Endoscopic Removal of an Obstructing Fecolith at the Entrance of Appendix

A 78-year-old female with a history of medically treated acute appendicitis 1 year prior was evaluated for lower abdominal pain for 7 days. CT demonstrated an dilated appendiceal lumen with thickened walls obstructed by a 10.5-mm high-density presumed fecolith (Fig. 1). Endoscopic evaluation revealed a clearly raised appendiceal orifice that appeared edematous and inflamed (Fig. 2a). Intubation via endoscopic retrograde appendicitis therapy (ERAT) failed despite repeated attempts; an endoscopic snare (ENDO-FLEX) was used to make multiple radial incisions above the surface of the fecolith (Fig. 2b), which was then removed completely (Fig. 2c, f; Video 1). Subsequently, ERAT was performed with intubation into the distal appendiceal lumen, with resultant outflow of white pus (Fig. 2d). Further imaging revealed appendiceal cystic dilation with no residual fecolith. The cavity was flushed and drained with a plastic stent (Figs. 2e, 3). The patient was discharged 2 days later. On 4-week follow-up, the patient confirmed complete resolution of symptoms. A large obstructing fecolith at the entrance of appendix is a relative rare and difficult-to-treat clinical setting [1]. In this report, ERAT approaches with mucosal incision and fecolith removal enabled safe and effective management, thereby avoiding surgical morbidities [2, 3].

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