscle layers of the appendix can be seen. Blue arrow: Abnormal veins.

OUTCOME AND FOLLOW-UP

Postoperative recovery was uneventful with no evidence of bleeding. The hemoglobin level on postoperative day 3 was 120 g/L; therefore, he was discharged from hospital. No recurrence of GIB was noted during the six-month follow-up.

DISCUSSION

Lower GIB is relatively common, with approximately 80% of cases originating from the colon and rectum. However, appendiceal bleeding is extremely rare[3]. A PubMed/MEDLINE search of articles published from January 2000 to March 2025 using the terms “appendiceal bleeding” or “appendiceal hemorrhage” identified 37 cases, as summarized in Table 1[2-32]. Appendiceal bleeding was more frequent in males (86.49%), and the median age was 44 years (range: 21-90 years). Thirty-one patients presented with hematochezia as the chief complaint, while six patients presented with melena. The reported causes of appendiceal bleeding included angiodysplasia, ulceration, mucosal erosion, diverticulum, tumors, Dieulafoy’s lesions, and post-appendectomy changes in 23 research reports[2,4-25]. The etiology of appendiceal bleeding remained unknown in approximately 30% cases. Up until now, only 6 cases[6,8,17,19,22,25] of bleeding from the appendix, specifically caused by angiodysplasia have been reported in English literature. Among these, six had hematochezia and one had melena. Reportedly, angiodysplasia, a common vascular malformation of the gastrointestinal tract, often causes recurrent bleeding, but it is more prevalent in older adults[33]. The most common sites of angiodysplastic lesions (54%-81.9%) are the caecum and ascending colon[34]. Seven previously reported cases mostly involved middle-aged and elderly patients. However, the present case is the youngest patient (28 years old) to be reported in the literature till date.

Table 1 Clinical presentation and treatment of appendiceal bleeding reported in the English literature from the year 2000 onwards.

Ref.	Age/sex	Presenting symptom	Diagnostic method	Pathological finding	Treatment
Jiao et al[4], 2025	24/M	Hematochezia	Endoscopy	Appendiceal ulcer	Appendectomy
Tabcheh et al[5], 2024	79/F	Hematochezia	Endoscopy	Appendiceal ulcer	Appendectomy
Ma and Du[6], 2024	33/F	Hematochezia	Endoscopy	Appendiceal angiodysplasia	Appendectomy
Ma et al[29], 2024	33/M	Hematochezia	Endoscopy	Unknown	Appendectomy
Ikehata et al[7], 2025	35/F	Hematochezia	Endoscopy	Appendiceal ulcer	Appendectomy
Siddiqui et al[27], 2024	42/M	Melena	Computed tomography angiography	Unknown	Conservative management
Dung et al[2], 2023	32/M	Hematochezia	Endoscopy	Appendiceal ulcer	Appendectomy
Xing et al[8], 2023	63/M	Hematochezia	Endoscopy	Appendiceal angiodysplasia	Appendectomy
Xing et al[8], 2023	33/M	Hematochezia	Endoscopy	Appendiceal angiodysplasia	Appendectomy
Xing et al[8], 2023	48/M	Melena	Endoscopy	Appendiceal ulcer	Appendectomy
Xing et al[8], 2023	67/M	Hematochezia	Endoscopy	Post-appendectomy	Colonoscopic clipping
Xing et al[8], 2023	42/M	Melena	Endoscopy	Unknown	Conservative management
Xing et al[8], 2023	38/M	Hematochezia	Endoscopy	Unknown	Conservative management
Nakashima et al[9], 2023	71/M	Hematochezia	Endoscopy	Appendiceal diverticulum	Colonoscopic clipping failed, appendectomy
Zhou et al[10], 2022	32/M	Hematochezia	Endoscopy	Dieulafoy’s lesion	Appendectomy
Liu et al[11], 2022	32/M	Hematochezia	Endoscopy	Appendiceal ulcer	Appendectomy
Karatas et al[12], 2022	88/M	Hematochezia	Endoscopy	Appendiceal mucinous adenoma	Appendectomy
Maeda et al[33], 2021	90/M	Melena	Endoscopy	Unknown	Appendectomy
Smith et al[26], 2021	67/M	Hematochezia	DSA	Unknown	Conservative management failed, embolization failed, appendectomy
Murakami et al[31], 2021	54/M	Hematochezia	Endoscopy	Unknown	Appendectomy
Wijayaratne et al[13], 2021	73/M	Hematochezia	Endoscopy	Appendiceal mucinous adenoma	Appendectomy
Ahn et al[14], 2021	82/M	Hematochezia	Endoscopy	Acute eosinophilic appendicitis	Laparoscopic partial cectomy
Xue et al[15], 2020	21/F	Hematochezia	Endoscopy	Dieulafoy’s lesion	Appendectomy
Kim et al[32], 2019	44/M	Hematochezia	Endoscopy	Unknown	Appendectomy
Ogawa et al[16], 2018	63/M	Hematochezia	Endoscopy	Appendiceal diverticulum	Appendectomy
Song et al[28], 2016	54/M	Hematochezia	Endoscopy	Unknown	Intra-appendiceal stent insertion and detachable snare wrapping
Choi et al[17], 2016	72/M	Hematochezia	Endoscopy	Appendiceal angiodysplasia	Appendectomy
Reynolds et al[18], 2015	68/M	Hematochezia	Endoscopy	Dieulafoy’s lesion	Appendectomy
Gu et al[19], 2013	41/M	Melena	Endoscopy	Appendiceal angiodysplasia	Appendectomy
Chung and Kim[3], 2011	70/M	Hematochezia	Endoscopy	Unknown	Colonoscopic clipping
Chiang et al[20], 2011	25/M	Hematochezia	Endoscopy	Appendiceal ulcer	Appendectomy
Chung and Gao[21], 2011	33/M	Hematochezia	Endoscopy	Appendiceal mucosal erosion	Appendectomy
Park et al[22], 2010	44/M	Hematochezia	Endoscopy	Appendiceal angiodysplasia	Colonoscopic clipping
Park et al[22], 2010	34/M	Melena	Endoscopy	Unknown	Colonoscopic clipping
Baek et al[23], 2009	42/M	Hematochezia	Endoscopy	Appendiceal mucosal erosion	Appendectomy
Kim et al[24], 2007	56/M	Hematochezia	Endoscopy	Gastrointestinal stromal tumor	Right hemicolectomy + appendectomy
Kyokane et al[25], 2001	76/F	Hematochezia	DSA	Appendiceal angiodysplasia	Embolisation, appendectomy
Current case	28/M	Hematochezia	Endoscopy	Appendiceal angiodysplasia	Appendectomy

DSA: Digital subtraction angiography; F: Female; M: Male.

Appendiceal bleeding poses diagnostic challenges, as it is often difficult to distinguish from ileocecal bleeding. CTA, digital subtraction angiography (DSA), and colonoscopy are commonly employed for the diagnosis of appendiceal bleeding. CTA is suitable for detecting active bleeding, whereas the diagnostic utility of DSA depends on the bleeding rate. Previous case reports suggested that although CTA and DSA may be helpful[25-27], their positive diagnostic yield remains low[8]. Colonoscopy can be useful for detecting appendiceal bleeding, provided there is active bleeding or oozing from the appendiceal orifice during the colonoscopy. Repeated water flushing and meticulous observation during colonoscopy can aid in the diagnosis of appendiceal bleeding. Additionally, with the advent of endosonography, enhanced visualization of the vascular structures within the colonic wall and its surrounding tissues is possible[35], aiding in the diagnosis of vascular malformations, ulcerative lesions, appendiceal tumors and so on. More recently, investigators have attempted to use an ultrathin gastroscope to visualize the appendiceal mucosa and its lumen[4]. This method of visualization of the appendiceal mucosa can also aid in controlling the appendiceal bleeding endoscopically in the same sitting.

Treatment options for appendiceal bleeding include medical therapy, endoscopic therapy, transcatheter arterial embolization, and appendectomy. The choice of treatment generally depends on the patient's overall clinical status and the underlying etiology of the bleeding. Endotherapy with argon plasma coagulation can resolve bleeding in 85% of patients with colonic angiodysplasia[34]. On similar lines, the appendiceal bleeding due to vascular malformations can be controlled using an ultrathin gastroscope[4] or cholangioscope[36]. Currently, endoscopic retrograde appendicitis therapy[37], an endoscopic technology for appendiceal diseases, has proven to be effective in the treatment of acute appendicitis and appendix-related conditions. Technologies like endoscopic retrograde appendicitis therapy integrated with cholangioscope may be highly useful for diagnosing and treating appendiceal bleeding. As summarized in Table 1, the reported patients were initially managed with conservative treatment, endoscopic therapy, or arterial embolization[8,22,27]. One case reported successful hemostasis by intra-appendiceal stent insertion combined with detachable snare wrapping[28]. However, in case of failure, appendectomy was performed[9,25,26]. Appendectomy remains the treatment of choice for most investigators, as it is reliable, effective, and provides the most definitive management. In our case, topical hemostatic agents were used during colonoscopy, but the effect was considered suboptimal. Notably, because the appendix has secretory functions, partial obstruction of the appendiceal orifice by colonoscopic clipping or embolization of the appendiceal artery carries the risk of acute appendicitis and recurrent hemorrhage[9]. Therefore, after consultation with the general surgery team, an emergent laparoscopic appendectomy was performed. On postoperative day 3, the patient was discharged, and no recurrence of hematochezia was observed during the six-month follow-up.

CONCLUSION

Appendiceal bleeding is rare, and its diagnosis is challenging due to its rarity and the absence of established guidelines. Colonoscopy and CTA can be very useful in detecting appendiceal bleeding as seen in the present case. Overall, it generally carries a favorable prognosis, and currently, appendectomy remains the primary treatment, serving both therapeutic and diagnostic purposes. In the future, with the rapid development of endoscopic-related technologies, the diagnosis and treatment of appendiceal diseases via direct visualization will be greatly improved, offering new solutions for managing appendiceal bleeding.