Reference growth curves for normal appendiceal diameter in childhood.

The aim of this study was to investigate the relationship between the appendiceal diameter (AD) and age, sex, height, and body weight in children and to verify how does the normal AD grows in childhood. We evaluated the AD of patients younger than 16 years of age who underwent laparoscopic surgery at our hospital. We statistically examined the relationship between the AD and the age, sex, height, and weight. A final cohort of 188 patients participated in the study. The median AD for the sample population was 5 mm (range, 3.2-8.1). There was no significant difference in the AD between males and females in the multivariate analysis (P = 0.500). There was a positive correlation between the age and the AD (R = 0.396, P < 0.001). The AD had a significant positive correlation with the height and weight (P < 0.001, P < 0.001, respectively). The reference curve with regard to the AD can be useful in clinical situations, although it should be kept in mind that the range of individual differences in AD is large, and the growth degree by age is not uniform during childhood.

Imaging the Vermiform Appendix.

Near the ileocecal valve, at the junction of the small intestine and large intestine, lies a blind-ended tube and possible homeostatic regulator called the vermiform appendix. The organ can cause several abdominal maladies that, if left untreated, can result in a complicated recovery or death. Imaging professionals should understand the structure and function of the entire gastrointestinal tract to provide optimal care for patients undergoing diagnostic imaging. This article provides a brief overview of gastrointestinal anatomy, appendix physiology and function, clinical evaluation, appendix imaging, and treatment of appendicitis.

Ultrasound for Appendicitis: Performance and Integration with Clinical Parameters.

Objective. To evaluate the performance of ultrasound in pediatric appendicitis and the integration of US with the pediatric appendicitis score (PAS) and C-reactive protein (CRP). Method. An institution-based, retrospective study of children who underwent abdominal US for suspected appendicitis between 2012 and 2015 at a tertiary pediatric surgery center. US results were dichotomized, with a nonvisualized appendix considered as a negative examination. Results. In total, 438 children were included (mean 8.5 years, 54% boys), with an appendicitis rate of 29%. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for US were 82%, 97%, 92%, and 93%, respectively, without significant age or gender differences. Pediatric radiologists had significantly higher sensitivity compared to general radiologists, 88% and 71%, respectively (p < 0.01), but no differences were seen for specificity, PPV, and NPV. The sensitivity, NPV, and negative likelihood ratio for the combination of negative US, PAS < 5, and CRP < 5 mg/L were 98%, 98%, and 0.05 (95% CI 0.03-0.15). Conclusion. US may be a useful tool for evaluating children with suspected appendicitis, regardless of age or gender, and should be the first choice of imaging modalities. Combining US with PAS and CRP may reduce several unnecessary admissions for in-hospital observation.

Does appendiceal diameter change with age? A sonographic study.

OBJECTIVE: The purposes of this study were to determine whether age-related changes in appendiceal diameter identified on CT and pathology are apparent on sonography and to assess the relationship between normal appendiceal diameter and patient-specific factors. MATERIALS AND METHODS: Ultrasound examinations from 388 unique pediatric patients with normal appendixes, evenly distributed by age, were reviewed. Appendiceal diameter and wall thickness were correlated with patient age, sex, height, weight, and presence of enlarged lymph nodes. RESULTS: Mean (± SD) anteroposterior and transverse appendiceal diameters were 4.4 ± 0.9 and 5.1 ± 1.0 mm, respectively. Appendiceal diameter was normally distributed across the population but was not significantly associated with age. Centers for Disease Control and Prevention (CDC) weight percentile for age was the only statistically significant patient-specific predictor of transverse diameter (p = 0.001) and approached significance for anteroposterior diameter (p = 0.051). The presence of enlarged lymph nodes was a significant predictor of anteroposterior diameter (p = 0.029) and approached significance for transverse diameter (p = 0.07). Wall thickness was normally distributed across the population and was significantly associated with age (p = 0.011; effect size, -0.05 mm/y). CONCLUSION: Appendiceal diameter measured on ultrasound is normally distributed in children and does not depend on age. Age-dependent diagnostic cutoffs for normal sonographic diameter are thus not needed. There is, however, a relationship between age and appendiceal wall thickness, suggesting the need for age-dependent diagnostic values if this criteria are to be used to diagnose appendicitis. Although the CDC weight percentile for age and the presence of enlarged lymph nodes affect appendiceal diameter on ultrasound, these effects are small and of doubtful clinical significance.

The vermiform appendix: a review.

New research on the vermiform appendix has shed light on its function. In further understanding the function of the appendix, this information should not negatively impact the clinical judgment in the event of appendicitis. Although the appendix and its pathology have been noted for centuries, it still presents a challenge in the operating room. The most common emergency surgical procedure performed is an appendectomy. Its highly variable position within the abdomen can cause confusion for clinicians. However, improved imaging modalities have heightened the physician's ability to diagnose disease of this organ. This article reviews germane literature regarding the human vermiform appendix.

Development of the vermiform appendix inchildren from different age ranges

There is no precise anatomical trace that limits the vermiform appendix of the cecum in the newborn and in the child in the first years of life. The appendix presents a conical form, with an enlarged base and a narrow apex. The objective of the present work was to identify certain anatomical parameters, and to relate them chronologically to the different age groups in order to define when exactly the base of implantation of this organ in the cecum resembles the adult’s anatomy. Sixty-seven (67) ileocecal transition pieces were grouped according to the different age groups: Group A (18 pieces of newborns at term) – Group B (14 pieces of six months-old children) – Group C (13 pieces of 12 month-old children) – Group D (11 pieces of 24 month-old children) and Group E (11 pieces of adults). The point of contact of the ileum anti-mesenteric edge in the cecum was identified and the distance between this and the edges, right (d.r.e.i) and left (d.l.e.i.), of the appendix implantation was assessed. The results were demonstrated through the crossing of variables in the different age groups and the statistical significance level was considered for p < 0.05. From the sixty-seven (67) pieces, forty-seven (70.1%) were obtained from males and twenty (29.9%) from females. The average extension of the vermiform appendix length was 5.3 cm. The retro ileum position was predominant in the first year of life (groups A, B and C). The average of the variables according to the age group (groups A, B, C, D and E) was: D.L.E.I. = 0.0-0.0-0.5-2.0-2.5 cm respectively. D.R.E.I. = 1.1-1.0-1.3-2.3-2.8 cm respectively. DIAMETER of the BASE = 1.0-0.8-0.4-0.3-0.5 cm respectively. The crossing of the average values of the distances from the left margin of the appendix base to the ileum (d.l.e.i.) was performed in groups A, B, C and D with the average value in group E (adult)...

Observations on a vestigial organ: a potential surrogate for enteric neuromesenchymal disease.

Abnormalities of enteric nerves, interstitial cells of Cajal (ICC) and smooth muscle are often associated with severe gastrointestinal motility disorders. In this context, full-thickness biopsy of the gut may provide important diagnostic and prognostic clues as well as some possible therapeutic implications. Nonetheless, the unavoidable risk to further worsen prognosis evoked by laparotomy, and the unclear yield of histopathological analysis has hampered full-thickness gut sampling in patients with severe dysmotility. However, recent advances in minimally invasive surgery have refuelled enthusiasm in gastrointestinal neuromuscular pathology. In this issue of Neurogastroenterology and Motility, Miller et al. provide novel and exciting evidence that the appendix might be used as a surrogate tissue to analyse changes to enteric nerves, ICC and smooth muscle cells in patients with diabetic gastroenteropathy. The objective of this short review was to place this very important work in the context of current understanding of enteric neuromuscular dysfunction.

Distribution of interstitial cells of Cajal and nitrergic neurons in normal and diabetic human appendix.

The objective of this study was to determine the distribution of enteric nerves and interstitial cells of Cajal (ICC) in the normal human appendix and in type 1 diabetes. Appendixes were collected from patients with type 1 diabetes and from non-diabetic controls. Volumes of nerves and ICC were determined using 3-D reconstruction and neuronal nitric oxide synthase (nNOS) expressing neurons were counted. Enteric ganglia were found in the myenteric plexus region and within the longitudinal muscle. ICC were found throughout the muscle layers. In diabetes, c-Kit positive ICC volumes were significantly reduced as were nNOS expressing neurons. In conclusion, we describe the distribution of ICC and enteric nerves in health and in diabetes. The data also suggest that the human appendix, a readily available source of human tissue, may be useful model for the study of motility disorders.

The vermiform appendix: not a useless organ.

The appendix has often been seen more as a nuisance rather than an important part of the human anatomy. Early misconceptions have led to the indiscriminate removal of the appendix from the body. Long thought to be an evolutionary remnant of little significance to normal physiology, the appendix has more recently been identified as an important component of mammalian mucosal immune function, particularly B-lymphocyte-mediated immune responses and extrathymically derived T-lymphocytes. This structure helps in the proper movement and removal of waste matter in the digestive system, contains lymphatic vessels that regulate pathogens, and lastly, might even produce early defences that prevent deadly diseases. The appendix is one of the guardians of the internal environment of the body from the hostile external environment.

Multiple myenteric networks in the human appendix.

The general histological organization of the appendix, including its innervation, is believed to be generally similar to that of the large intestine. However, several authors described an unusual arrangement of the myenteric ganglia within the appendiceal muscle, but conflicting reports do not allow clear conclusions on this matter. The aim of this work was to examine the appendiceal innervation in detail. The myenteric plexus of the human appendix was examined using sections and whole mount preparations. Human small and large intestines were used for comparison. The nerves were stained using immunohistochemistry, enzyme histochemistry for NADPH-diaphorase, and vital staining with 4-(4-diethylaminostyryl)-methylpyridinium iodide. Appendices from rabbits were also studied. In most cases, the innervation of the external muscle of the appendix consisted of three concentric networks of ganglia. These networks were located both between the circular and longitudinal muscle layers and within them. The middle network made connections with the other two. Such arrangement was not observed in the human small and large intestines. The myenteric plexus in the rabbit appendix displayed a much smaller degree of three-dimensional distribution compared with that of the human appendix. It is concluded that the myenteric plexus in the human appendix consists of several distinct networks, and appears to be unique in comparison with the other parts of the intestine.

Implications of removing a normal appendix.

BACKGROUND: The diagnosis of acute appendicitis remains difficult and therefore 15-30% of the removed appendices appear to be normal. The aim of this study was to investigate morbidity, mortality and costs of removing a normal appendix in patients with suspected appendicitis. PATIENTS AND METHODS: Retrospective study of patients who underwent a negative appendectomy for suspected appendicitis in the period 1991-1999 with a median follow-up of 4.4 years. Patients who underwent an elective appendectomy or appendectomy for other reasons were excluded. RESULTS: In 285 patients (70% women, 30% men) a normal appendix was removed. In 192 (67%) patients a muscle-splitting incision was performed, in 6 (2%) a median laparotomy, and in 51 (18%) the normal appendix was removed by laparoscopy. In 36 patients (13%) a diagnostic laparoscopy was converted to a muscle-splitting incision. Complications occurred in 16 (6%) patients, in 5 (2%) a re-operation was needed. The mean hospital stay was 4.4 (SE 2.8) days, in case of complications 7.4 (SE 4.2) days. The mean extra hospital costs of a negative appendectomy were EUR 2712. CONCLUSION: The removal of a normal appendix has considerable complications and costs. In an attempt to prevent these costs, extra diagnostic tools should be considered. Expensive diagnostic tools such as diagnostic laparoscopy should be used selectively in order not to further increase costs.

Nitrergic hyperinnervation in appendicitis and in appendices histologically classified as normal.

CONTEXT: The pathogenesis of appendicitis remains poorly understood. Despite new diagnostic techniques, appendices removed from patients with suspected appendicitis often appear histologically normal on conventional examination. There is increasing evidence of involvement of the enteric nervous system in immune regulation and in inflammatory responses in the gastrointestinal system. OBJECTIVE: To investigate the nitrergic innervation of (a) acutely inflamed appendices, (b) appendices classified as histologically normal from patients with a clinical diagnosis of appendicitis, and (c) normal control appendix specimens, using the whole-mount preparation technique. PATIENTS AND DESIGN: Full-thickness specimens were collected from 28 acutely inflamed appendices (age range, 3.2-13.4 years), 31 histologically normal appendices removed from patients (age range, 5.7-13.6 years) with suspected appendicitis, and 23 histologically normal appendices from patients (age range, newborn to 12.1 years) undergoing elective abdominal surgery (controls). Whole-mount preparation using nicotinamide adenine dinucleotide phosphate (NADPH) diaphorase histochemistry and neuronal nitric oxide synthase immunohistochemistry were performed. The density of myenteric plexus was measured with a computerized analysis system. RESULTS: The density of myenteric plexus in normal appendix specimens was similar to that of large bowel from the newborn period up to 3 years of age; this density decreased significantly thereafter. The myenteric plexus of normal appendix specimens from patients older than 4 years demonstrated smaller ganglia connected by thin nerve bundles, compared to larger ganglia and nerve bundles in large bowel. Significant neuronal hypertrophy was found in 55% of acutely inflamed and 41% of histologically classified normal appendix specimens. The myenteric plexus of these appendix specimens had even thicker nerve bundles connecting an increased number of ganglion cells. CONCLUSIONS: Differences in the architecture of the myenteric plexus in patients older than 3 years suggest an altered function and motility of appendix in the early years of life. The significant increase in neuronal components of the myenteric plexus in a high proportion of acutely inflamed and histologically normal appendix specimens is unlikely to have developed during a single acute inflammatory episode. This suggests an underlying chronic abnormality as a secondary response to chronic luminal obstruction or repeated inflammatory episodes in the histologically normal appendix.

[Appendectomy reduces the risk of development of ulcerative colitis]. / Appendektomie senkt Kolitisrisiko.

The etiology and pathogenesis of ulcerative colitis are still unclear. There is, however, a growing consensus that the disease is characterized by a complex interaction between genetic and environmental influences. Many studies in the last few years have suggested that appendectomy reduces the risk of development and improves the course of ulcerative colitis. The underlying mechanism of this effect is unknown. The appendix seems to play a more important role in the development and modulation of the mucosal immune system than believed so far.

Role of appendix and spleen in experimental colitis.

There is growing clinical evidence suggesting that certain secondary lymphoid tissues (e.g., appendix and spleen) contribute to the initiation and/or perpetuation of ulcerative colitis. In this study, the importance of secondary lymphoid tissues in inducing colitis was assessed experimentally by removing the spleen and/or appendix (or sham operation) prior to inducing colitis in mice. Feeding 2.5% dextran sulphate sodium (DSS) in drinking water over 7 days induced colitis. Clinical disease activity was assessed based on weight loss, stool consistency, and presence of blood in stools. Additional measurements included white blood cell count and hematocrit, and myeloperoxidase activity (MPO) in colon samples. Colonic injury was assessed by histology and computerized image analysis. DSS treatment in sham-operated mice produced colitis associated with weight loss, bloody diarrhea, and mucosal ulceration. Clinical assessment of DSS-treated mice subjected to appendectomy or combined appendectomy/splenectomy exhibited a delayed onset and course of disease activity. Histomorphologic examination revealed significantly lower damage scores and a reduction in ulcerated mucosal surface area. Colonic MPO activity, which correlated with tissue injury and disease activity, was lowest in appendectomized mice. No beneficial effects of splenectomy were observed after 7 days of colitis. These findings support the hypothesis that appendicular lymphoid tissue, but not the spleen, contributes to the development of colitis.