Appendicular Duplication with Gangrenous Appendicitis in a 10-Year-Old Child: A Case Report

Acute appendicitis is the most common surgical emergency, and can sometimes be accompanied by congenital anomalies of the appendix. Vermiform appendix, thought to be vestigial in humans, would be expected to have many congenital variations, but this is not the case. The prevalence of appendicular duplication in appendectomy specimens is between 0.004% and 0.009% [1]. Ladd and Gross defined three characteristics of alimentary tract duplications: 1) contiguity with and strong adherence to some part of the alimentary tract, 2) a smooth muscle coat and 3) a mucosal lining consisting of one or more types of cells normally observed in the alimentary tract [2]. Thus, to be characterized as appendicular duplication, all these criteria need to be satisfied. In patients with appendicular duplication, acute appendicitis can occur in one or both of these appendixes [3]. The complications that may arise from an unidentified duplicate appendix can be disastrous for the patient. Herein, we report a case of appendicular duplication with gangrenous appendicitis in one of the moieties.

A 10-year-old boy presented to the emergency department of Sri Maharaja Hari Singh Hospital, Srinagar with pain in the epigastrium migrating to the right lower abdomen for 1 day accompanied by nausea and anorexia. The patient’s temperature was 101 0F and pulse rate was 110 beats per minute. On abdominal examination, he had guarding, tenderness, and rebound tenderness in the right iliac fossa. The blood counts were unremarkable except for leukocytosis (14300 cells/µL) with predominance of neutrophils (82%). Urine examination was normal. A presumptive diagnosis of acute appendicitis was made. Ultrasonography of the abdomen confirmed the presence of an aperistaltic, non-compressible gut loop with minimal interloop fluid in the right iliac fossa. The patient underwent emergency appendectomy. During surgery, minimal serous fluid was seen in the right paracolic gutter. An appendicular duplication was noted with gangrene of one of the moieties. Each of the two appendixes had its own mesentery but shared a common base with the caecum (Figure 1). The location of this duplication was subcaecal. Other neighboring viscera were grossly normal. The appendectomy was completed without any complications and both appendixes were removed. Patient had an uneventful recovery and was discharged on the second postoperative day. Histopathology confirmed the diagnosis of appendicular duplication with gangrenous appendicitis in one of the moieties.

Congenital anomalies of vermiform appendix are rarely reported in medical literature.The spectrum of congenital anomalies of appendix range from complete absence to ectopic locations, with duplications and diverticula being rare [4]. A triple appendix has also been reported in literature [5]. Based on their anatomic location, appendicular duplications were first classified by Cave in 1936 [6].