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A 48-year-old man presented to our institution with new onset lower abdominal pain and diarrhea for the past 6 weeks. He opened his bowels 1 to 4 times per day with a watery stool. He reported no fever, melena, hematochezia, or weight loss. He has a medical history of anti-DPPX encephalitis since 2016 and type 2 diabetes. His medications included daily insulin and regular rituximab infusions. Patients with anti-DPPX encephalitis have a 20% lifetime risk of hematologic malignancy including gastrointestinal lymphoma.
His recent laboratory tests revealed a normal hemoglobin of 14.8 g/dL and white cell count and ova, cyst, and parasites. A CT scan of the abdomen and pelvis showed a dilated fluid-filled appendix, without evidence of inflammatory change, which was concerning for a mucinous neoplasm of the appendix (Fig. 1). A colonoscopy was therefore planned. As good views of the appendix lumen were important in this case, we elected to combine colonoscopy with “appendixoscopy” using a single-operator digital cholangioscope (Video 1, available online at www.giejournal.org).
Figure 1A CT scan of the abdomen and pelvis showed a dilated fluid-filled appendix, without evidence of inflammatory change, concerning for a mucinous neoplasm of the appendix.
In this case an adult colonoscope (Olympus, Centre Valley, Penn, USA) with a clear cap was advanced to the cecum. The cecum and the appendix orifice were normal on initial inspection with no visualized mucus in the cecum or extruding from the Gerlach valve (Fig. 2). A single-operator cholangioscope (Boston Scientific, Marlborough, Mass, USA), measuring 3.6 mm in diameter, passed easily through the 3.7-mm channel of an adult colonoscope. The appendix orifice was successfully cannulated with the cholangioscope over a 0.025-inch VisiGlide wire (Olympus America) (Video 1) or using the “freehand” approach (Fig. 3). Once the cholangioscope was within the appendix lumen, saline irrigation was used to expand the lumen and allow the cholangioscope to be advanced to the most distal part of the appendix under endoscopic vision (Video 1). The cholangioscope was then slowly withdrawn and the appendix mucosa carefully inspected. The appendix mucosa was unremarkable (Video 1). A biopsy of the appendix wall was taken with Spybite biopsy forceps (Boston Scientific). Pathology reported normal colonic mucosa without evidence of neoplasm (Fig. 4).
Endoscopic retrograde appendiceal therapy (ERAT) is a minimally invasive technique for the treatment of uncomplicated acute appendicitis. During the colonoscopy, the appendiceal orifice was cannulated with a sphicterotome and a wire and the appendix was irrigated and stented as required. Data from recent ERAT studies have shown that cannulation of the appendix is feasible in 95% to 100% of cases and adverse events are uncommon (0%-5% of cases).
Diagnosis of acute appendicitis by endoscopic retrograde appendicitis therapy (ERAT): combination of colonoscopy and andoscopic retrograde appendicography.
Digital single-operator cholangioscopy is typically undertaken in conjunction with ERCP to visualize the bile and pancreatic ducts. It has an established role in tissue acquisition, tumor staging, selective biliary cannulation, and fragmentation of bile and pancreatic duct stones using electrohydraulic lithotripsy.
Case reports have previously described using a single-operator digital cholangioscope via a therapeutic colonoscope in cases of altered biliary anatomy
Biliary intervention using SpyGlass DS cholangioscopy through a cap-attached variable-stiffness colonoscope in a patient following Billroth II gastrectomy.
This case highlights that the digital single-operator cholangioscope can be easily advanced through the therapeutic channel of an adult colonoscope and used to evaluate the appendix mucosa and that biopsies can be safely performed with microbiopsy forceps.
Disclosure
Dr Khashab is a consultant for Boston Scientific, Olympus, Medtronic, and GI Supply; he also receives royalties from UpToDate and Elsevier. All other authors disclosed no financial relationships.
Diagnosis of acute appendicitis by endoscopic retrograde appendicitis therapy (ERAT): combination of colonoscopy and andoscopic retrograde appendicography.
Biliary intervention using SpyGlass DS cholangioscopy through a cap-attached variable-stiffness colonoscope in a patient following Billroth II gastrectomy.
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