Mitigating and Impending Appendicitis in Dyscopic Snare-Based Appendicolith Therapy Appendicoliths are hardened or calcified structures that form and can get retained within the appendiceal orifice. They are typically composed of fecal material, mucus, or other debris. When appendicoliths obstruct the narrow appendiceal lumen, they increase the risk for developing complicated appendicitis. The formation mechanism is not fully understood, and standardized treatment guidelines are lacking. A 54-year-old female underwent a surveillance colonoscopy. Her previous colonoscopy five years ago showed a 6 mm tibial adenoma that was resected by a Kossner polypectomy. Her background included obesity, metabolic dysfunction associated steatotic liver disease, and she had a previous Rho and Y gastric bypass. Her colonoscopy was unremarkable, but the bowel preparation was inadequate. Subsequent repeat colonoscopy after enhanced bowel preparation revealed a large periapendicular protrusion that was caused by an appendicolith. This was not present at the last colonoscopy. A yellowish thick adhering material was projecting from the appendiceal orifice. In this case, we used an adult colonoscope with distal attachment and also a 20 mm stiff snare to perform endoscopic decompression of the appendicolith. We performed endoscopic snare-based appendicular therapy. We call that ESAT. In the cecum, there was a large periapendicular protrusion that had an adherent yellow material at the tip of the appendiceal orifice. This was maneuvered using a snare catheter, but without ability to dislodge the adhering material. After multiple attempts of probing to remove the adhering material, a pus was noted draining out of the appendiceal orifice. Hence, an ESAT technique was used to facilitate the release of the appendicolith out of the appendiceal orifice. This was performed using a large 20 mm stiff snare. After initial release of the tip of the appendicolith, the appendiceal orifice was examined and the protrusion persisted with a more harder material of the appendicolith still remaining within the appendiceal orifice. Hence, the ESAT technique was repeated. As the snare is large in diameter, using a cold-fashioned technique with large mucosal and submucosal surface acquisition, complete snare transection through the captured tissue is not a risk. Here we can see that a significant portion of the appendicolith was successfully released out of the appendiceal orifice into the sacral lumen. Despite that, the peri-appendicular protrusion persisted and the ESAT technique was repeated multiple times to release the retained appendicolith. Here we can see more of the tubular-shaped appendicolith material is being exposed out of the appendiceal orifice. Here the peripendicular protrusion is resolving and a final sweep is performed to release any residual appendicolith with gradual release of the smear and capturing at the higher end towards the tip of the appendiceal orifice to milk out all the retained appendicoliths. Finally, the perpendicular protrusion resolved and the area returned to normal configuration without a clinically significant mucosal injury or deep mural injury. There was no significant bleeding that required any endoscopic treatment. and the procedure was completed and this is the cecum and the peripendicular area prior and post ESAT. Post ESAT the patient was pain-free and McBain's point signs revealed no tenderness, guarding or rebound tenderness. Inflammatory markers were unremarkable apart from slightly elevated CRP. The patient was discharged home on oral antibiotics for five days. CT abdomen day 2 post ESAT revealed a borderline appendiceal caliber at 6 millimeter surrounded by subtle stranding but no perforation or connection. At 30 days follow-up the patient remained asymptomatic and inflammatory markers were normal. The clinical implications of this case includes recognizing appendicolith as a risk factor for developing complicated appendicitis. Additionally ESAT is a minimally invasive intervention using simple and widely available tools for treating appendiculitis and helps to mitigate an impending appendicitis. Moreover ESAT may be a reasonable bridging therapeutic option for elective endoscopic retrograde appendicitis therapy also known as ERAT or elective surgical appendectomy. In conclusion ESAT is a simple and viable endoscopic technique for mitigating and impending appendicitis and a reasonable bridging therapeutic option prior to an elective ERAT or surgical appendectomy. Long-term effectiveness in preventing recurrent appendicolith formation is unknown.

appendicoliths

ESAT

appendicitis

minimally invasive

colonoscopy