Acute appendicitis remains one of the most common surgical emergencies worldwide, traditionally managed by appendectomy or, more recently, conservative antibiotic therapy. In recent years, endoscopic retrograde appendicitis therapy (ERAT) has emerged as a novel, minimally invasive, appendix-preserving technique. ERAT utilizes colonoscopy access to the appendiceal orifice, allowing for decompression, irrigation, removal of obstructive material such as fecaliths, and stent placement where necessary. Evidence suggests that ERAT achieves high technical and clinical success rates, with reduced post-procedural pain, shorter recovery times, and preservation of appendiceal function. However, challenges including recurrence risk, operator dependency, limited global availability, and lack of standardized protocols persist. ERAT has the potential to redefine the treatment paradigm for appendicitis, particularly in patients seeking non-surgical management or those with high surgical risk. This review explores the role of ERAT in the management of acute appendicitis, including its procedural techniques, indications, clinical outcomes, advantages, limitations, and future perspectives.