S2364 Endoscopic Removal of an Inverted Appendix

Abstract

INTRODUCTION: IA occurs when the appendix is turned inside out and contained within the lumen of the cecum. This could occur spontaneously or can be the result of a surgical intervention. It is an exceedingly infrequent finding on colonoscopy, appearing as a cecal intraluminal projection that could mimic a polyp or neoplasm. CASE DESCRIPTION/METHODS: A 51-year-old female with PMH of acute appendicitis and resultant appendectomy at 5 years of age underwent screening colonoscopy. Endoscopic report described a 10 mm polyp originating from the appendiceal orifice with pathology describing mild neutrophilic infiltration of the lamina propria with no evidence of granulomas or dysplasia. Endoscopic images revealed a smooth, non-adenomatous vermiform lesion, suspicious for an IA (Figure 1). Repeat colonoscopy confirmed the suspicion of a persistent, inverted, non-inflamed appendix, which measured 40 mm in length. A PolyLoop was applied to the base of the lesion, which was then removed using a hot snare (Figures 2 and 3). Subsequently, a Padlock OTSC was deployed below the level of the ligature to ensure a durable full-thickness closure. Pathology of the specimen confirmed that it was an IA with prominent submucosal edema and vascular congestion. Our patient underwent endoscopic removal of her inverted appendix, with no immediate or delayed post-procedural sequelae at a 12 month follow up. DISCUSSION: IA, an exceedingly rare finding, can be congenital, spontaneous, provoked or maybe the result of surgical intervention. Provoked IA can be benign or may occur due to underlying appendiceal pathologically. IA can be entirely asymptomatic or may present with abdominal pain, vomiting or blood per rectum. Expanses in endoscopic equipment and the emergence of a subspecialized group of Interventional Endoscopists has facilitated expertise in partial as well as full-thickness endoscopic resections. One of the proposed areas of continued expansion of endoscopic techniques is endoscopic appendectomy. Early feasibility case reports, as well as proof of concept and non-inferiority case series have been published with enthusiasm. This case highlights the importance of endoscopic identification of appendiceal pathology and serves to promote awareness for physicians to keep appendiceal inversion in the differential diagnosis of cecal projections; among more common cecal pathology such as polyps, lipomas, and neoplasm. Successful completion of this case is a testament to the potential for successful endoscopic appendectomy.Figure 1.: Endoscopic view of the inverted appendix.Figure 2.: Inverted appendix following application of PolyLoop.Figure 3.: Inverted appendix following hot scare resection.