Exploring Anatomical Variations of the Vermiform Appendix on Multidetector CT

• Hajer A. Alfadeel

  Diagnostic Radiology Department, Faculty of Medicine, Omer Al-Mukhtar University, Libya

  Author

Acute appendicitis is the most common cause of acute abdominal pain requiring urgent abdominal surgical intervention. Computed tomography (CT) is the preferred imaging examination for the evaluation of patients due to its high sensitivity and specificity. The appendix is a highly variable organ with many possible configurations of its location. Depending on the position of the appendix, the signs and symptoms of appendicitis may also vary and mimic other surgical conditions. Diagnosing appendicitis requires an understanding of the anatomy of the vermiform appendix, which may vary from patient to patient. This study aims to describe the prevalence of anatomical variations of the vermiform appendix on multidetector CT (MDCT). Methods: A retrospective review of consecutive abdominal CT exams (age ≥ 15) performed over eleven months was done. The final study population consisted of 669 patients, 317 men and 352 women, mean age of 51.85 years ± 16.39 (SD), age range, 15-91 years. A classification system was used to describe the different positions of the appendix apex. Results: The most common location of appendix apex was subcecal in 180 (26.9%), followed by pelvic in 153 (22.9%), midline in 130 (19.4%), retrocecal in 100 (14.9%), postileal in 29 (4.3%), paracecal in 20 (3%), others in 19 (2.8%), antececal in 18 (2.7%), hepatic in 14 (2.1%), preileal in 6 (0.9%). Analysis of relative frequencies of appendix locations in relation to patient gender using a chi-square test showed that the pelvic and post-ileal positions of the appendix were statistically significantly higher in females compared to males (p<0.0001, P=0.0158 respectively). The most common 

Azhagiri, R., Anitha, M., & Hemapriya J. (2019). PREVALENCE OF ANATOMICAL VARIATIONS OF THE POSITION OF APPENDIX IN ACUTE APPENDICITIS BY CT SCAN. International Journal of Anatomy and Research, 7(4.1), 7051-7055. DOI: 10.16965/ijar.2019.304

Burrill, J., Dabbagh, Z., Gollub, F., & Hamady, M. (2007). Multidetector computed tomographic angiography of the cardiovascular system. Postgraduate medical journal, 83(985), 698–704. https://doi.org/10.1136/pgmj.2007.061804

Charoensak, A., Pongpornsup, S., & Suthikeeree, W. (2010). Wall thickness and outer diameter of the normal appendix in adults using 64 slices multidetector CT. Journal of the Medical Association of Thailand = Chotmaihet thangphaet, 93(12), 1437–1442.

Chidambaram, B., Rajasekaran V, Selvam VM, & Shanmugam, G. (2021). A cross-sectional study of the position of the appendix in the South Indian population, comparison with the Western population, and its diagnostic dilemma. Journal of Evidence-Based Medicine and Healthcare, 8(25), 2127-2131. DOI: 10.18410/jebmh/2021/399

De León, L. & De León, J. (2021). Anatomical variations of the caecal appendix on tomography, a retrospective study. Revista Ciencias Biomédicas, 10(3), 163-171. https://doi.org/10.32997/rcb2021-3350

De Souza, S. C., Da Costa, S. R. M. R., & De Souza, I. G. S. (2015). Vermiform appendix: positions and length – a study of 377 cases and literature review. Journal of Coloproctology, 35(4), 212-216. https://doi.org/10.1016/j.jcol.2015.08.003

de Wijkerslooth, E. M. L., van den Boom, A. L., & Wijnhoven, B. P. L. (2020). Disease burden of appendectomy for appendicitis: a population-based cohort study. Surgical endoscopy, 34(1), 116–125. https://doi.org/10.1007/s00464-019-06738-6

Drake, F. T., Florence, M. G., Johnson, M. G., Jurkovich, G. J., Kwon, S., Schmidt, Z., Thirlby, R. C., Flum, D. R., & SCOAP Collaborative (2012). Progress in the diagnosis of appendicitis: a report from Washington State's Surgical Care and Outcomes Assessment Program. Annals of Surgery, 256(4), 586–594. https://doi.org/10.1097/SLA.0b013e31826a9602

D'Souza, N., Marsden, M., Bottomley, S., Nagarajah, N., Scutt, F., & Toh, S. (2018). Cost-effectiveness of routine imaging of suspected appendicitis. Annals of the Royal College of Surgeons of England, 100(1), 47–51. https://doi.org/10.1308/rcsann.2017.0132

Guan, L., Liu, Z., Pan, G., Zhang, B., Wu, Y., Gan, T., & Ouyang, G. (2023). The global, regional, and national burden of appendicitis in 204 countries and territories, 1990-2019: a systematic analysis from the Global Burden of Disease Study 2019. BMC gastroenterology, 23(1), 44. https://doi.org/10.1186/s12876-023-02678-7

Hong, H. S., Cho, H. S., Woo, J. Y., Lee, Y., Yang, I., Hwang, J. Y., Kim, H. M., & Kim, J. W. (2016). Intra-Appendiceal Air at CT: Is It a Useful or a Confusing Sign for the Diagnosis of Acute Appendicitis?. Korean journal of radiology, 17(1), 39–46. https://doi.org/10.3348/kjr.2016.17.1.39

Kacprzyk, A., DroŚ, J., Stefura, T., Krzysztofik, M., JasiŃska, K., PĘdziwiatr, M., Major, P., & KHołda, M. (2020). Variations and morphometric features of the vermiform appendix: A systematic review and meta-analysis of 114,080 subjects with clinical implications. Clinical anatomy (New York, N.Y.), 33(1), 85–98. https://doi.org/10.1002/ca.23474

Kaya, B., & Eris, C. (2011). Different clinical presentation of appendicolithiasis. The report of three cases and review of the literature. Clinical medicine insights. Pathology, 4, 1–4. https://doi.org/10.4137/CPath.S6757

Khatun, S., Thakur, D., & Shah, D. K. (2019). Prevalence of Retrocaecal Appendix among Patients with Appendicitis in A Tertiary Care Hospital of Nepal. JNMA; Journal of the Nepal Medical Association, 57(217), 150–153. https://doi.org/10.31729/jnma.4370

Kim, M. Y., Kim, Y., Ryu, J. A., & Kim, T. Y. (2014). How to evaluate appendices with borderline diameters on CT: proposal of a quick solution to overcome the limitations of the established CT criteria. Academic radiology, 21(12), 1573–1578. https://doi.org/10.1016/j.acra.2014.07.005

Krisem, M., Jenjitranant, P., Thampongsa, T., & Wongwaisayawan, S. (2023). Appendiceal wall thickness and Alvarado score are predictive of acute appendicitis in patients with equivocal computed tomography findings. Scientific reports, 13(1), 998. https://doi.org/10.1038/s41598-023-27984-8

Krzyzak, M., & Mulrooney, S. M. (2020). Acute Appendicitis Review: Background, Epidemiology, Diagnosis, and Treatment. Cureus, 12(6), e8562. https://doi.org/10.7759/cureus.8562

Lee, S. L., Ku, Y. M., Choi, B. G., & Byun, J. Y. (2014). In Vivo Location of the Vermiform Appendix in Multidetector CT. Journal of the Korean Society of Radiology, 70(4), 283-289. https://doi.org/10.3348/jksr.2014.70.4.283

Lewis, C. L., Laudicina, N. M., Khuu, A., & Loverro, K. L. (2017). The Human Pelvis: Variation in Structure and Function During Gait. Anatomical record (Hoboken, N.J.: 2007), 300(4), 633–642. https://doi.org/10.1002/ar.23552

Monsonis, B., Mandoul, C., Millet, I., & Taourel, P. (2020). Imaging of appendicitis: Tips and tricks. European journal of radiology, 130, 109165. https://doi.org/10.1016/j.ejrad.2020.109165

Moskowitz, E., Khan, A. D., Cribari, C., & Schroeppel, T. J. (2019). Size matters: Computed tomographic measurements of the appendix in emergency department scans. American journal of surgery, 218(2), 271–274. https://doi.org/10.1016/j.amjsurg.2018.12.010

Mwachaka, P., El-Busaidy, H., Sinkeet, S., & Ogeng'o, J. (2014). Variations in the position and length of the vermiform appendix in a black Kenyan population. ISRN anatomy, 2014, 871048. https://doi.org/10.1155/2014/871048

Nur Bazlaah, B., Khairuzi, S., Nabiha, F., Mohd Nadzri, M., Nur Bazilah, B., Hirdayu, A. B., & Fazlin, F. (2021). Incidence of Retrocaecal Acute Appendicitis at the Hospital Sultanah Nora Ismail (HSNI) Batu Pahat. The Medical Journal of Malaysia, 76(2), 223–228.

Ozer, H., Yazol, M., & Senturk, M. (2021). Appendix Vermiformis Morphology in the Adult Age Group: What we've learned from more than 250 Patients on Computer Tomography. Gazi Medical Journal, 32, 628-631. https://medicaljournal.gazi.edu.tr/index.php/GMJ/article/download/2745/2398/34079

Parmar, P.D., Dave, J., Vekariya, M., & Pandya, K. (2017). Study of variations in position of appendix in 100 operated cases of appendicitis. Journal of Health Sciences & Research, 7(5), 42-46.

Ranieri, D. M., Enzerra, M. D., & Pickhardt, P. J. (2021). Prevalence of Appendicoliths Detected at CT in Adults With Suspected Appendicitis. AJR. American Journal of roentgenology, 216(3), 677–682. https://doi.org/10.2214/AJR.20.23149

Tamburrini, S., Brunetti, A., Brown, M., Sirlin, C., & Casola, G. (2005). CT appearance of the normal appendix in adults. European Radiology, (15), 2096–2103. https://doi.org/10.1007/s00330-005-2784-z

Whitley, S., Sookur, P., McLean, A., & Power, N. (2009). The appendix on CT. Clinical radiology, 64(2), 190–199. https://doi.org/10.1016/j.crad.2008.06.015

Willekens, I., Peeters, E., De Maeseneer, M., & de Mey, J. (2014). The normal appendix on CT: does size matter?. PloS one, 9(5), e96476. https://doi.org/10.1371/journal.pone.0096476

Zacharzewska-Gondek, A., Szczurowska, A., Guziński, M., Sąsiadek, M., & Bladowska, J. (2019). A pictorial essay of the most atypical variants of the vermiform appendix position in computed tomography with their possible clinical implications. Polish Journal of Radiology, 84, 1-8. https://doi.org/10.5114/pjr.2018.81158

• PDF

Copyright (c) 2024 Hajer A. Alfadeel (Author)

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

Copyright of the articles Published by Almukhtar Journal of Science (MJSc) is retained by the author(s), who grant MJSc a license to publish the article. Authors also grant any third party the right to use the article freely as long as its integrity is maintained and its original authors and cite MJSc as the original publisher. Also, they accept the article remains published by the MJSc website (except in the occasion of a retraction of the article).