E5443. Unhappy Appy: Don’t Ignore the Appendix
  1. Priyanka Prajapati; Massachusetts General Hospital
  2. Nabih Nakrour; Massachusetts General Hospital
  3. Soumyadeep Ghosh; Massachusetts General Hospital
  4. Mukesh Harisinghani; Massachusetts General Hospital
This exhibit aims to highlight the challenges in diagnosing appendix pathologies due to their unusual anatomy, presentation, pathologies, and uncommon mimics. It emphasizes the importance of vigilant evaluation to detect subtle conditions early. Additionally, it explains the need for comprehensive imaging for seemingly benign appendiceal issues that can have serious consequences. This exhibit also emphasizes the role of the appendix in hernias and anomalies, stressing the importance of understanding its mobility for accurate diagnosis and effective treatment strategies.

Educational Goals / Teaching Points
1) Routine abdominal imaging can sometimes miss appendix pathologies, including malignancy. Vigilant evaluation is crucial to detect these subtle conditions early, leading to improved patient outcomes. 2) Appendiceal pathologies with serious consequences can have benign appearances. Comprehensive diagnostics are essential, even for mild symptoms, to avoid missing these pathologies and the mimics. 3) The appendix can play a role in different hernias and congenital anomalies. Understanding its mobility and interactions can increase diagnostic accuracy and eventually the treatment strategies.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
• Appendix cancer: the dark side of routine abdominal imaging – contrast-enhanced CT (CECT) revealed a focally dilated appendix with hypodense material, suspicious for mucinous appendiceal neoplasm. • Deceptively harmless: the severe consequences of appendix pathologies that have benign presentations. - CECT revealed a dilated cystic structure with hypodense content along the inferior and medial wall of caecum. Appendix is not seen separately on CT. • Appendix on the move: understanding its inclusion in different types of hernias - Amyand hernia: CT reveals a blind ending tubular structure entering the inguinal area, superolateral to the inferior epigastric artery. - De Garengeot’s hernia: the presence of a low-positioned cecum along with a tubular structure within the hernia sac and stranding of nearby fat on CT. - Spigelian hernia: dilated tubular structure projecting through the defect within the transversus abdominis and the internal oblique aponeuroses. • Congenital anomalies: abnormal positioning of the appendix - uncommon anatomical position of the appendix and the differential diagnosis of the pathologies. • Disorders that imitate appendicitis: a diagnostic challenge - appendiceal endometriosis: CT reveals enhancing wall of intraluminal inverted appendix secondary to endometrial implants. - Diverticulosis of the appendix (DA): appears as round air-filled outpouchings from the wall of the appendix.

This exhibit emphasizes the significance of vigilant evaluation for detecting overlooked appendix pathologies to improve patient outcomes. It highlights unusual mimics, pathologies, anatomy, and presentation of appendiceal pathologies, which is crucial for managing right lower quadrant pain. Preoperative imaging with CT can be a vital tool for effective diagnosis and management in cases with ambiguity.