У пациентки обнаружили врожденную аномалию: у нее было два аппендикса, один из которых заполнился слизью

A 45-year-old woman had already been through one round of treatment for a burst appendix. An abscess measuring about seven centimeters had been drained through the skin; antibiotics had cleared the infection, and she went home. Two months later, the pain in her right lower abdomen came back. Surgeons went in prepared to find a tumor. What the pathologist eventually found in the specimen was stranger and, in its way, more consequential: she had been born with two appendices, and one of them had quietly filled with mucus. The case was posted online in early September by the American Journal of Case Reports, from a surgical team at Sir Ganga Ram Hospital in Delhi. An Abscess, a Return of Pain, and an Operation Planned for Cancer Her first presentation was straightforward enough on paper. In the United States, appendicitis is the most common cause of abdominal pain requiring surgery, and a ruptured appendix walled off into an abscess is a recognized, if serious, version of it. She had two months of right-sided abdominal pain, intermittent fever, severe tenderness and rigidity on examination, and a white cell count of 20,000. A contrast-enhanced CT showed a large, thick-walled, loculated collection in the right lower abdomen with a volume of 163 cubic centimeters. The appendix itself could not be seen separately on that scan. A drain was placed, and culture-guided intravenous antibiotics were started. The drain came out after a week, and she was discharged, apparently resolved. When she returned two months later with a week of pain and no fever, the repeat CT looked different. It showed a distended tubular structure about 2.5 centimeters across, sitting behind the cecum with subtle inflammatory stranding around it. The radiological read was a mucocele of the appendix, a lumen swollen with accumulated mucus after the opening becomes blocked. At diagnostic laparoscopy, the surgeons found dense adhesions between bowel loops and the abdominal wall, an inflamed and dilated appendix, and a mass-like clump of tissue near its base. That combination raised the possibility of an underlying cancer they could not rule out on sight. Rather than a limited appendectomy, they converted to a laparoscopic right hemicolectomy, removing the right side of the colon. She recovered without complications and went home on the fifth day after surgery. What the Pathologist Found in the Specimen The gross examination, detailed in the published case report, is where the case turns. Two distinct tubular structures were arising separately from the cecum, each opening independently into the bowel, with no connection between them. The native appendix had a lumen 1.2 centimeters at its widest. The second structure was 2.8 centimeters long with a lumen up to 1.5 centimeters, containing mucoid material. Under the microscope, both were sampled in their entirety, and each had its own complete wall, with no shared muscle layer at any level. This was not a partially split single appendix. These were two organs. Under the Cave Wallbridge system, first proposed in 1936 and modified in 1962, this was a Type B2 duplication, meaning one appendix in the normal position and a second arising along the taenia coli. The mucus-filled structure turned out to be a simple retention mucocele caused by chronic blockage of the lumen, with no hyperplasia, no cystadenoma, and no cancer anywhere in the specimen or the sampled lymph nodes. Appendiceal duplication is reported in roughly 0.004 to 0.009 percent of appendectomy specimens, a figure that traces back to a review of 50,000 appendix specimens published in 1955. Duplication paired with a mucocele is rarer still. The authors describe the combination as very uncommon in the literature, and none of the recent duplication cases they tabulated for comparison involved one. The Version of This That Ends Badly There is a reason this anomaly gets discussed in the same breath as medicolegal risk. If a surgeon removes one appendix without knowing a second exists, the patient can develop appendicitis again in an organ nobody knows is there. That recurrence is easily misread as stump appendicitis, an inflammation of the small remnant left behind at the first operation. Preoperative detection is uncommon, because CT and MRI rarely identify a duplicated appendix unless someone is specifically looking for one. Most cases are found during surgery or, as here, only after the pathology report. The authors put the requirement bluntly: "Diagnosis requires a high index of suspicion and careful intraoperative assessment." There is a quieter finding buried in this case that supports the point. When the team went back and reviewed the preoperative scan afterward, the duplicated appendix with its two separate lumens could be identified. Nobody had been looking for it. What This Case Does and Does Not Establish This is one patient, and it does not tell surgeons how often to expect a second appendix or when to extend a resection. The article is currently available as an in press corrected proof, which means it is citable but not yet the final version of record. The authors' argument is procedural rather than statistical. When anatomy is distorted, when a mass involves the cecal wall, and when a low-grade appendiceal mucinous neoplasm cannot be confidently excluded on inspection, a limited appendectomy may not be safe. They also note the flip side: appendectomy or limited resection is normally appropriate for a mucocele, and a hemicolectomy is a larger operation with its own risks. Their patient was a year past surgery and disease-free when they wrote it up. For readers, the practical thread is narrower. Recurrent right-sided abdominal pain after appendicitis has apparently been treated is worth reporting to a clinician rather than dismissing, because the pain sometimes has an anatomical explanation nobody has found yet. Federal health guidance is that suspected appendicitis is a medical emergency requiring immediate care. Key Questions Answered What is a duplicated appendix? It is a rare congenital anomaly in which a person is born with two appendices rather than one. It is reported in roughly 0.004 to 0.009 percent of appendix specimens removed at surgery. Why did surgeons remove part of her colon? Because they could not rule out cancer during the operation. Dense adhesions and a mass-like clump at the base of the appendix made a limited appendectomy unsafe, so they removed the right side of the colon. Did she have cancer? No. The pathology showed a benign retention mucocele in one of the two appendixes, with no evidence of a tumor in the specimen or the lymph nodes examined. Why does a missed second appendix matter? If one appendix is removed and a second is left behind, the patient can develop appendicitis again in the remaining organ, which is often misdiagnosed as inflammation of the surgical stump. Can imaging find this before surgery? Rarely. CT and MRI seldom identify appendiceal duplication unless a radiologist is specifically looking for it. In this case, the anomaly was visible on the preoperative scan only in hindsight. How reliable is this report? It is a single-patient case report published as an in-press corrected proof. It documents an unusual combination of findings but cannot establish how often duplications occur or how they should generally be managed. Published by Medicaldaily.com