Gastrointestinal duplication is a rare congenital anomaly, and more than 80% of the patients present before the age of two years with acute abdomen or bowel obstruction [
6]. Appendix duplications were first classified by Cave in 1936 [
7] according to their anatomic location. This classification system was updated and modified in 1963 by Wallbridge [
8]. After the most quoted version [
8], two more types of appendix anomalies (Table
1) also have been described [
9,
10].
Table 1
Modified Cave-Wallbridge classification
| Single cecum with various degrees of incomplete duplication |
| Two appendixes symmetrically placed on either side of the ileocecal valve |
| One appendix arises from the cecum at the usual site, and the second appendix branches from the cecum along the lines of the tenia at various distances from the first |
| One appendix arises from the usual site, and the second appendix arises from the hepatic flexura |
| One appendix arises from the usual site, and the second appendix arises from the splenic flexura |
| Double cecum, each with an appendix |
| One appendix has two openings into a common cecum |
| One appendix arises from the cecum at the usual site, and two additional appendixes arise from the colon |
In our case, a type B2 appendix anomaly (Cave-Wallbridge classification) was encountered. This duplication is reported as developing from the persistence of the transient cecal protuberance of the sixth embryonic week [
6‐
8]. The diagnosis was evaluated according to the Alvarado Scale on the basis of clinical examination and laboratory findings [
11].
Explorative laparotomy was performed in our patient. Laparotomy has also been performed in patients described in other studies [
3,
4]. However, Travis
et al. [
5] preferred laparoscopy for the diagnosis in their patient who had undergone a previous appendectomy. Diagnostic laparoscopy as a minimally invasive technique is now the most widely used and preferred technique compared with laparotomy. Advanced radiologic techniques can be useful for the diagnosis of intra-abdominal pathology before surgery. Even though computed tomography scans are not useful [
5] and are not used in all cases [
3], the diagnosis of appendix duplication with inflammation can be made [
4]. Misdiagnosis and mismanagement are common occurrences in such cases because of the rarity of the appendix anomalies. As in our case, previously reported appendix duplications have also been diagnosed during surgery in these patients [
2]. It has been reported that the second appendix could be histologically normal during the appendectomy [
3,
12,
13], which leads to a delay in misdiagnosis. Delays in diagnosis of a second appendix may lead to increased risk of perforation [
5]. Duplication of the appendix should be considered in all cases of lower abdominal pain, even if the patient reports a previous appendectomy. An inflammatory mass associated with a solitary cecal diverticulum may have a similar clinical presentation and may be discovered together with appendix duplication during a laparotomy [
8]. However, it may not be possible to differentiate them clinically, and the distinction may be made only by histologic examination of the specimen. The wall of a cecal diverticulum lacks lymphoid tissue that is typically present in the vermiform appendix specimen [
8]. Appendix duplication may also present as a constricting lesion of the ascending colon and mimic a colonic adenocarcinoma [
14].