International Journal of Current Research and Review
ISSN: 2231-2196 (Print)ISSN: 0975-5241 (Online)
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IJCRR - Vol 05 Issue 16, August, 2013

Pages: 27-30

Date of Publication: 28-Aug-2013


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DUPLEX APPENDIX: A MORPHOLOGICAL, EMBRYOLOGICAL AND APPLIED ASPECT

Author: Vandana Dave, Hitendra Kumar Loh, Avinash Thakur, Rajesh Kumar Suri

Category: Healthcare

Abstract:The vermiform appendix has been noted as a vestigial structure that has lost most of its original functions through the process of evolution. Duplication of appendix is extremely rare congenital entity which can be related with other anomalies of gastrointestinal tract. Double appendix represents a challenging clinical scenario in cases of right lower quadrant pain. In the present study we report a peculier case of double appendix. Understanding of appendiceal duplication is essential for clinicians to prevent acute and serious intestinal, genitourinary conditions; for surgeons performing surgeries and for medico legal connotations.

Keywords: vermiform appendix, vestigeal, appendicitis, double appendix.

Full Text:

INTRODUCTION
The vermiform appendix is positioned at the commencement of the large gut and has the same basic structure. It is an elongated tubular cul-desac connected to the caecum situated in the right iliac fossa of the abdomen. Though proposed as vestigeal in humans after losing its original functions during evolution, it still serves as a significant lymphoid organ. Large masses of confluent lymphatic nodules in the walls of appendix contain germinal centers for local defense against infection and make up a part of Gut Associated Lymphoid Tissue (GALT). It is presumed that these are homolog of the avian bursa of fabricus related to the acquisition of immunological competence by certain lymphocytes. In lower mammals particularly herbivores, the caecum and appendix are large and significant sites of digestion of cellulose by symbiotic bacteria1 . Though the length and position of the appendix exhibit normal anatomical variations, its duplication is a rare occurrence reported with an incidence of 0.004% 2 . The first case of appendix duplex was reported in a female patient who had associated anomalies of duplication of entire large bowel, two uteri with two vaginae, ectopia vesicae and exomphalos3 . Most anomalies of appendix have been observed in adults and most were noticed incidentally during surgery not primarily involving the appendix 4 . The complications that might arise from an unidentified duplicate appendix may have serious, life-threatening consequences for the patient.

Embryological Aspect:
Initially the appendix is a tiny diverticulum of the caecum. It increases rapidly in length. At birth it is relatively a long tube arising from the distal caecal end. After birth the right wall of the caecum grows excessively and pushes the appendix medially5 . The appendix is subject to considerable, positional variations. It may pass posterior to the caecum (retrocaecal appendix) or colon (retrocolic appendix) or it may descend on the pelvic brim (pelvic appendix). Although In majority of people (64%), it is retrocaecal in position5 .

CASE REPORT
During routine dissection hall teaching curriculum of medical undergraduates, two appendices, normal and accessory were identified in a 56 years old male Indian cadaver. The normal appendix was subcaecal in position situated 2 cms below the ileocaecal junction and had a patent lumen. This appendix measured 3.1 cms in length from its base to the tip. The maximum outer diameter using vernier calipers was 0.9 cms. The accessory appendix was positioned at iliocaecal junction along the taenia line. It was smaller than the normal appendix and measured 2.6 cms in length from its base to the tip. The maximum outer diameter measured 0.4 cms. It was found in promonteric position. The lumen of this accessory appendix was obliterated. Both the appendices had mesoappendix containing appendicular artery at their free margin. The respective appendicular arteries were branches of iliocolic artery. Histologically, both appendices revealed normal mucosa, submucosa, muscularis externa and serosa.

DISCUSSION
Double appendix is usually asymptomatic. Accessory appendices are mostly diagnosed during abdominal surgeries, postmortem examination or on barium enema studies6 . Appendiceal duplication was first classified by Cave in 19367 . Wallbridge and Waugh in 1963 worked on the appendiceal duplication and divided these duplications into three groups as Type A, Type B and Type C8 . Type A consists of various degrees of partial duplication on a normally localized appendix with a single caecum. Type B consists of a single caecum with two completely separated appendices. Type B is divided further into two subgroups. B1 group includes two appendices localized symmetrically on either side of the ileo-cecal valve; this resembles the normal phylogenetical arrangement in birds, so this group was called the ‘bird-like or avian’ type. In B2 group (taenia-coli type) there is a normally localized appendix arising from the caecum at the usual site and a second, separate, rudimentary appendix localized along the taenia line. In type C there are two caeca, each bearing its own appendix8 . Some cases are difficult to categorize into a suitable type so the authors started to add additional types. Type D includes a horse-shoe appendix with two opening at the common caecum9 . The present case can be compared with type ‘B2’ variety, as one appendix arose from the normal site while the other accessory appendix which was smaller in size rather rudimentary, arose from the ileo-caecal junction. Most of the cases of double appendix studied by Wallbridge were of the ‘B’ type; out of the 50 reported cases, 30 were of this variety8 . Phylogenetically, the appendix is absent in several species like Felis (tiger, leopard, lion) and Canis (dog, wolf, fox) 10. Morphologically there is no reason why the human being might not have two appendices. Duplication is said to be possible in any part of gastrointestinal tract11. Aetiology of the double appendix has been explained by many workers. Environmental factors such as trauma or hypoxia during early fetal development have also been suggested to play a role11. Despite normal embryogenesis, the pathogenesis of appendiceal duplication is yet unclear. There are four theories to explain the embryology of gastrointestinal duplication namely the split notochord theory, the median septum formation, failure of the normal regression of embryonic diverticula and partially twinning procedure12. Embryogenesis of appendiceal duplication can be explained to some extent by the theory of ‘failure of the normal regression of embryonic diverticula’. Cave explained the embryological basis of its occurrence by referring to the work of Kelly and Hurden, Gladstone and Wakeley and emphasized that a transient appendix develops from the tip of the caecum at the beginning of the 5th week, atrophies at the 7th week and disappears soon after7 . The normal vermiform appendix differentiates later. The transient appendix may be substantiation of ancestral caecal duplicity in mammalia7 .

APPLIED ASPECT
The anomalies of appendix detected during childhood are always associated with severe intestinal, genitourinary or bony malformations, seen most often in conjunction with Type B1 and Type C duplication13. Carcinoma of the intestinal tract with coexistent duplication has also been reported. This condition is very rare and appears limited to a few number of cases14, 15 . In case of double appendix, the symptoms are usually the result of obstruction and inflammation of the bowel. In patients with appendiceal duplication, it has been reported that acute appendicitis occurs in one16 or both11 appendices and reoccurs six years after the first appendectomy17. In patient with appendicular duplication both appendices are removed whenever one is found inflamed. This is done to avoid diagnostic confusion that may arise on removal of a single appendix 11. The clinical presentation can vary according to the location of the appendices. Anomalies of the appendix such as duplication and malposition are of great practical importance and a surgeon must acknowledge this fact during operations.

CONCLUSION
A double appendix is rather rarest which accounts for surgical complications or may be associated with a carcinoma of gastrointestinal tract. Embryologically this duplication occurs due to the failure of normal regression of embryonic diverticula. Acknowledging such appendiceal duplications can circumvent diagnostic perplexity and help clinicians foresee acute or chronic intestinal or genitourinary conditions.

References:

1. Williums PL, Bannister LH. The anatomical basis of medicine and surgery. ELBS with Chrchil Livingstone Grays Anatomy.1995; 38th ed. pp 1775-76.

2. Kjossev KT, Losanoff JE. Duplicated vermiform appendix. Br J Surg. 1996; 83; pp 1259.

3. Picoli G. (Quoted by Gupta and Kak, 1964) Progresso Medico (Napoli). 1892; 6; pp 32.

4. Eroglu E, Erdogan E, Gundogdu G, Dervisoglu S, Yeker D. Duplication of appendix vermiformis : a case in a child. Tech Coloproctol. 2002; 6; pp 55-57.

5. K. L. Moore, T.V.N. Persaud. The developing human, clinically oriented embryology. 2009; 8 th ed. pp 227-229.

6. Mitchell IC, Nicholls JC. Duplication of the vermiform appendix. Report of a case: Review of classification and medico legal aspects. Medicine, Science, Law. 1990; 30(2); pp 124- 26.

7. Cave AJE. Appendix vermiformis duplex. J Anat. 1936; 70; pp 283-292.

8. Wallbridge PH. Double appendix. Br J Surg. 1963; 50(221); pp 346- 347.

9. Drino E, Radnic D, Kotjelnikov B, Aksamija G. Rare anomalies in the development of the appendix. Acta Chir Iugosl. 1991;38; pp 103- 11.

10. Chew DK, Borromeo JR, Gabriel YA, Holgersen LO. Duplication of the vermiform appendix. J Pediatr Surg. 2000; 35; pp 617- 618.

11. Bishop HC, Koop CE. Surgical management of duplications of the alimentary tract. Am J Surg. 1964; 107; pp 434-442.

12. Jimenez SG, Oliver MR, Stokes KB, Morreau PN, Chow CW. Case report: Colonic duplication: a rare cause of obstruction. J Gastroenterol Hepatol. 1999; 14; pp 889–892.

13. Tinckler LF. Triple appendix vermiformis: a unique case. Br J Surg. 1968;55; pp 79-8.

14. Holcomb GW 3rd, Gheissari A, O'neill JA Jr, Shorter NA, Bishop HC. Surgical management of alimentary tract duplications. Ann Surg. 1989; 209; pp 167-174

15. Chen CC, Yeh DC, Wu CC, Li MC, Kwan PC. Huge cystic duplication of the ascending colon in adult. Zhonghua Yixue Zazhi (Taipei). 2001; 64; pp 174-178

16. Griffiths EA, Jagadeesana J, Fasihe T, MercerJonesa M. Bifid vermiform appendix: a case report. Curr Surg. 2006; 63; pp 176-178.

17. Travis JR, Weppner JL, Paugh JC. Duplex vermiform appendix: case report of a ruptured second appendix. J Pediatr Surg. 2008; 43; pp 1726–1728.

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A Study by Amr Y. Zakaria et al. entitled "Single Nucleotide Polymorphisms of ATP-Binding Cassette Gene(ABCC3 rs4793665) affect High Dose Methotrexate-Induced Nephrotoxicity in Children with Osteosarcoma" is awarded Best Article for Vol 13 issue 19
A Study by Kholis Ernawati et al. entitled "The Utilization of Mobile-Based Information Technology in the Management of Dengue Fever in the Community Year 2019-2020: Systematic Review" is awarded Best Article for Vol 13 issue 18
A Study by Bhat Asifa et al. entitled "Efficacy of Modified Carbapenem Inactivation Method for Carbapenemase Detection and Comparative Evaluation with Polymerase Chain Reaction for the Identification of Carbapenemase Producing Klebsiella pneumonia Isolates" is awarded Best Article for Vol 13 issue 17
A Study by Gupta R. et al. entitled "A Clinical Study of Paediatric Tracheostomy: Our Experience in a Tertiary Care Hospital in North India" is awarded Best Article for Vol 13 issue 16
A Study by Chandran Anand et al. entitled "A Prospective Study on Assessment of Quality of Life of Patients Receiving Sorafenib for Hepatocellular Carcinoma" is awarded Best article for Vol 13 issue 15
A Study by Rosa PS et al. entitled "Emotional State Due to the Covid – 19 Pandemic in People Residing in a Vulnerable Area in North Lima" is awarded Best Article for Vol 13 issue 14
A Study by Suvarna Sunder J et al. entitled "Endodontic Revascularization of Necrotic Permanent Anterior Tooth with Platelet Rich Fibrin, Platelet Rich Plasma, and Blood Clot - A Comparative Study" is awarded Best Article for Vol 13 issue 13
A Study by Mona Isam Eldin Osman et al. entitled "Psychological Impact and Risk Factors of Sexual Abuse on Sudanese Children in Khartoum State" is awarded Best Article for Vol 13 issue 12
A Study by Khaw Ming Sheng & Sathiapriya Ramiah entitled "Web Based Suicide Prevention Application for Patients Suffering from Depression" is awarded Best Article for Vol 13 issue 11
A Study by Purushottam S. G. et al. entitled "Development of Fenofibrate Solid Dispersions for the Plausible Aqueous Solubility Augmentation of this BCS Class-II Drug" is awarded Best article for Vol 13 issue 10
A Study by Kumar S. et al. entitled "A Study on Clinical Spectrum, Laboratory Profile, Complications and Outcome of Pediatric Scrub Typhus Patients Admitted to an Intensive Care Unit from a Tertiary Care Hospital from Eastern India" is awarded Best Article for Vol 13 issue 09
A Study by Mardhiah Kamaruddin et al. entitled "The Pattern of Creatinine Clearance in Gestational and Chronic Hypertension Women from the Third Trimester to 12 Weeks Postpartum" is awarded Best Article for Vol 13 issue 08
A Study by Sarmila G. B. et al. entitled "Study to Compare the Efficacy of Orally Administered Melatonin and Clonidine for Attenuation of Hemodynamic Response During Laryngoscopy and Endotracheal Intubation in Gastrointestinal Surgeries" is awarded Best Article for Vol 13 issue 07
A Study by M. Muthu Uma Maheswari et al. entitled "A Study on C-reactive Protein and Liver Function Tests in Laboratory RT-PCR Positive Covid-19 Patients in a Tertiary Care Centre – A Retrospective Study" is awarded Best Article of Vol 13 issue 06 Special issue Modern approaches for diagnosis of COVID-19 and current status of awareness
A Study by Gainneos PD et al. entitled "A Comparative Evaluation of the Levels of Salivary IgA in HIV Affected Children and the Children of the General Population within the Age Group of 9 – 12 Years – A Cross-Sectional Study" is awarded Best Article of Vol 13 issue 05 Special issue on Recent Advances in Dentistry for better Oral Health
A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" is awarded Best Article of Vol 13 issue 06
A Study by Chen YY and Ghazali SRB entitled "Lifetime Trauma, posttraumatic stress disorder Symptoms and Early Adolescence Risk Factors for Poor Physical Health Outcome Among Malaysian Adolescents" is awarded Best Article of Vol 13 issue 04 Special issue on Current Updates in Plant Biology to Medicine to Healthcare Awareness in Malaysia
A Study by Kumari PM et al. entitled "Study to Evaluate the Adverse Drug Reactions in a Tertiary Care Teaching Hospital in Tamilnadu - A Cross-Sectional Study" is awarded Best Article for Vol 13 issue 05
A Study by Anu et al. entitled "Effectiveness of Cytological Scoring Systems for Evaluation of Breast Lesion Cytology with its Histopathological Correlation" is awarded Best Article of Vol 13 issue 04
A Study by Sharipov R. Kh. et al. entitled "Interaction of Correction of Lipid Peroxidation Disorders with Oxibral" is awarded Best Article of Vol 13 issue 03
A Study by Tarek Elwakil et al. entitled "Led Light Photobiomodulation Effect on Wound Healing Combined with Phenytoin in Mice Model" is awarded Best Article of Vol 13 issue 02
A Study by Mohita Ray et al. entitled "Accuracy of Intra-Operative Frozen Section Consultation of Gastrointestinal Biopsy Samples in Correlation with the Final Histopathological Diagnosis" is awarded Best Article for Vol 13 issue 01
A Study by Badritdinova MN et al. entitled "Peculiarities of a Pain in Patients with Ischemic Heart Disease in the Presence of Individual Combines of the Metabolic Syndrome" is awarded Best Article for Vol 12 issue 24
A Study by Sindhu Priya E S et al. entitled "Neuroprotective activity of Pyrazolone Derivatives Against Paraquat-induced Oxidative Stress and Locomotor Impairment in Drosophila melanogaster" is awarded Best Article for Vol 12 issue 23
A Study by Habiba Suhail et al. entitled "Effect of Majoon Murmakki in Dysmenorrhoea (Usre Tams): A Standard Controlled Clinical Study" is awarded Best Article for Vol 12 issue 22
A Study by Ghaffar UB et al. entitled "Correlation between Height and Foot Length in Saudi Population in Majmaah, Saudi Arabia" is awarded Best Article for Vol 12 issue 21
A Study by situs slot and Siti Sarah Binti Maidin entitled "Sleep Well: Mobile Application to Address Sleeping Problems" is awarded Best Article for Vol 12 issue 20
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A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16
A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13 
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for  Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma situs slot entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
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A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
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A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR. 
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Late to bed everyday? You may die early, get depression situs slot
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A Study by Ese Anibor et al. "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award


A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award


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