Appendicitis and beyond: a pictorial review of various appendiceal abnormalities

Abstract

Acute appendicitis is the most common disease of the appendix. However, the differential diagnosis for an abnormal appendix includes other conditions that often present with symptoms and imaging features that overlap with acute appendicitis. In this pictorial essay, we review the normal anatomy of the appendix and outline the pathogenesis, clinical manifestations, and imaging findings that are characteristic of acute appendicitis and other less common appendiceal abnormalities. Inflammatory/non-neoplastic processes including appendiceal diverticulitis, stump appendicitis, foreign body appendicitis, Crohn’s appendicitis, and appendiceal hernias are discussed. Neoplastic considerations include appendiceal neuroendocrine tumors, mucinous and non-mucinous (colonic type) epithelial neoplasms, and lymphoma. It is important for the radiologist to be able to differentiate these alternative diagnoses for the purpose of directing appropriate patient management.

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References

  1. 1.

    O’Connor CE, Reed WP (1994) In vivo location of the human vermiform appendix. Clin Anat 7:139–142

    Article  Google Scholar 

  2. 2.

    Rao PM, Rhea JT, Novelline RA (1997) Sensitivity and specificity of the individual CT signs of appendicitis: experience with 200 helical appendiceal CT examinations. J Comput Assist Tomogr 21(5):686–692

    CAS  Article  Google Scholar 

  3. 3.

    Ung C, Chang ST, Jeffrey RB, Patel BN, Olcott EW (2013) Sonography of the normal appendix: its varied appearance and techniques to improve its visualization. Ultrasound Q 29(4):333–341

    Article  Google Scholar 

  4. 4.

    Addiss DG, Shaffer N, Fowler BS et al (1990) The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 132(5):910–925

    CAS  Article  Google Scholar 

  5. 5.

    Schumpelick V, Dreuw B, Ophoff K, Prescher A (2000) Appendix and cecum. Embryology, anatomy, and surgical applications. Surg Clin North Am 80(1):295–318

    CAS  Article  Google Scholar 

  6. 6.

    Garcia EM, Camacho MA, Karolyi DR, Kim DH, Cash BD, Chang KJ, Feig BW, Fowler KJ, Kambadakone AR, Lambert DL, Levy AD, Marin D, Moreno C, Peterson CM, Scheirey CD, Siegel A, Smith MP, Weinstein S, Carucci LR (2018) ACR Appropriateness Criteria. Right lower quadrant pain-suspected appendicitis. J Am Coll Radiol 15(11S):S373–S387

    Article  Google Scholar 

  7. 7.

    Rao PM, Wittenberg J, McDowell RK et al (1997) Appendicitis: use of arrowhead sign for diagnosis at CT. Radiology 202(2):363–366

    CAS  Article  Google Scholar 

  8. 8.

    Rybkin AV, Thoeni RF (2007) Current concepts in imaging of appendicitis. Radiol Clin North Am 45(3):411–422

    Article  Google Scholar 

  9. 9.

    Kim HY, Park JH, Lee YJ, Lee SS, Jeon JJ, Lee KH (2018) Systematic review and meta-analysis of CT features for differentiating complicated and uncomplicated appendicitis. Radiology 287(1):104–115

    Article  Google Scholar 

  10. 10.

    Abdullgaffar B (2009) Diverticulosis and diverticulitis of the appendix. Int J Surg Pathol 17(3):231–237

    Article  Google Scholar 

  11. 11.

    Ito D, Miki K, Seiichiro S, Hata S, Kobayashi K, Teruya M, Kaminishi M (2015) Clinical and computed tomography findings of appendiceal diverticulitis vs acute appendicitis. World J Gastroenterol 21(13):3921–3927

    Article  Google Scholar 

  12. 12.

    Lee KH, Lee HS, Park SH, Bajpai V, Choi YS, Kang SB, Kim KJ, Kim YH (2007) Appendiceal diverticulitis: diagnosis and differentiation from usual acute appendicitis using computed tomography. J Comput Assist Tomogr 31(5):763–769

    Article  Google Scholar 

  13. 13.

    Dikicier E, Altintoprak F, Ozdemir K, Gundogdu K, Uzunoglu MY, Cakmak G, Onuray F, Capoglu R (2018) Stump appendicitis: a retrospective review of 3130 consecutive appendectomy cases. World J Emerg Surg 13:22

    Article  Google Scholar 

  14. 14.

    Manatakis DK, Aheimastos V, Antonopoulou MI, Agalianos C, Tsiaoussis J, Xynos E (2019) Unfinished business: a systematic review of stump appendicitis. World J Surg 43(11):2756–2761

    Article  Google Scholar 

  15. 15.

    Shin LK, Halpern D, Weston SR, Meiner EM, Katz DS (2005) Prospective CT diagnosis of stump appendicitis. Am J Roentgenol 184(3 Suppl):S62–S64

    Article  Google Scholar 

  16. 16.

    Klingler PJ, Seelig MH, DeVault KR, Wetscher G, Floch N, Branton S, Hinder R (1998) Ingested foreign bodies within the appendix: a 100-year review of the literature. Dig Dis 16(5):308–314

    CAS  Article  Google Scholar 

  17. 17.

    Green SM, Schmidt SP, Rothrock SG (1994) Delayed appendicitis from an ingested foreign body. Am J Emerg Med 12(1):53–56

    CAS  Article  Google Scholar 

  18. 18.

    Prieto-Nieto I, Perez-Robledo JP, Hardisson D, Rodriguez-Montes JA, Larrauri-Martinez J, Garcia-Sancho-Martin L (2001) Crohn’s disease limited to the appendix. Am J Surg 182(5):531–533

    CAS  Article  Google Scholar 

  19. 19.

    Han H, Kim H, Rehman A, Jang SM, Paik SS (2014) Appendiceal Crohn’s disease clinically presenting as acute appendicitis. World J Clin Cases 2(12):888–892

    Article  Google Scholar 

  20. 20.

    Ruiz V, Unger SW, Morgan J et al (1990) Crohn’s disease of the appendix. Surgery 107(1):113–117

    CAS  PubMed  Google Scholar 

  21. 21.

    Soyer P, Boudiaf M, Dray X, Sirol M, Martin-Grivaud S, Duchat F, Fargeaudou Y, Hamzi L, Tiah D, Marteau P, Rymer R (2010) Crohn’s disease: multi-detector row CT-enteroclysis appearance of the appendix. Abdom Imaging 35(6):654–660

    Article  Google Scholar 

  22. 22.

    Michalinos A, Moris D, Vernadakis S (2014) Amyand’s hernia: a review. Am J Surg 207(6):989–995

    Article  Google Scholar 

  23. 23.

    Constantine S (2009) Computed tomography appearances of Amyand hernia. J Comput Assist Tomogr 33(3):359–362

    Article  Google Scholar 

  24. 24.

    Guenther TM, Theodorou CM, Grace NL, Rinderknecht TN, Wiedeman JE (2020) De Garengeot hernia: a systematic review. Surg Endosc doi 35:503–513. https://doi.org/10.1007/s00464-020-07934-5

    Article  Google Scholar 

  25. 25.

    Latyf R, Slater R, Garner JP (2011) The vermiform appendix presenting in a laparoscopic port site hernia. J Minim Access Surg 7(3):181–183

    Article  Google Scholar 

  26. 26.

    Connor SJ, Hanna GB, Frizelle FA (1998) Appendiceal tumors: retrospective clinicopathologic analysis of appendiceal tumors from 7,970 appendectomies. Dis Colon Rectum 41(1):75–80

    CAS  Article  Google Scholar 

  27. 27.

    Moertel CG, Dockerty MB, Judd ES (1968) Carcinoid tumors of the vermiform appendix. Cancer 21(2):270–278

    CAS  Article  Google Scholar 

  28. 28.

    Leonards LM, Pahwa A, Patel MK, Petersen J, Nguyen MJ, Jude CM (2017) Neoplasms of the appendix: pictorial review with clinical and pathologic correlation. Radiographics 37(4):1059–1083

    Article  Google Scholar 

  29. 29.

    Goede AC, Caplin ME, Winslet MC (2003) Carcinoid tumour of the appendix. Br J Surg 90(11):1317–1322

    CAS  Article  Google Scholar 

  30. 30.

    Rymer B, Forsythe RO, Husada G (2015) Mucocoele and mucinous tumours of the appendix: a review of the literature. Int J Surg 18:132–135

    Article  Google Scholar 

  31. 31.

    Wang H, Chen YQ, Wei R, Wang QB, Song B, Wang CY, Zhang B (2013) Appendiceal mucocele: a diagnostic dilemma in differentiating malignant from benign lesions with CT. Am J Roentgenol 201(4):W590–W595

    Article  Google Scholar 

  32. 32.

    Collins DC (1963) 71,000 human appendix specimens. A final report, summarizing forty years’ study. Am J Proctol 14:265–281

    CAS  PubMed  Google Scholar 

  33. 33.

    Ito H, Osteen RT, Bleday R, Zinner MJ, Ashley SW, Whang EE (2004) Appendiceal adenocarcinoma: long-term outcomes after surgical therapy. Dis Colon Rectum 47(4):474–480

    Article  Google Scholar 

  34. 34.

    Pickhardt PJ, Levy AD, Rohrmann CA Jr, Abbondanzo SL, Kende AI (2002) Non-Hodgkin’s lymphoma of the appendix: clinical and CT findings with pathologic correlation. Am J Roentgenol 178(5):1123–1127

    Article  Google Scholar 

Download references

Acknowledgments

Drawings courtesy of Jennifer Armstrong, Medical Illustrator, Faculty of Medicine, Memorial University of Newfoundland.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This study was approved by the Health Research Ethics Board at Memorial University.

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Waived by the Health Research Ethics Board at Memorial University.

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No funding was received for this study.

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Correspondence to Andrew K.C. Fenwick.

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Fenwick, A.K., Hartery, A. Appendicitis and beyond: a pictorial review of various appendiceal abnormalities. Emerg Radiol (2021). https://doi.org/10.1007/s10140-021-01908-3

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Keywords

  • Gastrointestinal tract
  • Appendix
  • Appendicitis
  • Appendiceal neoplasm