A Case of Endoscopic Removal of a Giant Appendicolith Combined with Stump Appendicitis
A 48-year-old man was referred to our hospital for further evaluation of a 2-cm, large, protruding lesion in the cecum found on colonoscopy performed at a nearby hospital. He had been experiencing right lower quadrant discomfort for 1 month. He had undergone surgery for acute appendicitis 35 years earlier. During his recent hospital visit, his vital signs were measured, including blood pressure 120/70 mm Hg, pulse rate 72 beats per minute, respiration 20 beats per minute, and body temperature 36.0℃. Physical examination revealed light tenderness in the right lower quadrant of the abdomen, but there was no rebound tenderness, palpated mass, or muscle guarding. The results of the blood test were normal, with white blood cell count 8,900/mm3 (segmented neutrophil count, 76.7%), hemoglobin level 15.4 g/dL, platelet count 192,000/mm3, total bilirubin level 1.5 mg/dL, and aspartate aminotransferase/alanine aminotransferase level 21/31 U/L. An abdominal CT scan showed that the appendix was thickened owing to the presence of a 2-cm appendicolith; therefore, stump appendicitis was diagnosed (). We consulted the surgery department; they recommended biopsy and colonoscopy to identify the protruding lesion because the patient did not have typical signs of appendicitis, such as right lower quadrant pain, tenderness, and rebound tenderness. Therefore, we conducted a colonoscopy that revealed a 2×3-cm, large, protruding lesion covered by normal mucosa around the appendiceal orifice of the cecum. An embedded stone was visible through the appendiceal orifice. Because the orifice was too small for the stone to be removed, we made a 4-mm incision to widen the orifice by using an IT knife (KD-611L; Olympus, Tokyo, Japan). Next, with a snare, we grasped the lower part of the protruding lesion adjacent to the cecal wall. Then, as we strangulated the lower portion of the protruding lesion, a large stone (fecalith) with whitish pus gushed out of the orifice. During the procedure, complications such as perforation and bleeding were not noted (). An abdominal CT scan and a colonoscopy 2 months later did not show any sign of appendicolith recurrence. The patient has been under outpatient care and has had no symptoms for 2 years.