Double Appendix: Implications for the Emergency Department.

BACKGROUND: A double appendix, also known as vermiform appendix duplex, is a rare anomaly in humans, with a reported incidence of 1 in 25,000. The rarity of vermiform appendix duplication makes it a noteworthy medical occurrence. Approximately 100 reported cases have been documented since the first observed case in 1892. There are multiple types of appendiceal duplications, some of which include duplications of other organs. CASE REPORT: A 10-year-old boy was diagnosed with acute appendicitis by clinical examination and ultrasound. He underwent a laparoscopic appendectomy and had an unremarkable recovery. His pathology revealed acute suppurative appendicitis. Two months later, he presented to the emergency department due to bilateral lower abdominal pain with guarding and distension on examination. He underwent a computed tomography of the abdomen and pelvis secondary to concern for a postoperative abscess, which instead showed a normal-appearing retrocecal appendix containing oral contrast. The patient was diagnosed with constipation, and his symptoms resolved with an enema. Our patient had two completely separate appendices, one arising from the cecal tinea coli, and one retrocecal. Why Should an Emergency Physician Be Aware of This? Clinicians should be aware of this rare anomaly as a potential diagnosis in a patient with a history of prior appendectomy and clinical signs consistent with recurrent appendicitis. This also underscores the need for communication between doctors and patients, along with their families, to avoid delays in diagnosis in the future.

Multi-institutional trial of non-operative management and surgery for uncomplicated appendicitis in children: Design and rationale.

Traditionally, children presenting with appendicitis are referred for urgent appendectomy. Recent improvements in the quality and availability of diagnostic imaging allow for better pre-operative characterization of appendicitis, including severity of inflammation; size of the appendix; and presence of extra-luminal inflammation, phlegmon, or abscess. These imaging advances, in conjunction with the availability of broad spectrum oral antibiotics, allow for the identification of a subset of patients with uncomplicated appendicitis that can be successfully treated with antibiotics alone. Recent studies demonstrated that antibiotics alone are a safe and efficacious treatment alternative for patents with uncomplicated appendicitis. The objective of this study is to perform a multi-institutional trial to examine the effectiveness of non-operative management of uncomplicated pediatric appendicitis across a group of large children's hospitals. A prospective patient choice design was chosen to compare non-operative management to surgery in order to assess effectiveness in a broad population representative of clinical practice in which non-operative management is offered as an alternative to surgery. The risks and benefits of each treatment are very different and a "successful" treatment depends on which risks and benefits are most important to each patient and his/her family. The patient-choice design allows for alignment of preferences with treatment. Patients meeting eligibility criteria are offered a choice of non-operative management or appendectomy. Primary outcomes include determining the success rate of non-operative management and comparing differences in disability days, and secondarily, complication rates, quality of life, and healthcare satisfaction, between patients choosing non-operative management and those choosing appendectomy.

A therapeutic barium enema is a practical option to control bleeding from the appendix.

BACKGROUND: Acute lower gastrointestinal hemorrhage originating from the appendix is rare and often intractable, because it is almost impossible to approach the bleeding point by endoscopy. We herein describe the first case of bleeding from the appendix, which was successively controlled by a therapeutic barium enema administered into the appendix. CASE PRESENTATION: A 71-year-old male visited our hospital because of melena. He has been receiving an anti-coagulation drug, ticlopidine hydrochloride, for 10 years. By an emergency colonoscopy, a hemorrhage was detected in the appendix, and the lesion responsible for the bleeding was regarded to exist in the appendix. Two hundred milliliters of 50 W/V% barium was sprayed into the orifice of the appendix using a spraying tube. The bleeding could thus be immediately stopped, and a radiological examination revealed the accumulation of barium at the cecum and the orifice of the appendix. The barium accumulation disappeared by the next day, and no obvious anal bleeding was observed. Two weeks after stopping the bleeding from the appendix, an appendectomy was performed to prevent any further refractory hemorrhaging. The patient has had no complaints of any abdominal symptoms or anal bleeding for 10 months. CONCLUSIONS: A therapeutic barium enema is a useful procedure to control bleeding from the appendix and to avoid emergency surgery, such as partial cecectomy and hemicolectomy.

Perforated appendicitis and appendicolith in a child presenting as intussusception: a case report.

Simultaneous diagnoses of intussusception and appendicitis in the same patient have rarely been described in the pediatric literature. A case of a 30-month-old boy is presented with an initial diagnosis of intussusception that was successfully reduced by air contrast enema. When the patient's condition deteriorated, a diagnostic search surprisingly revealed a missed perforated appendicitis with an appendicolith that had been part of the intussusception. The patient's hospitalization and surgical course is described along with a discussion of the intermingling of intussusception and appendicitis in a young child. This case illustrates the need to consider alternative diagnoses when a patient's course takes an unexpected and confusing turn.

Preoperative sonographic diagnosis of appendiceal intussusception: a case report.

Appendiceal intussusception is an uncommon form of intussusception. Most of the literature regarding appendiceal intussusception discusses the colonoscopic diagnosis or surgical treatment of the condition. Sonographic findings have rarely been described. We present a case of preoperative sonographic diagnosis of appendiceal intussusception.

Multimodality imaging of an appendiceal intussusception.

Appendiceal intussusception is a rare entity. The majority of cases reported in the literature address surgical and colonoscopic approaches to treatment of the condition. The existing radiologic literature largely describes the sonographic and double-contrast enema findings of appendiceal intussusception. We present a case of appendiceal intussusception and describe the air-contrast enema, sonographic and CT findings.

[Left-sided appendicitis: description of a rare case in an adult patient diagnosed in Antananarivo]. / Appendicite a gauche: a propos d'un cas exceptionnel chez l'adulte diagnostiqué a Antananarivo.

The purpose of this report is to describe a case of appendicitis in the left iliac fossa. Clinical presentation involved pain in the right iliac fossa with all classical signs of appendicitis. Anomalous location of the appendix was suspected on the basis of a special clinical feature and the patient's family history. Confirmation was achieved by colic contrast enema before surgical treatment.

The appendix sign: a radiographic marker for irreducible intussusception.

PURPOSE: Radiographic reduction (hydrostatic or pneumatic) of intussusception has become the standard of care in the pediatric population with success rates of more than 80%. Identification of those patients who are likely to fail nonoperative management could lead to earlier operation, a reduction in radiation exposure, and a decreased risk for complications after repeated attempts at enema reduction. During successful radiographic reduction, the small bowel is almost always visualized before the appendix. Visualization of the appendix before visualization of the small bowel during a successful reduction of an intussusception is a rare event. We report a new radiographic sign that we have termed the appendix sign (radiographic visualization of the appendix without reflux of air or contrast into the small intestine), which we hypothesize may have association with failure of nonoperative management. METHOD: We performed a retrospective review of the last 12 years of irreducible intussusception. The associated studies were then reviewed to examine the incidence, sensitivity, and specificity of this radiographic finding. RESULTS: Ninety-one cases of intussusception were identified and had films available for review. Seventy-seven (76%) of the studies included the appropriate image. The appendix sign was visualized in 14 studies for an incidence of 18%. Of 14 patients, 10 failed enema reduction (positive predictive value, 71%). The sensitivity of the appendix sign is 43%. The specificity of the sign is 93%. CONCLUSIONS: Our experience suggests that the presence of an appendix sign is associated with failing enema reduction of an intussusception and may be useful as a marker for determining the end point for further attempts at radiographic reduction.

Appearance of a type B duplex appendix on barium enema.

Anomalies of the appendix are rare and are usually found in the adult population as an incidental finding during the course of surgery. We describe the appearances of a Type B duplicated appendix demonstrated on a barium enema for the first time. A review of the literature is presented with a discussion of different forms of duplicated appendices and the clinical significance of this finding.

McBurney's point: are we missing it?

A prospective study of 100 post-evacuation barium enemas was done. Films were centered at McBurney's point, with an opaque skin marker at that point. Analysis of these revealed that in only one case (1%) was the base of the appendix at McBurney's point. In 67% it was cephalic and in 32% it was caudal to this point. The limitations of McBurney's point as an anatomical landmark should be recognized. This needs to be highlighted in teaching anatomy, especially to surgical trainees. Planning and choice of surgical incisions should be based on an understanding of these anatomical variations since McBurney's original description was clinical rather than anatomical.

Improved sonographic visualization of the appendix with a saline enema in children with suspected appendicitis.

OBJECTIVE: To determine whether abdominal sonography after a saline enema can identify the appendix that is not visualized at graded compression sonography in children with suspected appendicitis. METHODS: High-frequency compression sonography was prospectively performed in 120 consecutive children with suspected appendicitis; the appendix was not identified in 27 of these patients. Among the 27 patients with a nonvisualized appendix, abdominal sonography after a saline enema was performed in 12 to identify the appendix. RESULTS: Abdominal sonography after the saline enema revealed the appendix in all 12 children in whom the appendix was not visualized at graded compression sonography. A normal appendix was found in 11 children, and acute appendicitis confined to the appendiceal tip was found in 1. The appendix was located in the pelvis (n = 5), posterior to the cecum (n = 4), posterior to the ileum (n = 2), and anterior to the ileum (n = 1). The appendix could be identified by using a window of the saline-filled sigmoid colon (n = 5), saline-filled cecum (n = 4), and saline-filled terminal ileum (n = 2). CONCLUSIONS: Abdominal sonography after a saline enema is a helpful technique for depiction of the appendix that is not visible at graded compression sonography in children with suspected appendicitis. Key words: appendix, sonography; appendicitis; children, gastrointestinal tract.

Sonographic diagnosis of intussusception of the appendix vermiformis.

We present 2 cases of intussusception of the appendix vermiformis (IAV) in children. Sonographic examination demonstrated a lead point within a characteristic multiconcentric ring sign, and longitudinal sonograms showed the inverted appendix protruding into the cecal lumen. A contrast-enema study, using a water-soluble contrast medium, was performed in each case, and a "coiled-spring" sign or "spiral shell" appearance confirmed the diagnosis. A surgical reduction of the appendix and an appendectomy were performed in each case.

The impact of imaging in the management of intussusception owing to pathologic lead points in children. A review of 43 cases.

OBJECTIVE: To review the imaging appearances, management and outcome of a large number of children with intussusception owing to pathologic lead points (PLP) in an attempt to define the role of various imaging modalities in this clinical setting. MATERIALS AND METHODS: Review of the records and imaging studies of 43 children with intussusception due to PLP diagnosed between 1986 and 1999. RESULTS: The commonest PLP found were Meckel diverticulum, polyps, Henoch-Schonlein purpura and cystic fibrosis. PLP were depicted on sonography in 23 (66%) of 35 patients, on computed tomography in 5 (71%) of 7, on air enema in 3 (11%) of 28, and on barium enema in 6 (40%) of 15. Air enema successfully reduced 60% of the intussusceptions. Nine children had recurrent intussusceptions. CONCLUSION: Sonography depicted two-thirds of PLP and provided a specific diagnosis in nearly one-third of our series. Our review does not provide sufficient data on how to continue the investigation of those patients in whom sonography does not depict a PLP but in whom there is a high index of suspicion for its presence. It remains a diagnostic challenge as to how to search for PLP in these patients, and other imaging modalities have to be requested according to each particular case.

Imaging of mucocoele of the appendix with emphasis on the CT findings: a report of 10 cases.

AIM: Mucocoele of the appendix denotes an obstructive dilatation of the appendiceal lumen due to abnormal accumulation of mucus. It is sometimes associated with pseudomyxoma peritonei, which predicts a malignant origin. We present the CT findings and additional imaging studies of 10 patients with neoplastic appendiceal mucocoele and discuss the clinical implications. MATERIALS AND METHODS: Abdominal CT findings from 10 patients with appendiceal mucocoele were reviewed. Barium enema, US and MRI were additionally performed in three patients. There were five men and five women aged 45-80 years. Special attention was directed to the shape and nature of the mass, its relation to the caecum and the presence of ascites or peritoneal implants, as well as possible additional ovarian tumours in female patients. RESULTS: The mucocoele was an incidental finding in five patients. They were either spherical or elongated cystic lesions, attached to the wall of the caecum, six of them with mural calcification. Ascites were present in six patients and hypodense large peritoneal implants representing pseudomyxoma peritonei in four. Pathologically the series included five cases of cystadenoma (in one, a malignant pseudomyxoma peritonei subsequently developed), four cases of cystadenocarcinoma and one villous adenoma (this patient later developed pseudomyxoma peritonei). Pseudomyxoma peritonei was found in five cases. Three women had associated ovarian cystic tumour. CONCLUSION: The appearance of an appendiceal mucocoele is quite characteristic and can be diagnosed on CT. CT can also depict additional findings suggesting pseudomyxoma peritonei. In women with an appendiceal mucocoele the ovaries should be examined closely for cystic tumour and vice versa.

Laparoscopic diagnosis of appendicovesical fistula in a pediatric patient.

Appendicovesical fistula is a rare complication of acute appendicitis in children that is difficult to diagnose preoperatively. A 21-month-old boy with signs and symptoms of recurrent urinary tract infections underwent abdominal ultrasonography, computed tomography (CT), barium enema examination, and cystography, none of which was sufficient to establish a diagnosis; an appendicovesical fistula was demonstrated by laparoscopy. The patient underwent open appendectomy, with resection of the fistula through a small incision, and has recovered without complications.

Appendicitis: usefulness of color Doppler US.

PURPOSE: To assess whether color Doppler ultrasonography (US) can help diagnose early acute appendicitis in appendices of equivocal size at gray-scale US. MATERIALS AND METHODS: In a retrospective study, color Doppler US findings were evaluated in 20 individuals with proved normal appendix at barium enema examination and in 50 patients in whom pathologic findings confirmed acute appendicitis. In a prospective study, the diagnostic value of hyperemia in the wall of the appendix in differentiating a normal from an inflamed appendix was evaluated in 26 patients with appendices of equivocal size (5-7 mm in maximal outer diameter) at grayscale US. RESULTS: In the retrospective study, 44 of the 50 patients had hyperemia at color Doppler US. The remaining six patients had no hyperemia, and pathologic findings confirmed gangrenous appendices. The 20 patients with proved normal appendix at barium enema examination had no detectable blood flow in the wall. In the prospective study, 10 of 26 patients had hyperemia at color Doppler US, and pathologic findings confirmed early acute appendicitis. Results of barium enema examination (n = 12) or clinical follow-up (n = 4) confirmed no appendicitis in the remaining 16 patients. CONCLUSION: Hyperemia in the wall of the appendix at color Doppler US is a sensitive indicator for inflammation. A simple additional color Doppler US examination may be helpful in the diagnosis of early acute appendicitis when an appendix is well depicted and is equivocal in size at gray-scale US.