Management of Eosinophilic Inflammation of the Appendix
Eosinophilic appendicitis is typically managed with appendectomy when discovered, as it most commonly presents as acute appendicitis requiring surgical intervention, with medical management reserved only for cases identified as part of systemic eosinophilic gastrointestinal disease. 1, 2
Clinical Context and Diagnosis
Eosinophilic appendicitis is a rare inflammatory condition characterized by eosinophilic infiltration of the appendix that mimics acute appendicitis in presentation 1. The condition is often discovered incidentally during appendectomy performed for presumed acute appendicitis 1, 2. Key clinical features include:
- Right lower quadrant pain with localized peritonitis and leukocytosis, indistinguishable from conventional acute appendicitis 3
- Peripheral eosinophilia may be present (though not always), with reported cases showing 3% eosinophilia on differential 4
- Atopy is a significant risk factor, with 34.2% of acute appendicitis patients showing positive atopy testing compared to 8% of controls 5
Primary Management Approach
Surgical Management
Laparoscopic appendectomy is the definitive treatment when eosinophilic appendicitis presents as acute appendicitis 1, 3. The surgical approach should be:
- Standard appendectomy technique for patients presenting with acute appendicitis symptoms 1
- Small bowel biopsy should be obtained if there is suspicion of systemic eosinophilic gastroenteritis during surgery 3
- Pathological examination is essential to confirm eosinophilic infiltration and rule out parasitic causes (particularly Taenia species) 4
When to Consider Medical Management
Medical management should only be considered if eosinophilic appendicitis is identified as part of systemic eosinophilic gastrointestinal disease rather than isolated appendiceal involvement. In such cases:
- Corticosteroids for 8-12 weeks before evaluating histological response 6
- Proton pump inhibitors may be considered as complementary therapy: omeprazole 20 mg twice daily for 8-12 weeks 6
- Dietary elimination under dietitian supervision if food allergies are identified as triggers 6, 7
Important Clinical Pitfalls
Do not assume isolated eosinophilic appendicitis requires long-term medical therapy - this differs fundamentally from eosinophilic esophagitis or colitis. The appendix guidelines [8-7] apply to esophageal and colonic disease, not isolated appendiceal involvement 1, 2.
Always investigate for parasitic causes, particularly in endemic areas, as Taenia saginata and other parasites can cause acute eosinophilic appendicitis requiring different post-operative management 4.
Consider systemic eosinophilic gastroenteritis if the patient has:
- Diffuse gastrointestinal symptoms beyond appendicitis 3
- Ascites on imaging 3
- Evidence of gastritis or small bowel involvement 3
In these cases, glucocorticoid therapy is highly effective and should be initiated post-operatively 3.
Post-Operative Follow-Up
- Pathology review is mandatory to confirm diagnosis and exclude parasitic infestation 4
- Three-month follow-up to assess for recurrent symptoms or systemic disease 4
- No long-term medical therapy is typically needed for isolated eosinophilic appendicitis after successful appendectomy 1
- If systemic eosinophilic gastroenteritis is confirmed, initiate maintenance therapy with topical steroids or PPIs and refer to gastroenterology 6, 7