Appendiceal Duplication: A Comprehensive Review of Published Cases and Clinical Recommendations. World J Surg. 2018;42:574-581. [PMID: 28799135 DOI: 10.1007/s00268-017-4178-1]

A rare case of congenital appendiceal duplication complicated by an appendiceal-sigmoid fistula: A case report

INTRODUCTION

Duplication of the appendix is a rare congenital anomaly, occurring in approximately 0.004 % to 0.009 % of the population. In contrast, appendiceal-sigmoid fistulas are uncommon acquired conditions, usually associated with chronic inflammation or neoplastic processes. To our knowledge, the coexistence of these two entities has not been previously reported.

CASE PRESENTATION

A 26-year-old female presented with a one-month history of right lower quadrant abdominal pain, loss of appetite, and low-grade fever. Imaging findings initially suggested chronic appendicitis. During exploratory laparotomy, a Type A appendiceal duplication was discovered, with one of the appendices forming a fistulous connection to the sigmoid colon. Surgical treatment involved appendectomy, excision of the fistula, and primary repair of the colonic defect. Histopathological examination confirmed the diagnosis of duplicated appendix with chronic inflammatory changes. The patient had an uneventful postoperative recovery.

DISCUSSION

Appendiceal duplication typically remains an incidental finding, rarely causing clinical symptoms. The coexistence of appendiceal duplication and sigmoid fistula formation haven't been previously reported. Diagnosis can be challenging due to the limitations of preoperative imaging in identifying these anomalies. Therefore, surgical exploration remains crucial, particularly in symptomatic patients, to manage symptoms and prevent potential complications.

CONCLUSION

Clinicians should maintain a high index of suspicion for rare congenital anomalies like appendiceal duplication in patients who present with atypical symptoms of appendicitis.

Horseshoe appendix: A case report and literature review

RATIONALE

Horseshoe appendix is 1 of the rarest types of duplex appendix characterized by 1 appendix having 2 openings at the cecum. Clinically, it is extremely rare and is detected incidentally at surgery. Therefore, accurate and timely diagnosis is important for enhanced prognosis, treatment planning, and optimizing patient outcomes. This case report presents the first case of horseshoe appendix in France.

PATIENT CONCERNS

A French 15-year-old boy, presented to the emergency department with pain in the right iliac fossa that had been worsening for 4 days. Considering his symptoms, abdominal ultrasound, radiological examination, and computed tomography (CT) scan results, an acute appendix was suspected.

DIAGNOSES

Acute appendicitis (AA) with "horseshoe" type appendix.

INTERVENTIONS

Surgical intervention with exploratory laparoscopy was performed immediately.

OUTCOMES

We found a heterogeneous image, partially fluid in the right iliac fossa, measuring approximately 16 × 9 mm, with inflammatory remodeling of the fat upon contact. The radiological examination concluded that complicated AA was suspected. Finally, the pathological report revealed acute suppurative appendicitis with peritoneal reaction.

LESSONS

Horseshoe appendix is rare. Considering his symptoms, radiological examination, ultrasound, and CT scan results, an acute appendix was suspected. The patient was successfully treated using emergency surgery and antibiotics treatment thanks to further diagnosis via exploratory laparoscopy and pus microbial analysis.

Perforated anterior tenia coli-type appendicitis in a case of vermiform appendix duplex in a toddler: a case report

Duplication of the vermiform appendix is a rare anomaly observed in patients undergoing appendectomy. A 27-month-old male toddler presented with a 9-day history of abdominal pain, vomiting, and diarrhea, progressing to an acute abdomen with signs of severe peritonitis. Intraoperative findings revealed a periappendicular infiltrate from a perforated vermiform appendix of the tenia coli type. A second, inflamed appendix was incidentally discovered in its typical location during the procedure. Vermiform appendix duplication presents a clinical challenge due to its rarity and potential for complications. According to the Cave-Wallbridge classification, this case represents Type B2, or the tenia coli variant, characterized by a perforated appendix originating at the tenia coli convergence and a smaller, secondary appendix in a retrocecal position. This case emphasizes the importance of thorough distal and proximal exploration during initial appendectomy when this anomaly is suspected, particularly in cases of Type B2.

Atypical Duplex appendix arising from the ascending colon: a case report

BACKGROUND

Duplex or vermiform appendix refers to the presence of an appendix beside the naturally occurring one. Although, duplex appendix emerges from the caecum most of the time, yet it is encountered in other parts of the colon. Inflammation of duplex appendix may represent not only a clinical, but also a surgical dilemma, and this would be confusing further among patients who already had prior appendectomy.

CASE PRESENTATION

We present a case of 29-years old Egyptian male patient with history of appendectomy one and half year before presenting to the emergency department with recurrent acute abdominal pain that was linked to duplex appendicitis abnormally emerged from the mid-ascending colon. The first episode was treated conservatively considering atypical right colon diverticulitis as a potential differential diagnosis. Seven months later the patient was treated by laparoscopic appendectomy and experienced an uneventful pot-operative course.

CONCLUSION

Duplex appendicitis, though rare, should be considered in the differential diagnosis of recurrent acute abdomen even after appendectomy.

Case report: Acute appendicitis in appendix duplication

INTRODUCTION

Duplication of the appendix is a very rare presentation. According to the Cave-Wallbridge classification, there are three types of duplicate appendix.

PRESENTATION OF CASE

A 43 year old female presented with classical symptoms of acute appendicitis, with unremarkable inflammatory markers. The diagnosis was confirmed on pre-operative computer tomography (CT). During laparoscopy two tubular structures were identified: one arising from the tenia libera of the caecum adjacent to the terminal ileum and one retrocaecally at the confluence of the teniae. Both structures were excised using a laparoscopic linear stapler. Histopathological analysis demonstrated the accessory structure to be a microscopically unremarkable blind-ended tubular structure. The other specimen demonstrated acute gangrenous inflammation of the appendix. The patient had an uneventful recovery and was discharged home the following day.

DISCUSSION

Appendix duplication is rare; however, failure to recognise it in a patient with acute appendicitis could result in a retained source of sepsis, requiring subsequent re-exploration of the abdomen. The case presented here represents a Type B2 according to the Cave-Wallbridge classification and is the most susceptible to inadvertent error due to having appendixes in both typical and atypical anatomical locations. This case also highlights the probability of this diagnosis being missed on pre-operative CT.

CONCLUSION

This case report presents a unique opportunity for surgical trainees to review intra-operative laparoscopic images of a duplicate appendix, both to allow them to recognise this pathology if encountered in the future, and to embed the importance of ruling it out with thorough intra-operative examination.

Appendiceal duplication an unusual cause of abdominal pain: A case report

Appendiceal duplication is exceedingly rare, with a prevalence of 0.004% to 0.009% in appendectomy specimens. Appendiceal duplications can occur alone or in conjunction with cecal duplication. The persistence of the temporary embryologic second cecal appendix is hypothesized to cause appendiceal duplications. We present a case of appendiceal duplication in a 26-year-old Ethiopian female patient who had been experiencing abdominal pain in the right lower quadrant for 1 week. She developed anorexia, a loss of appetite, and a low-grade fever as a result of this. She reported direct and rebound mild discomfort in the right lower quadrant on abdominal examination. She was then operated on and she had an appendiceal duplication intraoperatively. As a result, an appendectomy was performed, and the patient was discharged with improved health. To avoid unfavorable patient outcomes and medicolegal difficulties, surgeons and surgical trainees who conduct several appendectomies throughout their training should be aware of the likelihood of appendiceal duplication.

Duplication of the appendix masquerading as appendiceal tumor: a case report

BACKGROUND

This case report highlights the exceptional rarity of appendix duplication in adults, a condition that closely mimics appendiceal tumors, posing diagnostic challenges. The novelty of this case lies in its presentation of a Type A duplication, emphasizing the diagnostic intricacies involved in distinguishing it from other pathologies.

CASE PRESENTATION

We present the case of a 69-year-old male with a history of hypertension, hyperuricemia, and duodenal gastric ulcer, who presented with a positive occult blood test. Lower gastrointestinal endoscopy revealed an appendiceal orifice with atypical hyperemia and edema. Subsequent imaging and biopsy results suggested an appendiceal tumor, prompting laparoscopic ileocecal resection. Intraoperative findings revealed an unremarkable appendix, but histopathological analysis unveiled appendiceal duplication, characterized by bifurcation into two lumens within a thick serosal wall. The patient was discharged without complications.

CONCLUSIONS

This case underscores the importance of recognizing appendix duplication as a rare differential diagnosis for appendiceal tumors. Surgeons should remain vigilant, especially in cases of Type A duplication, where preoperative diagnosis remains challenging. Early identification can avert potential complications and missed congenital anomalies.

Appendiceal atresia causing recurrent right lower quadrant pain without inflammation

An 11-year-old girl presented with recurrent right lower quadrant (RLQ) pain. There was no evidence of inflammation and appendiceal swelling except at the initial onset. The repeated presence of a small amount of ascites at the time of abdominal pain triggered the performance of exploratory laparoscopy. Intraoperative examination revealed a non-inflamed, unswollen appendix with a cord-like atretic segment at the middle part and an appendectomy was performed. At 46 months follow-up, she remained asymptomatic. In patients with recurrent RLQ pain of unknown cause, it is necessary to consider diagnostic laparoscopy while keeping appendiceal atresia in mind as a differential diagnosis.

Case report: Duplicated appendicitis with history of cloacal exstrophy causing bowel obstruction

INTRODUCTION

Cloacal and bladder exstrophy are rare embryological defects that can cause developmental disruption of surrounding organ structures, the pelvis, spinal cord, and small intestines being the most commonly affected. Duplicated appendix is another rare embryological defect that has historically caused confusing clinical presentations. Our case highlights a rare instance of a patient with cloacal exstrophy who presented with a bowel obstruction and an associated inflamed duplicated appendix.

CASE PRESENTATION

A newborn male is born with omphalocele-exstrophy-imperforate anus-spinal defects (OEIS) complex. As primary surgical reconstruction was pursued, the patient was found to have a non-inflamed duplicated appendix, which was left unremoved. In the following months, the patient experienced episodes of small bowel obstruction, eventually requiring surgical intervention. During this operation, the duplicated appendix was noted to be inflamed, prompting removal of both appendices.

DISCUSSION

This case highlights the increased prevalence of duplicated appendix in a patient with cloacal exstrophy, as well as the utility of prophylactic appendectomy for patients incidentally found to have a duplicated appendix intraoperatively. The duplicated appendix may lead to increased rates of complications and atypical presentation of appendicitis, supporting the practice of prophylactic appendectomy in patients with an incidentally found duplicated appendix.

CONCLUSION

We suggest clinicians be aware of the association and potentially atypical presentation of appendicitis in patients with a duplicated appendix, particularly in the setting of cloacal exstrophy. The decision to prophylactically remove an incidentally found, non-inflamed duplicated appendix may be beneficial in preventing confusing clinical presentations and future complications.

Update on acute appendicitis: Typical and untypical findings

Acute appendicitis is the most common indication for emergency abdominal surgery throughout the world and a common reason for consultation in emergency departments. In recent decades, diagnostic imaging has played a fundamental role in identifying acute appendicitis, helping to reduce the rate of blind laparotomies and hospital costs. Given the results of clinical trials supporting the use of antibiotic therapy over surgical treatment, radiologists need to know the diagnostic criteria for complicated acute appendicitis to be able to recommend the best treatment option. This review aims not only to define the diagnostic criteria for appendicitis in different imaging modalities (ultrasonography, computed tomography, and magnetic resonance imaging), but also to explain the diagnostic protocols, atypical presentations, and other conditions that can mimic appendicitis.

Acute appendicitis with appendix duplicity in Eritrea: A case report

Duplicity of the appendices is very rare. A 32-year-old man presented with type B2 duplicity of the appendix and acute appendicitis. An appendectomy was done for both. Intraoperative incidental finding is the only chance to avoid missing appendix duplicity and appendicectomy should be done for both.

Autoamputation of the appendix and survival of the amputated part: a rare case report and literature review

Background

Autoamputation of the appendix, i.e., complete separation of a part of the appendix without any surgical intervention, has been rarely documented in the literature in recent years. Herein, we report a case where the amputated part of the appendix was viable after autoamputation and reviewed the related literature.

Case presentation

A 39-year-old female patient was admitted to our hospital complaining of abdominal pain and subsequently underwent an emergency laparoscopic appendectomy (LA). Intraoperatively, we found an abnormally short appendix protruding from the cecum and a strip-like tissue attached to the mesoappendix, considered a duplex appendix, was resected. Finally, in conjunction with the histopathology findings and the past medical history, the patient was diagnosed with “Pseudo-duplication of the Appendix”.

Conclusions

Autoamputation of the appendix resulting in preserved tissue viability and absence of necrosis at both ends, can be termed as “Pseudo-duplication of the Appendix”. This condition is very rare in clinical practice and has not been reported in China, to the best of our knowledge. It has been established that the autoamputated appendix can produce chronic inflammation, intestinal fistulae and even cancer, affecting the patient’s quality of life. Accordingly, a clear diagnosis and timely management are essential. In this report, we established a novel classification for “Pseudo-duplication of the Appendix”, hoping that our report will help surgeons better understand this anatomical anomaly of the appendix, to help during the differential diagnosis process and avoid confusion.

Recurrent appendicitis of vermiform appendix after a prior appendectomy: A case report and review of the literature

Introduction

Acute appendicitis is one of the leading causes of acute abdominal pain and surgical emergency. Stump appendicitis is a known complication of appendectomy whereby a retained appendiceal tip serves as a nidus for recurrent bouts of inflammation. Nevertheless, full-blown appendicitis of the vermiform appendix after a prior appendectomy remains a diagnostic conundrum.

Case presentation

A 45-year-old woman presented with a six-month history of right iliac fossa pain. Pertinently, she had undergone a prior open appendectomy twelve years ago. Further investigative workup revealed full-blown appendicitis, which was not attributable to a retained appendiceal stump. A subsequent laparoscopic appendectomy was performed, and the resultant specimen was sent for further evaluation, confirming the diagnosis of recurrent appendicitis.

Clinical discussion

Acute appendicitis is one of the most common life-threatening abdominal surgical emergencies worldwide, with 300000 appendectomies performed annually in the United States alone. Stump and chronic appendicitis are two separate and exceedingly rare clinical entities that may present simultaneously and develop serious complications unless promptly recognized and appropriately managed. The present paper prompts the clinicians to distinguish amongst the two at the initial surgery in order to thwart further exacerbations.

Conclusion

While stump appendicitis is a rare but well-characterized complication of a prior appendectomy, full-blown appendicitis of vermiform appendix remains elusive. It is therefore imperative to distinguish between a duplicated and a recurrent appendix at the initial operative procedure to facilitate optimal patient management.

Double appendixes: A rare case report

Anomalies of the appendix are rare, and one of the rarest is the double appendixes. Most anomalies of the appendix are observed in adults and are discovered incidentally during surgery that does not primarily involve the appendix. It is usually missed, often with life-threatening consequences.

Case report of the duplex vermiform appendix: A rare presentation in an elderly patient

Introduction and importance

Duplex appendix is a rare anatomical entity with incidence rate of 0.004 and 0.009%. Diagnosis is often missed despite growth in radiological investigations. Missed appendiceal anomalies can lead to undesirable medicolegal implications.

Case presentation

Here we discuss a case of a 76-year-old-male who initially presented to his primary care physician with right-sided abdominal pain for several weeks. A colonoscopy was performed and demonstrated a lesion arising from the appendicular orifice. The patient underwent staging imaging including Computerised Tomography of the abdomen and pelvis which demonstrated a dilated appendix. The patient underwent a laparoscopic right hemicolectomy. He made an uneventful recovery post-operatively and at his follow-up review at 4 weeks and 2 months.

Discussion

While duplex appendix has been reported in the literature, to our knowledge this is the first case report to describe duplicated appendix presenting as a colonic mass in an elderly patient.

Conclusion

Intra-operative examination of the cecum is paramount to rule out appendiceal anomalies and prevent medicolegal complications.

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Duplex appendix is a rare entity with incidence rate of 0.004–0.009%.

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Diagnosis of duplicated appendix is often missed despite growth in radiological investigation.

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Missed appendiceal anomalies can lead to undesirable medicolegal implications.

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Intra-operative examination is the only reliable option to rule out appendiceal anomalies.

First case report of horseshoe appendix in Morocco according according to SCARE guidelines

Introduction

The appendix duplication is a sporadic malformation in which the horseshoe form is the uncommon described variant. To our knowledge, we report the first Moroccan case of a horseshoe appendix in a girl admitted to managing of pain at the right iliac fossa.

Case presentation

Through this article, we present a very rare case of appendicular duplication. It has not been objectified in radiological exploration and discovered by chance during the operation. Resection then closure of the appendicular bases allowed our patient to heal. The objectives of this work is threefold: i) to report this sporadic case of horeshoe appendix, ii) to emphasize the importance of suspicion of appendicular duplication in appendicular syndrome and iii) to recommend the exploration of the ileoceacal region to avoid surgical complications and medicolegal problems.

Conclusion

Our case report shows that we have to take into consideration this sporadic presentation of appendicular syndrome and this even in the absence of radiological signs. Our work brings enriched the literature by a new case of horseshoe appendicitis highlighting the importance of surgical treatment.

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We report a case report of an appendix duplication witch is a very rare congenital malformation. To date, only fifteen cases were published.

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After careful examination of the literature, we found that this is the first case of this rare entity in Morocco.

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Appendicular duplication is a rare malformation that often escapes preoperative radiological imaging.

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We believe that this manuscript can add new perspectives to the surgery practice of this very rare presentation.

Congenital abnormalities and anatomical variations of the vermiform appendix and mesoappendix

Aim The purpose of this review was to present and discuss the anatomical variations and congenital abnormalities of the vermiform appendix and mesoappendix reported in recent years, and their associations with acute appendicitis and other associated pathologies.

Methods The search was carried out in the following databases: PubMed, Science Direct, and SciELO.

Results Thirty-seven studies were included in this review. Among the abnormalities of the vermiform appendix identified are agenesis and duplicity, and anatomical variations were related to length and positioning. Appendicular duplicity was a more frequent abnormality, mainly Type B2, associated with acute appendicitis, followed by agenesis, Type III. The first case of agenesis associated with acute appendicitis and volvulus-type duplicity of the appendix was identified. The most frequent position was retrocecal in adults and pelvic in children. In the mesoappendix, anatomical variations in its positioning, shape, absence, and length were identified.

Conclusion This review sought to present and discuss the anatomical variations and congenital abnormalities of the vermiform appendix and mesoappendix reported in recent years, and their associations with acute appendicitis and other associated pathologies, contributing to aid in clinical diagnosis and surgical interventions in patients with suspected acute appendicitis.

Incidental finding of double appendix during laparotomy for intussusception: A case report

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A double caecal appendix is an uncommon anatomical variation with significant surgical implications.

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Patients with double appendix are usually asymptomatic.

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When symptomatic, the problems that may arise from a missed diagnosis have serious health consequences.

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The double appendix can be classified using the Cave-Wallbridge classification.

Introduction

A double caecal appendix is an uncommon anatomical variation with significant surgical implications. A few cases of the double caecal appendix have been reported worldwide, mostly in adults. The diagnosis is, usually incidental, typically made intraoperatively.

Case report

We present the case of a 6-month-old boy with an incidental diagnosis of the double appendix during laparotomy for intussusception.

Discussion

The double appendix can be classified using the Cave-Wallbridge classification, which identifies three types of the duplicated appendix: A, B, and C. The complication of appendiceal duplications includes acute appendicitis, colonic perforation, obstruction, bleeding, pain, failure to thrive, abdominal mass. In the case of abdominal pain with diagnostic uncertainty, with appropriate patient selection (without hemodynamic instability), diagnostic laparoscopy may be offered as an initial intraoperative evaluation, and if the procedure cannot be safely completed laparoscopically, it can be converted to a laparotomy.

Conclusion

Although uncommon, knowledge of appendiceal duplication is of great significance in the surgical patient, as a missed diagnosis or delay in diagnosis in symptomatic patients may result in increased morbidity and possibly mortality secondary to sepsis, with its medico-legal ramifications in today's practice of medicine.

A case report of complete appendiceal duplication on the normal site of a single caecum: A new variant?

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Duplicated Appendix may be associated with imperforate anus.

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Duplicated Appendix may be associated with Situs Inversus Totalis.

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Complete duplication of an appendix on the normal site is possible.

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Patients with congenital anomalies need thorough evaluation for other associated anomalies.

Introduction

Duplicated appendix is an uncommon entity, typically discovered as an incidental finding during surgery for appendicitis or other abdominal pathologies. It may be associated with other congenital malformations. We report a case of a male neonate incidentally discovered to have an unrecognized variant of duplicated appendix during a laparotomy plus diversion colostomy for imperforate anus at 4 days of age.

Presentation of case

A baby delivered at home from an unbooked pregnancy at term, was referred from a primary care clinic to a specialist referral hospital, with a fever and suspected neonatal sepsis on day 1 of life. The patient had not passed meconium and physical examination revealed an imperforate anus. After initiating treatment for sepsis, the patient underwent a laparotomy where a situs inversus totalis and complete appendiceal duplication was found, with both appendices on the normal site of a single caecum. The appendices were left in situ and a diversion colostomy was performed. The patient did well following surgery and was discharged on postoperative day 10 to await definitive surgery.

Discussion

Appendiceal malformations have been reported either in isolation or in association with other congenital anomalies. Duplicated appendix occurs rarely and the pathogenesis is not fully understood. This case adds more evidence that the classification of appendiceal abnormalities should continue evolving as newer types are described.

Conclusion

Surgeons operating on patients with congenital anomalies must exercise extreme vigilance to identify and document other rare pathologies that may later pose challenges thus avoid morbidity, mortality and potential medicolegal pitfalls.

Endometriosis of the duplex appendix: A case report and review of the literature

BACKGROUND

Duplication of the appendix is an infrequent congenital malformation with a complex classification. The horseshoe appendix is a subtype of the duplex appendix and is rarely reported in the literature. Endometriosis is a common gynecological disease that rarely occurs in the appendix. Moreover, horseshoe appendix combined with endometriosis has not been previously reported.

CASE SUMMARY

Here, we describe a 44-year-old woman who was admitted with a 1-d history of migratory lower right quadrant pain. Physical examination was consistent with the signs of acute appendicitis. The patient underwent an emergency exploratory laparotomy. The distal tip of the appendix was in contact with the cecum by another base, or "horseshoe appendix". In addition, a small intestinal mass and an ovarian mass were identified. Subsequently, appendectomy, partial resection of the small intestine, and right oophorectomy were successively performed. The histopathology confirmed the diagnosis of acute inflammation of the duplex appendix with endometriosis, small intestine endometriosis, and ovarian endometriosis.

CONCLUSION

Surgeons need to be aware of the possibility of the duplex appendix when performing an appendectomy, and this study emphasizes the importance of exploring the entire abdomen.

Bifid appendix: a case report and a review of literature

Anomalies of the appendix are extremely rare, with a reported incidence of 0.004 to 0.009. Due to the wide range of variations, failing to recognize these anomalies may lead to failure of treatment and complications. We report a case of a 21-year-old female patient who presented to the Emergency Department with a clinical picture of acute appendicitis. After performing the proper laboratory and radiological tests, a decision was made to do a laparoscopic appendectomy which revealed a partially duplicated 'bifid' vermiform appendix with features of acute appendicitis.

One type of duplex appendix: horseshoe appendix

A horseshoe appendix is a subtype of duplex appendix, in which the appendix is shaped like a circle that may lead to an internal hernia and result in intestinal necrosis. This subtype is extremely rare, with only 13 cases reported worldwide to date, and easily triggers a series of medico-legal consequences due to the neglect of another infection base of the appendix. We describe a 22-year-old man who presented with a 3-day history of fever and was diagnosed with pneumonia. After receiving antibiotics for 3 days in the Department of Pneumology, he was found to have a periappendiceal abscess. He underwent appendectomy after 3 days of conservative treatment failure in the Department of General Surgery. During the operation, we found that he had a horseshoe appendix with the two bases forming a circle, each communicating with the cecum. We provide a review of 13 cases presented in the literature, with a discussion of the clinical features, diagnosis, and surgical approach of the horseshoe appendix to make the general surgeon get a clear concept of this type of appendicitis.

Acute single appendicitis in a female with a duplicated appendix

Appendiceal duplication is a rare congenital anomaly with an estimated incidence ranging from 0.004 to 0.009%. Preoperative diagnosis of a duplicated appendix is often difficult and is usually done intraoperatively. Histopathological examination of the surgical specimen is mandatory to confirm the presence of two appendices. In this case we report a female patient with acute inflammation in one of her two appendices. Surgeons should always bear in mind this rare anomaly to avoid serious ethical and legal consequences.