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PubMed1993

Is the appendix where you think it is--and if not does it matter?

For over 100 years the recognized surface marking for the appendix has been McBurney's point (the junction of the lateral and middle thirds of a line joining the umbilicus with the right anterior superior iliac spine (ASIS)). In order to test its validity, the relationship between McBurney's point and the appendix was determined on 275 double contrast barium enemas (DCBE). A wide spread of distribution of the site of the appendix base was seen. Only 35% of appendix bases were found to lie within 5 cm of McBurney's point, and 15% were more than 10 cm distant. Seventy-five per cent of appendix bases were below and medial to a line joining the umbilicus with the right ASIS. These findings are in agreement with world-wide studies conducted by the World Organisation of Gastroenterology which showed that less than half of all patients with appendicitis have tenderness maximal over McBurney's point. A record was also made in 93 cases of the position of the appendix in relation to the caecum. The importance of these results in the diagnosis and management of patients with suspected appendicitis is discussed.

Adolescent↗
PubMed2002

Pyeloureterostomy with interposition of the appendix.

PURPOSE: We describe the successful repair of a 6 cm. ureteral stricture involving the right ureteropelvic junction and proximal ureter using appendix as a ureteral substitute. MATERIALS AND METHODS: A 37-year-old man involved in a motorcycle accident presented with a retroperitoneal urinoma and a 6 cm. proximal ureteral stricture. At flank exploration we were unable to perform successfully primary pyeloureterostomy through renal descensus with ureteral mobilization. The appendix was selected to bridge the ureteral defect. The right colon and cecum were mobilized to the area of the diseased ureter and the appendix was transected across the base of the cecum. Ureteral scar tissue was resected and the appendix was interposed in an isoperistaltic orientation from renal pelvis to proximal ureter. RESULTS: Convalescence was unremarkable. Retrograde pyelography and flexible ureteroscopy 2 months postoperatively demonstrated a patent anastomosis and viable appendix. The ureteral stent was removed at that time. Excretory urography 3 months postoperatively revealed prompt enhancement of the 2 kidneys and visualization of the 2 ureters. Mercaptoacetyltriglycine-3 renal scan 5 months postoperatively confirmed no scintigraphic evidence of obstruction. The patient was asymptomatic 6 months postoperatively and renal function tests were normal. CONCLUSIONS: The appendix can be considered for proximal ureteral defects extending to the right renal pelvis.

Adult↗
PubMed1999

Enrichment of c-kit+ Lin- haemopoietic progenitor cells that commit themselves to extrathymic T cells in in vitro culture of appendix mononuclear cells.

The appendix as well as the small intestine have recently been found to carry c-kit+ stem cells which give rise to extrathymic T cells. In this study, the properties of c-kit+ stem cells in the appendix of mice were further characterized. When appendix mononuclear cells (MNC) were cultured in the presence of stem cell factor, interleukin-3, interleukin-6 and erythropoietin on a methylcellulose culture plate, the population of c-kitdull Lin- and that of c-kithi Lin- cells expanded. Morphological study revealed that these c-kithi Lin- cells were basophilic granular cells (possibly mast cells). Both populations of cultured appendix MNC were then injected into severe combined immunodeficient mice or cultured with Tst-4 thymic stroma cells. These in vivo and in vitro studies demonstrated that c-kitdull Lin- cells were oligopotent haemopoietic progenitor cells which gave rise to extrathymic T cells, while c-kithi Lin- cells lacked haemopoietic progenitor cell activity. In contrast to c-kit+ stem cells in the bone marrow, those in the appendix did not give rise to myeloid cells and conventional thymic T cells under any of the conditions tested. The present results suggest that the appendix primarily comprises c-kit+ cells which give rise to basophilic granular cells and extrathymic T cells and that such c-kit+ cells have the ability to replicate themselves in culture in vitro.

Animals↗
PubMed2000

Is the appendix graft suitable for routine biliary surgery in children?

BACKGROUND/PURPOSE: The appendix graft (AG) is used widely for urinary tract replacement in children. Biliary tract replacement is less common. The purpose of this retrospective multicentric study was to evaluate the safety of appendix grafting for biliary reconstruction. METHODS: The files of 33 patients treated at 7 European pediatric centers were reviewed. Indications included choledochal cyst (CC) in 5 cases, biliary trauma (BT) in 1, and biliary atresia (BA) in 27. In CC and BT patients, the graft was inserted isoperistaltically between the proximal biliary duct and second duodenum. In all but one of the BA patients, the graft was placed antiperistaltically by patching its cecal end onto the porta hepatis. RESULTS: Postoperatively, all CC and BT patients initially became asymptomatic but developed laboratory evidence of anicteric cholestasis within 1 year. The most common manifestation was increased gamma-glutamyl-transpeptidase level (GGT), whereas histologic findings showed liver damage (mainly fibrosis). Reoperation has been carried out in 4 CC and 1 BT patients within a mean period of 19 months after appendix grafting. The graft procedure was converted to hepaticojejunostomy (HJ) in 4 and to choledocoduodenostomy in 1. Surgical exploration showed kinking in 1 patient and stenosis in 1. In the remaining 3 cases, there was no discernible cause of cholestasis, and appendix histology findings were normal. In all 5 reoperated patients, liver function findings returned to normal within 1 month. Reoperation is scheduled for the remaining CC patient who currently requires ursodesoxycholic medication to maintain normal liver function and presents histologic evidence of "de novo" sclerosing cholangitis. Results of appendix grafting also were poor in the 27 BA patients. Procedure-related perioperative complications occurred in 4 (15%) including 1 early death from graft necrosis. Another early death resulted from intestinal hemorrhage. Jaundice cleared in only 8 (28%). CONCLUSIONS: The findings of this study suggest that the AG is unsuitable for routine biliary repair in children. It should be used only as a salvage technique when conventional HJ repair is contraindicated. Because of the high risk of graft dysfunction, we recommend screening tests to detect biochemical or histologic cholestasis in any patient previously treated with appendix grafting.

Adolescent↗
PubMed2004

The nonvisualized appendix: incidence of acute appendicitis when secondary inflammatory changes are absent.

OBJECTIVE: The objective of our study was to assess the importance of nonvisualization of the appendix and its association with acute appendicitis on helical CT when secondary inflammatory changes are absent. MATERIALS AND METHODS: After we received institutional review board approval, CT scans of 366 consecutive patients obtained for lower abdominal or right lower quadrant pain and to rule out appendicitis were retrospectively reviewed. Images were reviewed by an experienced abdominal radiologist and compared with the formal interpretation. The amount of right lower quadrant and pericecal fat was quantified on a scale of 0 (none) to 2 (abundant). Patients with a nonvisualized appendix and other findings compatible with acute appendicitis-such as abscess formation, localized perforation, periappendiceal fat stranding, or appendicolith-were excluded. RESULTS: The appendix could not be visualized by both reviewers in 46 (13%) of 366 cases. CT findings indicated another cause for the patient's symptoms in 12 cases (26%), including gastrointestinal and genitourinary processes. An alternate diagnosis was subsequently reached in 11 additional patients (24%) with follow-up imaging or clinical evaluation. Only one patient (2%) with a nonvisualized appendix had acute appendicitis, proven by surgical pathology. In this patient, there was paucity of fat in the right lower quadrant. CONCLUSION: In the absence of a distinctly visualized appendix and secondary inflammatory changes, the incidence of acute appendicitis is low. Nonvisualization of the appendix even when a small amount of fat is present in the right lower quadrant may safely exclude acute appendicitis if no secondary CT findings are present.

Abdomen, Acute↗
PubMed2002

Distinct clonal Ig diversification patterns in young appendix compared to antigen-specific splenic clones.

The young rabbit appendix is a dynamic site for primary B cell repertoire development. To study diversification patterns during clonal expansion, we collected single appendix B cells from 3- to 9-wk-old rabbits and sequenced rearranged H and L chain genes. Single cells obtained by hydraulic micromanipulation or laser capture microdissection were lysed, PCR amplified, and products directly sequenced. Gene conversion-like changes occurred in rearranged H and L chain sequences by 3-4 wk of age. Somatic mutations were found in the D regions that lack known conversion donors and probably also occurred in the V genes. A few small sets of clonally related appendix B cells were found at 3-5 wk; by 5.5 wk, some larger clones were recovered. The diversification patterns in the clones from appendix were strikingly different from those found previously in splenic germinal centers where an immunizing Ag was driving the expansion and selection process toward high affinity. Clonally related appendix B cells developed different amino acid sequences in each complementarity-determining region (CDR) including CDR3, whereas dominant clones from spleen underwent few changes in CDR3. The variety of combining sites generated by diversification within individual clones suggests that at least some clonal expansion and selection, known to require normal gut flora, may be driven through indirect effects of microbial components rather than solely by their recognition as specific foreign Ags. This diversity of combining sites within B cell clones supports the proposed role of appendix in generating the preimmune repertoire.

Amino Acid Sequence↗
PubMed1991

The gas-containing appendix: potential sonographic pitfall in the diagnosis of acute appendicitis.

The presence of gas within the appendix on plain abdominal radiographs is nonspecific and may or may not be associated with acute appendicitis. This finding, however, has not previously been reported with graded compression sonography of the right lower quadrant. Gas within the appendix was identified in four of 154 patients with a visualized appendix. All four patients had surgically confirmed acute appendicitis. Diagnostic difficulties were encountered in three of these four patients. In two patients, the findings were misinterpreted as an extraluminal gas-forming periappendiceal abscess. In an additional patient, the gas-filled appendix was initially mistaken for a segment of normal terminal ileum. The gas-filled appendix is a potential pitfall in the sonographic diagnosis of acute appendicitis. However, if other diagnostic criteria are met, gas within the appendix should not preclude establishing a sonographic diagnosis of appendicitis.

Acute Disease↗
PubMedDate not supplied

Hematuria: an unusual presentation for mucocele of the appendix. Case report and review of the literature.

Mucocele of the appendix is a nonspecific term that is used to describe an appendix abnormally distended with mucus. This may be the result of either neoplastic or non-neopleastic causes and may present like most appendiceal pathology with either mild abdominal pain or life-threatening peritonitis. Urologic manifestations of mucocele of the appendix have rarely been reported. Laparoscopy can be used as a diagnostic tool in equivocal cases. Conversion to laparotomy may be indicated if there is a special concern for the ability to remove the appendix intact or if more extensive resection is warranted, as in malignancy. We here report our experience with a woman presenting with hematuria whose ultimate diagnosis was mucocele of the appendix, and we review the appropriate literature. This case highlights the mucocele as a consideration in the differential diagnosis of appendiceal pathology and serves to remind the surgeon of the importance for careful intact removal of the diseased appendix.

Appendectomy↗
PubMed2000

The appendix as right ureteral substitute in children.

PURPOSE: The appendix has occasionally been used to replace sections of the right ureter. We reviewed the literature of the last 25 years on the use of the appendix as right ureteral replacement and report our experience with right ureteral substitution using the appendix. MATERIALS AND METHODS: We retrospectively reviewed the charts of 3 children who underwent appendiceal replacement of the right ureter. The appendix replaced the upper third of the ureter and the lower ureter in 1 and 2 cases, respectively. RESULTS: Followups of 4, 7 and 15 years, respectively, demonstrated that the appendix transports urine satisfactorily and permits renal function to be maintained with no evidence of obstruction. CONCLUSIONS: We believe that our small series supports the use of the appendix as a right ureteral substitute in select cases.

Adult↗
PubMed2004

[The selection and application of appendix in situ in the continent urinary diversion].

OBJECTIVE: To evaluate the elective method and the clinical experience of using appendix in situ in continent urinary diversion. METHODS: 26 continent urinary diversions have been performed since 1990. Among them, 11 cases underwent the intussuscepted technique and other 15 cases underwent embedded technique. RESULTS: The continent rate was 100% at the daytime among all the case, while intermittent incontinence occurred in 3 cases at night, which happened in the intussuscepted group. Other complications included catheterization difficulty in 3 cases, appendix perforation in 1 case, which happened in the embedded group, traction of the appendix into abdominal cavity in 1 case, and prolapse of the intussusepted appendix in 3 cases. CONCLUSIONS: The embedded technique shows better results than the intussuscepted technique in term of continence. The embedded technique, using appendix in situ as an efferent loop, shows the advantages of easily performing, timesaving, better outcome in continence and less complication. We believe the technique of appendix in situ as an efferent loop is an ideal modality in urinary diversion operation.

Adult↗
PubMed1989

Evaluation of two different dosage regimens of clindamycin and the penetration into human appendix.

The study objective was to evaluate serum, peritoneal fluid, and appendix tissue concentrations of clindamycin using two differing clindamycin regimens. Patients age 16 years and older who were about to undergo appendectomies were randomly assigned to receive gentamicin 1.5 mg/kg every 8 h admixed with clindamycin 900 mg every 8 h (8-h group) or clindamycin 600 mg every 6 h given separately (6-h group). Doses of each regimen were given preoperatively. Serum, peritoneal fluid, and appendix tissue samples were obtained intraoperatively, and frozen at -70 degrees C for gas chromatographic drug analysis. Twenty-one patients were evaluated, 11 patients in the 8-h group and 10 patients in the 6-h group. Values are reported as means +/- standard deviations. The values in the 8-h group were 12.3 +/- 14.1 micrograms/ml, 8.7 +/- 3.9 micrograms/ml, and 9.8 +/- 10.3 micrograms/g for serum, peritoneal fluid, and appendix tissue, respectively. The values in the 6-h group were 9.7 +/- 5.1 micrograms/ml, 5.8 +/- 5.3 micrograms/ml, and 6.2 +/- 4.9 micrograms/g for serum, peritoneal fluid, and appendix tissue, respectively. The 6-h group received more doses preoperatively (1.8 +/- 0.6) than the 8-h group (1.2 +/- 0.4; p less than 0.05). No differences in penetration of clindamycin into the serum, peritoneal fluid, and appendix tissue for the 8-h group and the 6-h group were noted. The study revealed a similarity in penetration of clindamycin into the serum, peritoneal fluid, and appendix tissue using either clindamycin 900 mg given by intermittent intravenous infusion every 8 h admixed with gentamicin or clindamycin 600 mg given every 6-h separately.

Adolescent↗
PubMed1986

The clinical significance of routine histopathologic study of the resected appendix and safety of appendiceal inversion.

A prospective study was done on 1,699 patients operated upon for appendicitis to correlate the operative diagnosis of the surgeon and the histopathologic diagnosis of the pathologist. There are surgeons who only send the appendices for histopathologic study when the operative findings are inconclusive and surgeons who invert rather than resect the appendices on finding a grossly normal appendix at operation. This study was done to find out whether or not these practices of leaving some of the appendix unexamined histopathologically are clinically safe. In this study, surgeons missed abnormal pathologic findings in the appendix in ten of 13 patients and this is irrespective of whether the appendix was normal, acutely inflamed, gangrenous or perforated. The majority of these lesions either require further investigation, treatment or they affected the prognosis of the patient. Nineteen per cent of the patients diagnosed as having normal appendices grossly were found to have acute appendicitis and 7.7 per cent diagnosed as acute appendicitis were normal. Based upon these data, we conclude that the operative diagnosis of the surgeon cannot be relied on to detect abnormal pathologic findings in the appendix. Additional important clinical information can be gained by routine histopathologic study of the resected specimens, and inversion of the appendix is clinically not safe.

Acute Disease↗
PubMed1983

Obstruction of the appendix lumen in relation to pathogenesis of acute appendicitis.

The role of obstruction of the pathogenesis of acute appendicitis was studied by measuring the pressure in the appendix peroperatively in 33 patients undergoing appendectomy because of suspected acute appendicitis. The technique involved insertion of a fine needle via the apex into the lumen of the appendix and measurement of the hydrostatic pressure required to inject a saline solution. In all six patients with gangrenous appendix and in two patients with phlegmonous appendix there were signs of obstruction of the appendix lumen expressed as raised intraluminal pressure. In 19 patients found at operation to have phlegmonous appendix there were no signs of obstruction. The experimental data suggest that obstruction is not an important factor in the causation of acute appendicitis, but may develop as a result of the inflammatory process.

Acute Disease↗
PubMed1996

[Can we recognize the pathological character of the appendix during laparoscopy? Prospective study: 81 cases].

In a prospective study of 81 patients, the appendix was photographed during a laparoscopy performed for pain in the right iliac fossa. An appendicectomy was performed in 65 patients, for the remaining 16, another cause for the pain was found and the appendix was left in place. The evaluation of the photographed appendix was formed afterwards by a group of 10 surgeons and compared with the histopathological results. In 20 cases (30%) the appendix was normal. In 7 (10%) minimal mucosal inflammation was found and in 38 (60%) acute appendicitis. All the surgeons correctly recognised acute appendicitis. The accuracy of recognition of a normal appendix was 70% overall, and the maximum risk of leaving an early form of appendicitis to evolve was 14%. We propose not removing an appendix judged to be normal during laparoscopy if no other cause for the pain is found. A short course of antibiotics would cover the low risk of allowing a very early appendicitis to develop.

Acute Disease↗
PubMed1996

[A clinicopathological observation of 15 cases of tuberculosis of the appendix].

OBJECTIVE: To study the clinicopathological features and diagnosis of tuberculosis of the appendix. METHOD: Fifteen cases (0.27%) with tuberculosis of appendix selected from 5,621 histopathologically examined appendectomy specimens between June 1959 and May 1995 were analyzed retrospectively. RESULTS: All the cases with tuberculosis of appendix were commonly occurred in the young (< or = 34 years in 12 cases) and in females (in 11 cases). They were usually secondary to tuberculosis elsewhere in the abdomen. By microscopy, proliferative type of the lesions were found in 11 cases, while ulcerative type in 4 cases. Fourteen cases (accounting for 93%) were clinically misdiagnosed. It was difficult to be differentiated from chronic appendicitis, tuberculosis or tumor of the ileocecum and malignant tumor of the appendix. CONCLUSIONS: Definite diagnosis of tuberculosis of the appendix mainly depend on the histopathological examination. It is recommended that in order to avoid misdiagnosis, all the surgically removed appendix specimens should be histopathologically examined, no matter whether the specimens are macroscopically normal or not.

Adolescent↗
PubMedDate not supplied

Catestatin--a novel neuropeptide in carcinoid tumors of the appendix.

BACKGROUND: The aim of the study was to investigate the immunohistochemical distribution of the novel neuropeptide catestatin in carcinoid tumors. Catestatin, a novel 21 amino acid neuropeptide derived from chromogranin A, was determined immunohistochemically in 30 carcinoid tumors of the appendix and various carcinoid tumors of other localities. MATERIALS AND METHODS: Paraffin-embedded tissues from 30 carcinoid tumors of the appendix and 16 other carcinoid tumors (5 bronchus-, 5 stomach-, 2 small bowel-, 4 large bowel carcinoid tumors) were incubated with antibodies specific for catestatin, chromogranin A and chromogranin B. Immunohistochemical staining of catestatin was compared to staining with chromogranin A and B. Western blot analysis was performed in one patient with ileal carcinoid. RESULTS: Thirty patients (20 women, 10 men) with carcinoid tumors of the appendix and 16 patients with other localized carcinoid tumors were investigated. Twenty-six of the appendiceal tumors were localized in the apex of the appendix and 4 tumors in the midportion; none of the tumors was localized at the base of the appendix. Median tumor diameter was 10.7 mm (range 4-18 mm). Immunoreactivity to catesatatin was positive in 28 patients (negative in 2, 0-10% in 11 patients, 11-50% in 14 patients, 51-100% in 3 patients). In 16 patients with carcinoid tumors in various other localizations, catestatin was also expressed. Western blot analysis of ileal carcinoid showed abundant catestatin reactivity with accelerated processing of chromogranin A in the tumor tissue. CONCLUSION: Catestatin derived from chromogranin A, which is the most widely distributed marker of neuroendocrine tumors, is expressed in high frequency in carcinoid tumors of the appendix (93.3%).

Appendiceal Neoplasms↗
PubMedDate not supplied

[Cystadenocarcinoma of the appendix. Report of a case].

Primary adenocarcinoma of the appendix is an uncommon disease frequently diagnosed surgery. It has an occurrence between 0.01 and 0.11% of all appendectomized patients, and it is more often found in patients older than fifty years. Symptoms are usually similar to those seen in acute appendicitis. Some authors consider the mucocele of the appendix a primary carcinoma as it is related with obstruction of the appendix lumen followed by a cystic dilatation with mucosal changes, mucus hypersecretion and extension outside of the appendix. We present one case with abdominal pain, constipation, weight loss of 26 kg, and a mass localized in the right lower quadrant. An exploratory surgery showed a partially retroperitoneal mass of 15 by 20 cm, irregular, cystic, with mucus content and the appendix included in it. The mass was removed and appendectomy was performed. Postoperatively the patient did well. The final pathologic report was a cystadenocarcinoma of the appendix.

Aged↗
PubMed1998

Rabbit appendix: a site of development and selection of the B cell repertoire.

As early as 1963, it was proposed that the rabbit appendix was a homologue of the chicken bursa of Fabricius (ARCHER et al. 1963). The finding that the young rabbit appendix was thymus independent contributed to the concept of central primary lymphoid tissue. Today we know that appendix is a site that generates the high copy number primary repertoire through diversification of rearranged VH genes by gene conversion-like and somatic hypermutation mechanisms. Thus the appendix of young rabbits functions as a mammalian bursal equivalent. In the appendix, newly generated B cells also undergo selection processes involving self and foreign antigens and superantigens. Preferential expansion and survival of B cells in normal and mutant ali rabbits based on FR1 and FR3 expression may involve "superantigen"-like interactions with endogenous and exogenous ligands. One endogenous ligand appears to be CD5. Additional ligands may be produced by gut flora. Further studies in the rabbit model are needed to determine the fates of emigrants from primary GALT, their sites of postulated self-renewal in the periphery, and the nature of secondary diversification in secondary germinal centers where populations of B lymphocyte memory cells may develop. These data may also be helpful in understanding how the repertoire of human B cells is formed and how this repertoire might be manipulated for clinical benefit.

Animals↗