A pictorial essay of the most atypical variants of the vermiform appendix position in computed tomography with their possible clinical implications
More details
Hide details
Submission date: 2018-08-13
Final revision date: 2018-08-25
Acceptance date: 2018-09-02
Publication date: 2019-01-04
Pol J Radiol, 2019; 84: 1-8
The tip of the appendix may be located in various areas of the abdominal cavity due to its variable length and/or the changeable position of the caecum. Although in the case of an atypical position the tip is usually located behind the caecum, there are possible locations that occur very rarely. Therefore, in the case of appendicitis the symptoms may lead to the wrong diagnosis. The aim of this study is to present the most atypical locations of the tip of the appendix found on CT (computed tomography) scans and thus help to avoid misdiagnoses.

Imaging findings:
The most unusual locations of the tip of the appendix found in healthy subjects included: left inferior quadrant, along the lower edge of the liver near the gallbladder and the right kidney, the tip touching the duodenum, the rectum or appendages, and a long appendix located in the scrotum as the content of a hernia. In these positions, appendicitis may mimic acute diverticulitis, cholecystitis, duodenal ulcer, duodenitis, enteritis, or adnexal or testis pathologies.

It is important to be aware of atypical locations of the appendix because appendicitis in an unusual area may mimic other acute abdominal diseases and delay the proper treatment.

Schumpelick V, Dreuw B, Ophoff K, Prescher A. Appendix and cecum. Embryology, anatomy, and surgical applications. Surg Clin North Am 2000; 80: 295-318.
Mwachaka P, El-Busaidy H, Sinkeet S, Ogeng’o J. Variations in the position and length of the vermiform appendix in a black kenyan population. ISRN Anat 2014; 2014: 871048.
Cilindro de Souza S, Rodrigues da Costa SRM, Silva de Souza GI. Vermiform appendix: positions and length – a study of 377 cases and literature review. J Coloproctology 2015; 35: 212-216.
Ahmed I, Asgeirsson KS, Beckingham IJ, Lobo DN. The position of the vermiform appendix at laparoscopy. Surg Radiol Anat 2007; 29: 165-168.
Alzaraa A, Chaudhry S. An unusually long appendix in a child: a case report. Cases J 2009; 2: 7398.
Wakeley CP. The position of the vermiform appendix as ascertained by an analysis of 10,000 cases. J Anat 1933; 67: 277-283.
Ghorbani A, Forouzesh M, Kazemifar AM. Variation in anatomical position of vermiform appendix among Iranian population: an old issue which has not lost its importance. Anat Res Int 2014; 2014: 313575.
Ting JY, Farley R. Subhepatically located appendicitis due to adhesions: a case report. J Med Case Rep 2008; 2: 339.
Nayak SB, George BM, Mishra S, et al. Sessile ileum, subhepatic cecum, and uncinate appendix that might lead to a diagnostic dilemma. Anat Cell Biol 2013; 46: 296-298.
Malik RA, Mir SH, Feroz I, et al. An unusual case report – longest appendix in India (20.5 cm). Oncol Gastroenterol Hepatol Reports 2013; 2: 45-47.
Yabunaka K, Katsuda T, Sanada S, Fukutomi T. Sonographic appearance of the normal appendix in adults. J Ultrasound Med 2007; 26: 37-43.
Kim HC, Yang DM, Jin W. Identification of the normal appendix in healthy adults by 64-slice MDCT: The value of adding coronal reformation images. Br J Radiol 2008; 81: 859-864.
Deshmukh S, Verde F, Johnson PT, et al. Anatomical variants and pathologies of the vermix. Emerg Radiol 2014; 21: 543-552.
Kim S, Lim HK, Lee JY, et al. Ascending retrocecal appendicitis: clinical and computed tomographic findings. J Comput Assist Tomogr 2006; 30: 772-776.
Evrimler S, Okumuser I, Unal N. Computed tomography (CT) findings of a diagnostic dilemma: atypically located acute appendicitis. Pol J Radiol 2016; 81: 583-588.
Okur SK, Koca YS, Yıldız İ, Barut İ. Right hydronephrosis as a complication of acute appendicitis. Case Rep Emerg Med 2016; 2016: 3231862.
Wu J, Zhang T, Zhu Y, Gong N. Diagnostic value of ultrasound compared to CT in patients with suspected acute appendicitis. Int J Clin Exp Med 2017; 10: 14377-14385.
Mostbeck G, Adam EJ, Nielsen MB, et al. How to diagnose acute appendicitis: ultrasound first. Insights Imaging 2016; 7: 255-263.
Vaghela K, Shah B. Diagnosis of acute appendicitis using Clinical Alvarado Scoring System and Computed Tomography (CT) Criteria in patients attending Gujarat Adani Institute of Medical Science – a retrospective study. Pol J Radiol 2017; 82: 726-730.
Abougabal AM, Hafez A, Kasem MI. Role of multidetector computed tomography (MDCT) in diagnosis of subhepatic appendicitis. Egypt J Radiol Nucl Med 2012; 43: 347-352.
Tamburrini S, Brunetti A, Brown M, et al. Acute appendicitis: diagnostic value of nonenhanced CT with selective use of contrast in routine clinical settings. Eur Radiol 2007; 17: 2055-2061.
Chiu YH, Chen JD, Wang SH, et al. Whether intravenous contrast is necessary for CT diagnosis of acute appendicitis in adult ED patients? Acad Radiol 2013; 20: 73-78.
Hlibczuk V, Dattaro JA, Jin Z, et al. Diagnostic accuracy of noncontrast computed tomography for appendicitis in adults: a systematic review. Ann Emerg Med 2010; 55: 51-59.e1.
Çağlar E, Aribaş B, Tiken R, Keskin S. Midgut malrotation presenting with left-sided acute appendicitis and CT inversion sign. BMJ Case Rep 2014; pii: bcr2013202709.
Meinke AK. Review article: appendicitis in groin hernias. J Gastrointest Surg 2007; 11: 1368-1372.
Journals System - logo
Scroll to top