Cholangioscope-assisted endoscopic retrograde appendicitis therapy for the diagnosis and treatment of occult appendicitis with a giant fecalith

As a main cause of appendicitis, fecaliths have been identified in approximately 40% of patients with acute appendicitis [11]. Appendicoliths are usually less than 1 cm in their largest dimension, and those that are larger than 2 cm are termed giant appendicoliths [22]. The most common imaging modalities used to diagnose appendicitis are ultrasound and computed tomography (CT). Because its lumen is long and thin, the appendix can vary greatly, and therefore the basic reliance on ultrasound and CT is not always sufficient to make a reliable diagnosis of appendicitis [33]. Currently, the diagnosis of appendicitis remains challenging. Herein, we report a rare case of a pediatric patient with occult appendicitis. By means of cholangioscope-assisted endoscopic retrograde appendicitis therapy (ERAT), a giant appendicolith was discovered and flushed out of the appendiceal cavity.

A 13-year-old boy was admitted to our hospital with a 2-day history of right lower abdominal pain. Both ultrasound ([Fig. 1Fig. 1] a) and low-dose CT ([Fig. 1Fig. 1] b) revealed his appendix was normal. As he had persistent lower right abdominal pain, colonoscopy and cholangioscope-assisted ERAT were (with written parental consent) performed ([Video 1Video 1]). Colonoscopy revealed the appendiceal orifice was normal ([Fig. 2Fig. 2] a). A cholangioscope was used to intubate the appendiceal cavity, and purulent fluid rapidly flowed out ([Fig. 2Fig. 2] b). With a clear direct view through the cholangioscope, an appendicolith measuring approximately 2.5 cm in size was discovered in the appendiceal cavity ([Fig. 3Fig. 3] a); the intraluminal mucosa was congested and edematous with white pus adhesions ([Fig. 3Fig. 3] b). The appendix was adequately irrigated with normal saline, and the appendicolith was successfully expelled from the cavity ([Fig. 4Fig. 4]). The patient reported his abdominal pain to be relieved after the cholangioscope-assisted ERAT.

Fig. 1 Fig. 1 Imaging studies showed the appendix was normal: a ultrasound; b low-dose CT.

Fig. 2 Fig. 2 a Colonoscopy revealed a normal appendiceal orifice. b On cholangioscope intubation, purulent fluid flowed out of the appendiceal cavity.

Fig. 3 Fig. 3 Cholangioscopic views. a A giant appendicolith, approximately 2.5 cm in size (the thin white scale bars on the cholangioscope indicate 1 cm); b congested and edematous intraluminal mucosa.

Fig. 4 Fig. 4 The appendicolith was successfully expelled from the cavity.

Cholangioscope-assisted endoscopic retrograde appendicitis therapy used to diagnose and treat occult appendicitis with a giant fecalith.Video 1Video 1

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Ranieri DM, Enzerra MD, Pickhardt PJ. Prevalence of appendicoliths detected at CT in adults with suspected appendicitis. AJR Am J Roentgenol 2021; 216: 677-682
• 2 Ishiyama M, Yanase F, Taketa T. et al. Significance of size and location of appendicoliths as exacerbating factor of acute appendicitis. Emerg Radiol 2013; 20: 125-130
• 3 Kong LJ, Liu D, Zhang JY. et al. Digital single-operator cholangioscope for endoscopic retrograde appendicitis therapy. Endoscopy 2022; 54: 396-400

Publication History

Article published online:
05 February 2025