Type:
Educational Exhibit
Keywords:
Anatomy, Abdomen, Gastrointestinal tract, CT, Ultrasound, Ultrasound-Colour Doppler, Education, Inflammation, Acute
Authors:
O. A. Furmaga1, A. KARAKOUSIS1, D. Sidiropoulos1, K. Koutroumanidis1, I. Tsanaktsidis1, I. Tsifountoudis1, N. J. Skoulikaris2, M. A. Kuczyńska3, E. Dionisiadis1; 1Thessaloniki/GR, 2Kavala/GR, 3Lublin/PL
DOI:
10.26044/ecr2019/C-2035
Background
APPENDICITIS
Appendicitis is considered to be among the most common pathologies to be observed at the emergency department worldwide as well as among the most common reasons for emergent abdominal surgery.
The diagnosis of acute appendicitis is being made on the basis of physical examination together with laboratory tests and well-taken history of the patient.
The radiological evaluation should be asked predominantly in order to establish the diagnosis in atypical cases.
It is important to recognize acute appendicitis correctly,
even in atypical location,
because a delay may increase the possibility of bowel perforation and therefore,
increase in morbidity.
Inflammation of atypically localized appendix often begins with unpredictable symptoms and therefore may be misdiagnosed.
Detailed information about the location of the vermiform appendix is advised to be included in the radiologic reports as it may help the surgeon to choose the most proper appendectomy incision spot.
Additionally,
in order for a surgeon to plan the dissection in an adequate way,
it is of great importance to know whether the tip of appendix lies free within the peritoneal cavity or is buried behind the caecum [1].
Both CT and US are highly accurate imaging techniques for establishing the diagnosis of acute appendicitis.
While choosing the most appropriate imaging technique,
a radiologist should always consider the age,
sex,
physical characteristics of the patient and the possible differential diagnoses.
The final choice of method used depends on the institutional preference,
availability and the experience of the operator.
ANATOMY
For many years the McBurney’s point has being considered to be a surgical topographical landmark for the localization of the base of appendix.
Due to the improvement of the imaging techniques,
this assumption has been proven non-accurate.
The base of the appendix has been identified in the McBurney’s point in about only 4% of the cases [2].
Anatomy of the appendix is variable and its identification might be problematic due to the fact that there exists no constant location of the organ.
The embryologic development of the caecum and appendix is complicated and it results in many anatomical variations.
Moreover,
conditions like pregnancy or filling of the caecum have impact on its position and therefore the location of the appendix may even vary in a given patient.
The only stable feature in the anatomy of the organ is that appendix merges with the caecum at the site where three teniae coli confluence [2,3].
The length of appendix is most commonly found to be between 5-10 cm,
although it can vary significantly from 1-25 cm.
The following topographic areas represent the most typical sites where the tip of the vermis can be found [4]:
- retrocaecal location (65%)
- pelvic location (30%)
- preileal location (<2%)
- post-ileal location (1%)
Congenital defects of the appendix are rare and of little clinical importance,
but awareness of their existence is significant.
The anatomic variation of appendix duplex or even triplex should be taken into consideration in a patient presenting with typical symptoms of appendicitis and a history of appendectomy[5].
If doubt persists,
explorative laparotomy must be performed to avoid overlooking rare,
acute,
intra-abdominal abnormalities.