Stump appendicolith removal using a pancreaticobiliary scope in an elderly patient: A case report

Abstract

BACKGROUND

Stump appendicitis is a rare complication following appendectomy, often diagnosed late due to nonspecific symptoms. The presence of appendicoliths in the stump is extremely uncommon and challenging to diagnose in elderly patients, as symptoms can be subtle and imaging findings inconclusive. We present a unique case of stump appendicitis with appendicolith incarceration occurring 60 years post-appendectomy, successfully treated with a pancreaticobiliary scope.

CASE SUMMARY

An 89-year-old male presented with persistent right lower abdominal pain for over one year, 60 years after undergoing an open appendectomy. Physical examination revealed mild tenderness. Laboratory tests and imaging results were unremarkable. Colonoscopy identified a fecal stone lodged in the appendiceal orifice. A pancreaticobiliary scope was employed to successfully remove the impacted fecalith using a basket and irrigation. The patient experienced an uneventful recovery and remained asymptomatic at follow-up.

CONCLUSION

Stump appendicolith should be considered in elderly patients with prior appendectomy. A pancreaticobiliary scope provides a safe treatment option.

Key Words: Stump appendicitis; Appendicolith; Pancreaticobiliary scope; Elderly patient; Case report

Core Tip: In a patient aged 89 years, we report a rare occurrence of stump appendicitis with appendicolith incarceration 60 years after appendectomy. Subtle symptoms and insignificant imaging made diagnosis a challenge. Colonoscopy showed the affected fecalith that was removed successfully with a pancreaticobiliary scope. Therefore, surgery was avoided. This case highlights the necessity to take into consideration the stump appendicolith in elderly patients with chronic abdominal pain and previous appendectomy. In the event of failure of conventional imaging, colonoscopic evaluation of the appendiceal orifice is necessary. The pancreaticobiliary scope is a safe, minimally invasive option to the management of stump appendicoliths in high-risk patients.

INTRODUCTION

Appendicitis is a frequent cause of acute abdominal pain, most of which are diagnosed based on typical symptoms and physical observation. It is caused by the obstruction of the appendiceal orifice resulting from various factors such as hyperplasia of lymphoid tissue surrounding the vermiform appendix, appendicoliths, inflammatory constriction, or tumors. Although appendicoliths are usually incidental findings among asymptomatic individuals, they can result in acute appendicitis by causing inflammation, and thus increasing the risk of perforation or abscess development[1]. Stump appendicitis is a rare but severe complication of appendectomy, in which inflammation recurs in the remaining tissue of the appendix, after it has been removed. Although the initial appendectomy is performed, the stump left may be inflamed and infected, but with symptoms similar to those of acute appendicitis[2]. It is very important to detect and control early to avoid complications and achieve positive results. This report describes a case of stump appendicitis with the formation of appendicoliths 60 years following the original appendectomy.

CASE PRESENTATION

Chief complaints

Recurrent abdominal distension and pain for over 20 years, worsening in the past year.

History of present illness

An 89-year-old male presented with a history of right lower abdominal pain lasting over one year, accompanied by abdominal distension and constipation, unresponsive to symptomatic treatment.

History of past illness

The patient had a history of hypertension and underwent an appendectomy 60 years ago for acute appendicitis.

Personal and family history

No significant personal or family history was reported.

Physical examination

Mild tenderness was noted in the right lower quadrant of the abdomen, with no rebound tenderness, palpable mass, or muscle guarding.

Laboratory examinations

Laboratory tests were unremarkable. The white blood cell count was 4.48 × 10⁹ (with a neutrophil count of 2.34 × 10⁹), hemoglobin was 93 g/L, and platelet count was 129 × 10⁹. Biochemical tests showed normal kidney and liver functioning. The fecal occult blood test was weakly positive with the tumor markers [alpha-fetoprotein, carcinoembryonic antigen, carbohydrate antigen (CA) 724, CA125, and CA199] being within normal range.

Imaging examinations

Abdominal ultrasound and enhanced computed tomography (CT) scans did not show any significant results except for liver and kidney cysts. After an in-depth consultation with the patient regarding the indications, procedure, and potential risks, a colonoscopy was performed as a further diagnostic examination. Since the patient was of advanced age and there were risks involved with general anesthesia, the procedure was carried out without sedation. The patient underwent bowel preparation using polyethylene glycol electrolyte solution, which led to sufficient cleansing of the colon. In the colonoscopy, it was possible to insert the endoscope until the cecum and to carefully examine the area around the appendices. A cylindrical fecal stone was seen, and it was tightly stuck in the appendiceal orifice. Repeated irrigation and gentle manipulation of the endoscope using biopsy forceps were conducted to dislodge the stone.

MULTIDISCIPLINARY EXPERT CONSULTATION

Since the patient presented with a long-standing history of right lower quadrant pain and a history of appendectomy, it was highly suspected that the affected fecal stone was contributing to recurrent inflammation of the remaining appendiceal stump. Even with careful irrigation and efforts to remove the stone with biopsy forceps, the fecal stone could not be dislodged. Based on the risk factors associated with the prolonged or repeated endoscopic manipulation, such as perforation, bleeding, or hemodynamic instability, immediate removal was not performed during the diagnostic procedure due to the advanced age of the patient (89 years). This was followed by a discussion on multidisciplinary team where the patient and the family were made fully aware of the management options: Conservative observation, surgical resection, and endoscopic extraction. Upon gaining informed consent, a formal treatment plan was determined. The patient underwent a second procedure two days after the initial diagnosis to endoscopically remove the fecalith. After performing standard colonoscopy and identifying the appendiceal orifice, a single-use video pancreaticobiliary scope (eyeMAX, Micro-Tech Nanjing Co., Ltd) was inserted through the working channel of the colonoscope into the appendiceal orifice.

FINAL DIAGNOSIS

The final diagnosis of this patient is appendicolith and stump appendicitis.

TREATMENT

Through the process, the colonoscope was further advanced to the cecum where the opening of the appendices was easily seen. It was found to have a firm, cylindrical fecal stone, tightly impacted on the lumen, completely blocking the lumen (Figure 1). Then, the eyeMAX was introduced via the working channel of the colonoscope and extended through the appendiceal orifice. This allowed high-definition imaging of the appendiceal lumen, which was completely filled with the affected fecal stone. A stone retrieval basket was loaded and inserted into the biopsy channel of the eyeMAX and manipulated around the stone under direct visualization. The fecal stone, a comparatively small stone, about 1.0 cm in diameter, was repeatedly irrigated, with a narrow, focused jet of water, to loosen the stone of the mucosal surface, and the fecal stone was successfully detached and removed in a single piece. The eyeMAX was again inserted post-removal to facilitate a comprehensive reassessment of the remaining residual appendiceal stump. The lumen was found to be about 2 cm long with slight inflammatory alterations evident in the mucosa, such as redness and congestion (Figure 2). In order to minimize the risk of infection, the stump was irrigated with a metronidazole solution, and the scope was withdrawn. The patient was awake and hemodynamically stable, and none of the pain or discomfort was reported.

Figure 1 Endoscopic view. A: Orifice of vermiform appendix; B: Fecal stones in the appendix.

Figure 2 EyeMAX view. A: Insertion of eyeMAX; B: Observation of fecal stones in the stump appendix; C: Stone retrieval basket through eyeMAX into stump appendix; D: Edema of the inner wall of the stump appendix after fecal stone was dislodged.

OUTCOME AND FOLLOW-UP

Following the procedure, the patient was transferred to the ward for supportive care, including intravenous fluids and prophylactic anti-infective therapy. He resumed a normal diet the following day without experiencing recurrence of abdominal pain or distension. The postoperative course was uncomplicated, and the patient was discharged in good condition three days after the procedure. Follow-up assessments at one and three months post-procedure confirmed that the patient remained completely asymptomatic, with normal bowel movements and no recurrence of symptoms.

DISCUSSION

This report describes an old patient with stump appendicitis and incarceration of appendicoliths complicating the treatment, who was successfully treated with endoscopic retrograde appendicitis therapy using a pancreaticobiliary scope. Stump appendicitis is another rare complication of appendectomy, which occurs when a portion of the appendix is left, and may result in inflammation, infection, and abdominal pain. It has a similar clinical presentation to that of acute appendicitis and presents with abdominal pain, fever, nausea, and vomiting. The diagnosis of the stump appendicitis can be difficult since the common symptoms, such as palpable mass or tenderness in the right lower quarter, may not be present. Imaging can also help in the diagnosis as it exposes the signs of inflammation or inflamed appendiceal stump[3]. Stump appendicitis in an elderly patient can present with less obvious symptoms, and the imaging studies might not give conclusive results. The pathophysiology of stump appendicitis is not fully understood, although it is believed that the pathophysiology of stump appendicitis is manifested by the presence of remnant appendiceal tissue, which may become infected or obstructed. Although infrequent, endoscopic retrograde appendicitis therapy has been reported to be used to treat coprolites in stump appendicitis[4], although no previous reports describe the use of endoscopic retrograde appendicitis therapy to treat coprolites in stump appendicitis.

One of the technical issues is whether the removal of the fecalith was possible with a standard colonoscope using a retrieval basket through its working channel. Although this might be possible in some anatomical conditions, a number of factors, in this case, precluded a safe blind approach. The appendiceal orifice was small, and the fecalith was firmly impacted. The diameter of the standard colonoscope was also too big to enter the appendiceal stump. Hence, direct visualization was not possible. Any attempt to blindly insert a retrieval basket into the stump would pose a high risk of failure, perforation, bleeding, or mucosal damage. The smaller diameter of the pancreaticobiliary scope (eyeMAX) combined with its increased flexibility and superior steerability allowed the scope to be directly inserted into the narrow, tortuous residual stump, which could be visualized in real time to view the affected fecalith. Moreover, the pancreaticobiliary scope has its own working channel, which enables independent presentation of a retrieval basket, allowing an accurate extraction of stones under direct sight of the surgeon. This method increased accuracy and reduced the chances of making mistakes in cases of blind handling. Other important information was also obtained through direct visualization of the residual stump length (about 2 cm) and mild mucosal inflammation, which could not have been obtained using a blind technique. In the case of the elderly patients, the endoscopic alternatives present a good alternative considering the increased risks involved in the surgical intervention.

Due to the clinical similarity between stump appendicitis and typical appendicitis, it is often misdiagnosed as another gastrointestinal condition, leading to delayed diagnosis. Nearly 70% of stump appendicitis cases are identified only after perforation occurs. While CT and ultrasound can aid in diagnosis, the condition remains prone to being overlooked. Recently, colonoscopy has gained popularity as a diagnostic tool for patients presenting with abdominal pain, often revealing inflammation or swelling around the appendiceal orifice or the ileocecal region, which may suggest acute appendicitis or abscess formation. In this case, a fecalith impaction was identified at the appendiceal orifice during colonoscopy.

Stump appendicitis is a rare and delayed complication, with a reported incidence of 1 in 50000[5], and it can develop anywhere from three weeks to as long as twenty-three years following appendectomy[6]. In this case, it occurred 60 years after the initial appendectomy. Laparoscopic resection of the appendiceal remnant remains the primary treatment for stump appendicitis. However, in elderly patients, such as this case, a non-invasive approach using a pancreaticobiliary scope to address fecalith impaction offers lower risk, reduced tissue damage, and faster postoperative recovery. This method effectively alleviated the patient’s abdominal pain symptoms.

CONCLUSION

Stump appendicitis presents a significant diagnostic challenge due to its rarity, and delays in diagnosis contribute substantially to patient morbidity. Clinicians should maintain a high index of suspicion for appendiceal stump inflammation, particularly in patients with long-standing chronic abdominal pain and a history of appendectomy. Fecalith impaction within the appendiceal stump may be difficult to detect through imaging or other diagnostic methods, especially when prior appendectomy has led to insufficient examination of the stump. Additionally, the small size of the appendiceal orifice often results in its neglect during colonoscopy, as it is not typically prioritized by endoscopists. Management of fecalith impaction in the appendiceal stump is crucial. Conventional colonoscopy often struggles to effectively remove impacted fecaliths from the stump. The use of alternative instruments, such as a pancreaticobiliary scope, allows direct insertion into the appendiceal orifice, facilitating the removal of fecaliths within the appendiceal cavity. In elderly patients, delayed-onset stump appendicitis demands heightened awareness, and endoscopic intervention represents a viable and effective treatment option for fecalith-induced stump appendicitis.