Sharique Nazir, MD, Ibrahim I Jabbour, MD MPH, Larry Griffith, MD FACS, Armand Asarian, MD FACS, Peter J Pappas, MD FACS. The Brooklyn Hospital Center
Acute appendicitis is the most common cause of emergent abdominal surgery in the United States (US). Less than 100 appendiceal duplications have been documented in the literature to date, of which less than 10 are cases of appendiceal duplication complicating acute appendicitis including this case.
A 33 year-old female presented with migratory right lower quadrant pain of four days duration with nausea and vomiting. She was febrile and had a tender right lower quadrant with rebound tenderness and guarding. Her white blood cell count was elevated with neutrophilia. CT Scan showed possible acute appendicitis with perforation and fluid collection in the pelvis. Diagnostic laparoscopy prior revealed two appendices attached via separate bases to one cecum. The anterior appendix was inflamed with a gangrenous tip while the posterior appendix was grossly normal. Both appendices were located on the taenia-coli and a single cecum was present. Laparoscopy did not reveal any other associated intra-abdominal anomalies. The patient underwent emergent laparoscopic appendectomy. Histology confirmed normal appendicular tissue in one specimen and severe acute transmural appendicitis in the other. There were no post-operative complications. The patient was discharged home in stable condition after three days.
In 1962 Wallbridge and Waugh contributed a classification system for appendiceal duplication which recognizes three major types of anomalies: Types A, B, and C. Coker et al suggested the embryological etiology for each of these etiologies Based on the above classification the case presented here can be classified as Type B2 due to two seperate appendices attached via seperate bases onto the cecum and are located over taeni-coli. Type B2 is the most frequently reported duplication.
Suspicion of a duplicated appendix should prompt further investigation into the possibility of other congenital anomalies, including duplications or anomalies of the gastrointestinal or genitourinary tracts, gastroschisis, and vertebral anomalies. Type B2 duplication is not known to be associated with any other congenital anomalies
Based on the different types appendiceal duplication the clinical presentation of acute appendicitis could vary extensively. It is likely that the lack of reported acute appendicitis in appendiceal duplication is most likely due to failure to diagnose the anatomical anomaly. This is most certainly the case when the clinical presentation mimics other conditions, such as adenocarcinoma of the colon or intussuception. In cases where appendiceal duplication is suspected, differential diagnoses such as appendiceal diverticulosis, solitary cecal diverticulum, triple appendix, and horseshoe appendix (Type D) must be ruled out. Histopathalogical examination can distinguish duplicate appendix.
The potential complication of missing a second or third normal appendix could make evaluation of right lower quadrant pain difficult, hence although the incidence of appendiceal duplication is 0.004% a thorough laparoscopic examination is reccomended to rule out any anatomical anomalies.
Although appendiceal duplication occurs very rarely, awareness of this congenital anomaly and thorough intra-operative inspection are critical to avoid the potential consequences of missing a second appendix, as well as any associated congenital anomalies, and to minimize confusion with other intraabdominal structures.
Session Number: Poster – Poster Presentations
Program Number: P082