\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[ngerman,english]{babel}



\usepackage{float}








\begin{document}

\title{Acute appendicitis with appendix duplicity in Eritrea : A case report}



\author[1]{Rami Mahmoud}%
\author[1]{mhmoud mohmed}%
\author[1]{Tekeste Gebrihiwet}%
\affil[1]{Orotta College of Medicine and Health Sciences}%


\vspace{-1em}



  
  \date{May 24, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Abstract: Duplicity of the appendices are very rare. A 32-year-old man
presented with type B2 duplicity of the appendix and acute appendicitis.
An appendectomy was done for both. Intraoperative incidental finding, is
the only chance to avoid missing appendix duplicity and appendicectomy
should be done for both.%
\end{abstract}%



\sloppy


\textbf{Acute appendicitis with appendix duplicity in Eritrea : A case
report}

\textbf{Rami Yassin\textsuperscript{1*}, Mhmoud
mohmed\textsuperscript{1}, Tekeste Fekadu\textsuperscript{1}}

\textsuperscript{1}Rami Yassin: Department of Surgery, Orotta College of
medicine and Health Sciences, Orotta Referral Hospital, Asmara, Eritrea.
Email: ramyyassin84@gmail.com. ORCID: https://orcid.org/
0000-0002-13256449.

\textsuperscript{1}Mhmoud Mohmed: Department of Surgery, Orotta College
of Medicine and Health Sciences, Orotta Referral Hospital, Asmara,
Eritrea. Email: hoota20@gmail.com.ORCID: https://orcid.org/

\emph{0000-0002-6512-740.}

\textsuperscript{1}Tekeste Fekadu: Department of Surgery, Orotta College
of Medicine and health sciences, Orotta Referral Hospital,
Asmara,Eritrea. Email: lilgenet@gmail.com.

\textsuperscript{*}Corresponding author: Rami Yassin, email:
ramyyassin84@gmail.com, Orotta College of Medicine and health sciences,
Orotta Referral Hospital, Asmara, Eritrea

\textbf{Abstract:}

Duplicity of the appendices are very rare. A 32-year-old man presented
with type B2 duplicity of the appendix and acute appendicitis. An
appendectomy was done for both. Intraoperative incidental finding, is
the only chance to avoid missing appendix duplicity and appendicectomy
should be done for both.

\textbf{KEYWORDS}

appendix duplicity, missed appendix, acute appendicitis

\textbf{1 INTRODUCTION}

Congenital anomalies of the appendix are extremely rare. The reported
incidence is 0.004\%. They include agenesis, duplication, and anatomical
variation related to length and position. Appendix duplicity is the most
common type, of which type B2 is the most common variant and commonly
associated with acute appendicitis. A total of 141 cases of duplicity
were reported.\textsuperscript{1} However, appendicitis of the double
appendix was reported in less than 15 cases.\textsuperscript{2}According
to the modified Cave-Wallbridge classification (Figure 1), type B2 is
the most common variant reported in the literature.

Routine preoperative imaging modalities, CT scans, and abdominal
abdominal ultrasound did not reveal duplicity.\textsuperscript{3} The
failure to identify duplicity in appendectomy can leads to significant
uncertainty in assessing the right lower quadrant pain if the second
appendix (missed appendix) is inflamed in the future. For this
uncertinity of the diagnosis, appendicitis of missed appendix may leads
to increased morbidity and mortality and serious medico-legal
consequences.

In this clinical case report, we present a rare case of double appendix
in a patient with acute appendicitis discovered incidentally during the
surgery. The surgery was done in Orotta referral hospital, Asmara,
Eritrea.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

FIGURE 1: Modified Cave-Wallbridge classification. Type A, partial
duplication of the appendix; Type B1 (bird type), two appendices are
placed symmetrically on both sides of the ileocaecal valve; Type B2
(taenia coli type), one appendix is in the usual place, and the other is
far along with the taenia coli; Type C, duplication of the caecum and
appendix; Type D (horseshoe type), one appendix has two openings in the
caecum(2).

\textbf{2 CASE REPORT}

A 32-year-old male was brought to the Emergency Department of the Orotta
Referral Hospital, Asmara, Eritrea, with complaints of central abdominal
pain that was shifted to the right iliac fossa for one day. It was
aggravated by movement and was associated with nausea and vomiting.
Otherwise, he had clear systemic review and denyed any significant past
medical history.

On physical examination, the pulse rate was 90/minute, the respiratory
rate was 18/minute and temperature of 37 \selectlanguage{ngerman}° C. There was right iliac
fossa tenderness and guarding. The white blood cell counts was normal
with a left neutrophilic shift. The urine examination and renal function
test were within the normal range. Preoperative imaging studies were not
performed, and the diagnosis of acute appendicitis was made based on
clinical evaluation.

An open appendectomy was performed in the same day of admission. A
minimal seropurulent fluid collection was found in the right iliac
fossa. There were two separate appendices attached to a single caecum in
the taenia coli and joined by a single mesoappendix (Figure 2,A). Only
one appendix was apparently inflamed. The mesoappendix was ligated, and
both appendices were removed (Figure 2,B\&C). The postoperative period
passed uneventful, and the patient discharged in good general condition
after 72 hours.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

\end{center}
\end{figure}

FIGURE 2 : The two appedecies based on a single caecum (A), the two
appediceal stumps after appendectomy (B), the two appedecies (C).

\textbf{3 DISCUSSION}

With regard to the extreme scarcity of appendiceal anomalies,
duplication of the appendix is the most common anomaly that has been
reported. A review of published reported cases identified 141 duplicate
appendices.\textsuperscript{1} According to the Modified Cave-Wallbridge
classification of the anatomical variation of duplication, B2 is the
most common type.\textsuperscript{2} The literature reported less than
15 cases of appendicitis in double appendices. For these considerable
matchings and similarity to our case, we think that the literature
background strongly support our findings.

The preoperative diagnosis of appendix duplicity is
challenging.\textsuperscript{3} It is almost always identified
intraoperatively. In this case, we did not perform image studies, as
signs and symptoms were typical of acute appendicitis. Duplicity of the
appendices may be missed if the second appendix is concealed in the
retrocaecal position.\textsuperscript{2,4} Generally, surgical field
exposure is inadequate during open appendectomy, and routine caecal
mobilization and retrocaecal exploration are not performed routinely
during the procedure. Laparoscopy can increase the detection rate due to
a better visualization of the abdominal cavity.\textsuperscript{5}

In our case, we fortunately detected and removed both appendices.
Intraoperative missing of the second appendix has serious medico-legal
consequences and increases the risk of complications if the missed
appendix got inflamed in the future. The literature reported a case of
ruptured appendix in the retrocaecal space presented after a previous
laparoscopic appendectomy.\textsuperscript{4} The diagnosis of appendix
duplicity should be considered in any patient with a history of
appendectomy who present with similar symptoms and signs of acute
appendicitis.

\textbf{CONCLUSION}

Duplicity in the Appendix, even though rare, should not be overlooked.
The clinical judgment in the diagnosis of typical acute appendicitis
without preoperative imaging studies, makes the diagnosis of duplicity
almost difficult before the surgery. Intraoperative incidental finding,
is the only chance to avoid missing appendix duplicity and
appendicectomy should be done for both.

\textbf{AUTHOR CONTRIBUTIONS}

Dr. R. Yassin provided patient's history and document and performed the
surgery supported by the photographs. Dr. M. Mohmed reviewed and
contribute to write the manuscript. All the authers read and approved
the final manuscript.

\textbf{ACKNOWLEDGMENTS}

We thank Dr. Mohmed Elfatih for his help in manuscript revision.

\textbf{CONFLICT OF INTEREST}

Non declared.

\textbf{DATA AVAILABILITY STATEMENT}

The data are available at the debartment of surgery Oratta referral
hospital, Asmara, Eritrea

\textbf{CONSENT STATEMENT}

Written informed consent was obtained from the patient to publish this
report in accordance with the journal's patient consent policy

\textbf{References:}

1. Nageswaran H, Khan U, Hill F, Maw A. Appendix duplication: A
Comprehensive Review of Published Cases and Clinical
Recommendations.World J Surg (2018) 42: 574-581.42: 574-581.

2. Vieira E de PL, Bonato LM, Silva GGP da, Gurgel JL. Congenital
abnormalities and anatomical variations of the vermiform appendix and
the mesoappendix. J Coloproctology. 2019;39(3):279--87.

3. Christodoulidis G, Symeonidis D, Spyridakis M, Koukoulis G, Manolakis
A, Triantafylidis G et al. Acute appendicitis in a duplicated appendix.
Int J Surg Case Rep. 2012;3(11):559--62.

4. Travis JR, Weppner JL, Paugh II JC. Duplex vermiform appendix: case
report of a ruptured second appendix. J Pediatr Surg.
2008;43(9):1726--8.

5. Nazir S, Bulanov A, Ilyas MIM, Jabbour II, Griffith L. Duplicate
appendix with acute ruptured appendicitis: A case report. Int Surg.
2015;100(4):662--5.

\selectlanguage{english}
\FloatBarrier
\end{document}

