appendix

 The diameter of the appendix is a key parameter in diagnosing appendicitis. The diagnostic threshold for this parameter is 6 mm, originally established through graded compression sonography of the right lower quadrant (RLQ) of the abdomen. However, without corroborative findings from computed tomography (CT), this threshold may not be a reliable indicator of appendicitis. To ensure accurate diagnosis, clinicians should perform a comprehensive, multiparameter imaging assessment of the appendix, rather than relying solely on appendix diameter.

 This study aimed to identify key factors for predicting appendicitis using contrast-enhanced coronal and sagittal CT images obtained through multiplanar reconstruction.
Patients and

 This single-center, retrospective, cross-sectional study included patients who presented to our emergency department (ED) with RLQ abdominal pain and subsequently underwent contrast-enhanced CT between July 2019 and September 2020. The primary study outcome was pathologically confirmed appendicitis. Two experienced radiologists assessed parameters such as appendix diameter, wall thickness, abnormal appendix enhancement, abnormal appendix content, appendix erection, and periappendiceal fat stranding. Multivariate logistic regression was performed to identify significant predictive factors for appendicitis.

 The study included 173 patients (median age: 37 years; women: 86). They were divided into appendicitis (n = 102) and alternative diagnosis (n = 71) groups. Significant differences were observed between the groups in terms of appendix diameter, wall thickness, wall enhancement, luminal content, appendix erection, and periappendiceal fat stranding (P < 0.001). The diagnostic sensitivity and specificity values for an appendix diameter threshold of 7.7 mm were 91% and 82%, respectively. An appendix diameter of > 7.7 mm (OR: 15.3; P < 0.001), abnormal appendix enhancement (OR: 12.5; P < 0.001), and appendix erection (OR: 6.1; P = 0.004) emerged as significant independent predictors of appendicitis.

 An appendix diameter of 7.7 mm appears to be the optimal threshold for diagnosing appendicitis. Additionally, the detection of abnormal appendix enhancement and appendix erection on contrast-enhanced CT images holds considerable diagnostic value.

 Fibrous obliteration or appendiceal neuroma is a rare type of appendiceal tumor that causes appendiceal obstruction and then presents as appendicitis. This neural tumor has no specific presentation and, after appendectomy, is diagnosed by the pathologist accidentally. Fibrous obliteration is described as a proliferative lesion. The pathogenesis of this lesion is unknown, but it is mentioned that the etiology of this problem is secondary to recurrent inflammation processes. These processes cause neuroendocrine cell hyperplasia in the submucosa and lamina propria of the wall of the appendix. The repetitive occurrence of these sub-clinical inflammatory processes causes fibrosis.

Cases Report: 

We presented a 55-year-old woman who was referred to our clinic with persistent pain in the right lower quadrant for five days in this report. The pain mimicked appendicitis presentation, and it suddenly started from the periumbilical area and then shifted to the right lower quadrant of the abdomen. Her laboratory study showed a 9600/microliter white blood cell count with 70% neutrophils. An increase in the appendix loop with 9 millimeters diameter was reported in the ultrasound. There was also severe fat haziness around the tissues and visceral inflammation of the terminal ileum in the sonogram. She underwent an appendectomy after the diagnosis of appendicitis, and the pathologist diagnosed fibrous obliteration or appendiceal neuroma.

 It is concluded that fibrous obliteration or appendiceal neuroma mimics acute appendicitis, and in patients with this presentation, appendectomy is the best choice for treatment. The main diagnostic method is pathologic assessment, and it is important for the differentiation of this tumor from other malignant tumors of the appendix because fibrous obliteration is a benign tumor.

Appendiceal carcinoid tumors are uncommon in children and are usually found incidentally during histopathological examination after appendectomy.

The aim of this study was to investigate the clinicopathologic characteristics and long-term outcomes of appendiceal carcinoid tumors in children.

Patients under 18 years old with a diagnosis of appendiceal carcinoid tumor were analyzed. Demographical, clinical, radiological, surgical, and pathological data and long-term outcomes were evaluated.

A total of 10 (0.64%) appendiceal carcinoid tumors were found in 1562 appendectomy specimens. The mean age of children with appendiceal carcinoid tumors was 12.6 years, and the male-to-female ratio was 2:3. Tumor localization was at the tip of the appendix in 9 (90%) patients. Seven (70%) tumors were smaller than 1 cm, while 3 (30%) tumors were between 1 and 2 cm. The depth of tumor penetration reached the subserosa in 8 (80%) patients and the mesoappendix in the remaining 2 (20%) cases. Surgical margins were intact in all patients, and no additional surgery was performed. The patients were followed up for an average of 42.4 months, and no recurrence was detected.

Appendiceal carcinoid tumors usually have nonspecific clinical-radiological findings and are almost always detected incidentally during the histopathological analysis of appendectomy specimens resected due to acute appendicitis. According to histopathology results, close follow-up and advanced surgical and medical treatments should be considered when necessary. Although the survival of patients is good, the possibility of colorectal malignancies should not be overlooked during follow-up.

Low-grade appendiceal mucinous neoplasm (LAMN) is a very rare condition, diagnosed in 0.2-0.7% of appendectomies. The pathophysiology of the neoplasm involves accumulation of large volume of mucin in the appendiceal lumen, resulting in its obstructive dilation. Most epithelial tumors affecting the appendix are of the mucinous type and are manifested by mucin accumulation within an inflamed appendix with fibrotic and hyalinized wall.

A 29-year-old female presented with a history of chronic and intermittent episodes of abdominal pain and a palpable mass in the right lower abdominal quadrant. Sonography showed a 58 mm mass anterior to the uterus and adjacent to the ovary, probably a uterine myoma. Laparotomy revealed normal uterus, and ovaries with a translucent mass originating from the appendix and fixed to the cecum. Pathologic examination of the mass was reported as low grade appendiceal mucinous neoplasm.

This is a rare case of appendiceal mucocele in a young female, mimicking a pelvic mass, which was misinterpreted by sonography as a gynecologic solid mass near the uterus. Preoperative diagnosis of appendiceal mucocele is important due to the risk of concurrent GI and ovarian malignancy associated with the condition.

Although Duplication anomalies are common in the Gastro-intestinal tract, appendicular anomalies are rare with variable anatomy.

 To describe the series of appendicular duplication cases managed at a tertiary care center.

 Data regarding the clinical features, associated anomalies and management of cases of appendicular duplication at a tertiary care center from January, 2019 to December, 2020 were collected retrospectively and analyzed.

 Four children with appendicular duplication were managed during this period; three neonates presented with high anorectal malformation and type two pouch colons with a large colovesical fistula. They had a single caecum with two separate appendices symmetrically on either side (type B1). They were managed by division of colo-vesical fistula, mobilization of colonic pouch after limited pouchoplasty and anoplasty as a single stage procedure. None of the appendix was removed. In one of these cases, bilateral ureters were dilated. The fourth case presented as a 3 year-old with pain abdomen and during surgery for suspected appendicitis, partial duplication of inflamed appendix was found (type A). Appendicectomy relieved this child of his symptoms. All patients are doing well on follow-up.

 The position, anatomy and associated anomalies of appendicular duplication can be variable complicating its presentation and management.

 Diagnosis of acute appendicitis is based on clinical manifestation .Some patients have atypical clinical symptoms, and diagnosis is difficult. Red blood cell distribution width (RDW) is a measure of heterogeneity in the size of circulating red blood cells. The aim of this study was to evaluate RDW values in diagnosis of appendicitis.

 This is a retrospective case-control study, in which 399 patients with pathological diagnosis of appendicitis were divided into two groups of acute appendicitis and complicated appendicitis and compared with 400 healthy controls for appendicitis. RDW, white blood cell (WBC), platelet count (PLT), and hemoglobin changes were compared in three groups of patients.

 In all three groups, the ratio of men was significantly higher than women (P<0.05). WBC (P=0.00), PLT (P=0.01), and RDW (P=0.01) had a significant difference between the three groups. However, there was no significant difference in the hemoglobin level between the three groups (P=0.3). RDW level was significantly higher in complicated appendicitis compared to acute (P=0.09) and control group (P=0.012).

 The results of this study showed that RDW value in three groups were significantly different. However, these values are not clinically useful for detecting appendicitis due to the slow progression of RDW value in patients.

A 76-year-old woman presented with a one-year history of intermittent right lower abdominal pain, little weight loss, and palpable mass in the right lower quadrant of the abdomen. Pelvic ultrasound scan identified a lobulated hypo-hetero-echoic mass with some calcified foci. Computed tomography scan revealed a low-attenuated lesion-like mass in the perineal region, which suggested a cystic localized tumor. Colonoscopy showed sub-mucosal lesion in the cecum. The patient underwent laparotomy, and a right hemicolectomy (include ileum) with ileocolic anastomosis was performed. She was treated successfully. In the Histological examination, two mass-like lesions were found to attach to the appendix. In the proximal portion of the appendix, there were cystic structures that showed a low-grade appendiceal mucinous neoplasm. The tip of the appendix showed a well-differentiated neuroendocrine tumor (carcinoid tumor). In this unusual case, even though the initial origins of these two tumors are quite different, two tumors appeared in a single histological section.

Synchronized evidence of bilateral ovarian masses with an asymptomatic  incidental appendiceal solitary mass is an unusual  event during  operation.  The main differential diagnosis in this status  is metastatic mucinous adenocarcinoma of ovary to appendix  versus  metastatic mucinous neoplasm of appendix  in both side ovaries. Herein, i present a  metastatic bilateral ovarian high grade serous carcinoma to the appendix as  a diagnosis pitfall. A 43-year-old woman, with menstrual irregularity was referred. Imaging studies  showed bilateral ovarian masses. She underwent total abdominal hysterectomy, bilateral salpingo oophorectomy , omentectomy,  pelvic lymph nodes dissection and appendectomy.  Final diagnosis, according to histopathological and immunohistochemical findings was metastatic bilateral ovarian high grade serous carcinoma of the appendix. These tumor markers may be useful for final diagnosis because tumoral tissue expression of them is not 100%. Therefore usage of several of them in correlation with histopathology findings, definitely helpful.

Diverticulosis of the appendix, as a rare and incident disorder, mimics acute or chronic appendicitis and is characterized by herniation of the appendiceal mucosa through the muscular wall. Symptom and laboratory data of diverticular disease usually represent chronic inflammation. In this study, a 43-year-oldfemale with a history of right lower quadrant pain and anorexia represented with abdominal tenderness and rebound tenderness in physical examination and normal laboratory tests. Abdominal sonography did not show any evidence of acute appendicitis. The removed appendix was 12 cm in length and had multiple diverticular protrusions along it. The histologic examination showed diverticulosis without evidence of inflammation. The patient was discharged 2 days later in optimal clinical condition. Diverticulosis of the appendix often is confused with acute or chronic appendicitis based on similar presenting symptoms and imaging studies. Although surgery is the definitive treatment of both conditions, appropriate diagnosis of diverticular disease before surgery is very important because of the association of the appendiceal diverticular disease with neoplasm and other complications.

Appendix tumors are rare tumors found in the gastrointestinal tract, observed at a rate of about 0.2%–0.3%. Our aim in this study was to present the clinicopathological classification, treatment and long-term prognosis of patients with low grade appendiceal mucinous neoplasm (LAMN)

Patients who underwent surgery in the Erciyes University Department of (Kayseri, Turkey), Department of General Surgery between December 2010 and December 2018, and who had LAMN as a result of pathology were included in our study. Demographic data, clinical and pathological features of the disease, their treatment and follow-up results after treatment were reviewed retrospectively.

We included 24 patients in the study. Of these patients, 10 (41.6%) were male. The mean age distribution was 56.4 ± 20.3 (21–91) years. Appendectomy was performed in 14 patients, and additional organ resections were performed in 8 patients. The most common symptom at the time of presentation was abdominal pain (79.1%; 95% CI, 58.3–91.7). The most common preliminary diagnosis in the preoperative period was acute appendicitis (50%; 95% CI, 29.2–70.8). Mean postoperative hospitalization time was 7.4 ± 7.96 (2–31) days. On pathological examination, appendectomy resection margins were positive in two patients. The mean (median) postoperative follow-up was 31.25 ± 23.9 (27) (1–90) months. One-year survival was 91.6%, and 5-year survival was 83.3%. Recurrence was detected in three patients during the follow-up period.

If appendix mucinous neoplasia (AMN) is suspected in patients undergoing surgery with an initial diagnosis of acute or plastron appendicitis, care should be taken to remove the lesion without perforation. Pseudomyxoma peritonei, which may develop as a result of perforation, is associated with recurrence and decreased survival.

Persistent müllerian duct syndrome (PMDS) in the majority of cases is discovered during surgery for inguinal hernia or cryptorchidism. A transverse testicular ectopia (TTE) with cryptorchidism may be very rarely associated to PMDS. Assuming that müllerian remnants have a very low malignant degeneration potential if compared to the malignancy risk of an undescended and not relocated testis, we describe a simplified surgical technique of orchiopexy that avoids an extensive anatomical dissection, in this way minimizing the risk of losing the deferential blood supply to the testis.

This paper introduces a novel technique, known as appendiceal conduit. It could be used as an alternative for ileal conduit and cutaneous ureterostomy, ultimately applied after radical cystectomy. The six-month follow-up indicated that the patient had appendix-stoma as nipple without any stenosis, nor did he have any hydronephrosis, as confirmed by abdominal sonography.

Carcinogen antigen 125 (CA-125) is a glycoprotein antigen, which has shown potentials in predicting peritoneal inflammation. The aim of this study is to determine the value of CA-125 in predicting acute appendicitis (AA). This prospective diagnostic accuracy study was conducted on 15 – 70 year-old patients with acute abdominal pain, suspected to AA, referred to emergency department. The serum level of CA-125 was measured for all patients before appendectomy and its screening characteristics in detection of AA case (confirmed by histology findings) were calculated and reported with 95% confidence interval (CI). 95 patients with the mean age of 31.65 ± 12.9 (15-75) years were studied (54.3% male). Based on the histologic findings, 72 (75.8%) cases were categorized as AA (23 cases as severe). AA and non-AA (NAA) groups were similar regarding the mean age (p = 0.59), mean duration of symptoms (p = 0.08), mean white blood cell (WBC) count (p = 0.37), and mean PMN percentage (p = 0.55). Mean CA-125 level was 16.5 ± 20.0 U/mL in the AA group and 30.5 ± 6.1 U/mL in the NAA group (p = 0.001). Adjustment of analysis based on gender revealed a significant correlation between CA-125 level and diagnosis of AA only in females (34.23 ± 39 U/mL in NAA versus 20.7 ± 26.7 U/mL in AA, p = 0.012). The area under the ROC curve of CA-125 was 0.62 (95%CI: 0.51 to 0.72). Sensitivity, specificity, NPV, PPV, NLR, and PLR of CA-125 in 16.4 U/mL cut off (best point) were 77.8% (95%CI: 66.4 - 86.7), 50.0% (95%CI: 28.2 - 71.8), 83.6% (95%CI: 76.7 - 88.7), and 40.7% (95%CI: 27.4 - 55.6), 0.44 (95%CI 0.2 - 0.8), and 1.56 (95%CI: 1.0 - 2.4), respectively. Considering the lower levels of CA-125 in patients with AA compared with NAA cases and also weak screening performance characteristics, it seems that it could not be considered as an accurate screening tool in this regard.

Introduction Appendicocecal intussusception is an uncommon condition which must be differentiated from other types of invagination due to different therapeutic approaches and its ultrasound findings are outspread and imperfectly presented in literature. We present a case with specific sonographic signs as well as review of related articles. Case Presentation A 3.5 year-old girl with intermittent crampy abdominal pain from one month ago that was recently exaggerated was associated with nausea and vomiting. She had specific sign of appendicocecal intussusception. Due to unsuccessful hydrostatic reduction, surgical intervention and appendectomy was performed. Conclusion The absence of clinical symptoms and ultrasound findings of small intestine obstruction and invagination target (transverse diameter less than 20 mm) adjacent to terminal ileum loop containing hypoechoic Peyer's patches can help differentiate appendicocecal invagination from the other types of invagination.

Clostridium difficile infection always manifests as diarrhea associated with antibiotic use. Nevertheless, extraintestinal infections caused by C. difficile are reported. The current report was on a case of C. difficile bacteremia in a 51-year-old male patient with appendiceal perforation and abscess as well as confirmed cirrhosis. The patient was admitted to the infectious diseases department with repeated abdominal pain associated with fever. His anaerobic blood culture was positive for C. difficile two days after transarterial chemoembolization. The same toxin strain was isolated from stool four days later. Both of the two isolates were confirmed positive for toxin A (tcd A) and toxin B (tcd B) genes by polymerase chain reaction, and identified as ST3 by multiple locus sequence typing. The two strains showed the same susceptibility to the tested antibiotics. The patient was treated with vancomycin intravenously, and got remitted shortly after that. The patient was discharged with good general health conditions and followed up. A patient with C. difficile bacteremia presenting with appendiceal perforation and abscess as well as confirmed cirrhosis was described, and the microbiological and molecular biological analysis suggested that C. difficile strains isolated from blood came from gut. It is necessary that clinicians detect C. difficile and/or toxins in patients with long terms antibiotic therapy, in case of transformation of intestinal flora, which could cause the infection outside the intestinal tract.

Invaginated appendices are a rare finding and a result of the appendix pulling itself into the cecum and can be caused by anatomical and pathological mechanisms. We present a case of an invaginated Appendix found during a routine colonoscopy.

A horseshoe kidney is the most common renal fusion anomaly and occurs in 0.2% to 0.3% of the population. Horseshoe kidneys are fused by the formation of an isthmus between the lower poles of the left and right kidneys during development. The insertion of the ureter in the renal pelvis is displaced super-laterally, probably as the result of incomplete renal rotation, and is associated with a significant rate of ureteropelvic junction (UPJ) obstruction.
We report a patient with single kidney at right side with obstruction in upper ureter. Before the surgery our plan was transureteroureterostomy according to failure of previous surgeries, dismembered pyeloplasty and ureterocalicostomy, but after mobilizing the proximal ureter we noticed that transureteroureterostomy was impossible because of short fibrotic ureter. Other choices such as Boari flap technique with psoas hitch is impossible because of small fibrotic bladder, so we decided to use appendix as ureter substitute.
According to our experience and previous studies, we can use appendix as a ureter substitution in refractory proximal and middle ureter stenosis, but in our case we anatomized proximal ureter to appendix instead of anastomosis of pelvic to appendix.