In human anatomy
, the appendix
(or vermiform appendix
; also cecal (or caecal) appendix
; also vermix
) is a blind ended tube connected to the cecum
(or caecum), from which it develops embryologically
. The cecum is a pouch-like structure of the colon
. The appendix is near the junction of the small intestine
and the large intestine
The term "vermiform" comes from Latin and means "worm-like in appearance".
Size and location
The appendix averages 10 cm in length, but can range from 2 to 20 cm. The diameter of the appendix is usually between 7 and 8 mm. The longest appendix ever removed measured 26 cm in Zagreb, Croatia
The appendix is located in the lower right quadrant of the abdomen
, or more specifically, the right iliac fossa
. Its position within the abdomen corresponds to a point on the surface known as McBurney's point
(see below). While the base of the appendix is at a fairly constant location, 2 cm below the ileocaecal valve
, the location of the tip of the appendix can vary from being retrocaecal
(74% ) to being in the pelvis
to being extraperitoneal
. In rare individuals with situs inversus
, the appendix may be located in the lower left side.
Given the appendix's propensity to cause death via infection
, and the general good health of people who have had their appendix removed, the purpose of the appendix has mystified scientists for some time. There have been cases of people who have been found, usually on laparoscopy
, to have a congenital
absence of an appendix. There have been no reports of impaired immune
function in these people.
The most common explanation is that the appendix is a vestigial structure
which now has no purpose. In The Story of Evolution
, Joseph McCabe
The vermiform appendage—in which some recent medical writers have vainly endeavoured to find a utility—is the shrunken remainder of a large and normal intestine of a remote ancestor. This interpretation of it would stand even if it were found to have a certain use in the human body. Vestigial organs are sometimes pressed into a secondary use when their original function has been lost.
One potential ancestral purpose put forth by Darwin was that the appendix was used for digesting leaves as primates. Over time, we have eaten fewer vegetables and have evolved, over thousands of years, for this organ to be smaller to make room for our stomach. It may be a vestigial organ of ancient man that has degraded down to nearly nothing over the course of evolution. Evidence can be seen in herbivorous animals such as the Koala. The cecum of the koala is attached to the juncture of the small and large intestines and is very long, enabling it to host bacteria specific for cellulose breakdown. Early man’s ancestor must have also relied upon this system and lived on a diet rich in foliage. As man began to eat more easily digested foods, they became less reliant on cellulose-rich plants for energy. The cecum became less necessary for digestion and mutations that previously had been deleterious were no longer selected against. These alleles became more frequent and the cecum continued to shrink. After thousands of years, the once-necessary cecum has degraded to what we see today; the appendix.
Evolutionary theorists have suggested that natural selection selects for larger appendices because smaller and thinner appendices would be more susceptible to inflammation and disease.
Loren G. Martin, a professor of physiology
at Oklahoma State University
, argues that the appendix has a function in fetuses
and adults. Endocrine
cells have been found in the appendix of 11 week old fetuses that contribute to "biological control (homeostatic
) mechanisms." In adults, Martin argues that the appendix acts as a lymphatic
organ. The appendix is experimentally verified as being rich in infection-fighting lymphoid cells
, suggesting that it might play a role in the immune system
. Zahid suggests that it plays a role in both manufacturing hormones
in fetal development
as well as functioning to 'train' the immune system, exposing the body to antigens
in order that it can produce antibodies
. He notes that doctors in the last decade have stopped removing the appendix during other surgical procedures as a routine precaution, because it can be successfully transplanted into the urinary tract
to rebuild a sphincter
muscle and reconstruct a functional bladder
Latest Interpretation: Maintaining gut flora
Although it was long accepted that the immune tissue, called gut associated lymphoid tissue
, surrounding the appendix and elsewhere in the gut carries out a number of important functions, explanations were lacking for the distinctive shape of the appendix and its apparent lack of importance as judged by an absence of side-effects following appendectomy. William Parker, Randy Bollinger, and colleagues at Duke University
proposed that the appendix serves as a haven for useful bacteria
when illness flushes those bacteria from the rest of the intestines. This proposal is based on a new understanding of how the immune system supports the growth of beneficial intestinal bacteria
, in combination with many well-known features of the appendix, including its architecture and its association with copious amounts of immune tissue. Such a function is expected to be useful in a culture lacking modern sanitation and healthcare practice, where diarrhea
may be prevalent. Current epidemiological
data show that diarrhea is one of the leading causes of death in developing countries
, indicating that a role of the appendix as an aid in recovering beneficial bacteria following diarrhea may be extremely important in the absence of modern health and sanitation practices.
The most common diseases
of the appendix (in humans) are appendicitis
accounts for about 1 in 200 of all gastrointestinal malignancies. Adenomas
also (rarely) present.
Appendicitis (or epityphlitis) is a condition characterized by inflammation of the appendix. Pain often begins in the center of the abdomen, corresponding to the appendix's development as part of the embryonic midgut. This pain is typically a dull, poorly localised, visceral pain.
As the inflammation progresses, the pain begins to localise more clearly to the right lower quadrant, as the peritoneum becomes inflamed. This peritoneal inflammation, or peritonitis, results in rebound tenderness (pain upon removal of pressure rather than application of pressure). In particular, it presents at McBurney's point, 1/3 of the way along a line drawn from the Anterior Superior Iliac Spine to the Umbilicus. Typically, point (skin) pain is not present until the parietal peritoneum is inflamed as well. Fever and an immune system response are also characteristic of appendicitis.
Many cases of appendicitis require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, the appendix may rupture, leading to peritonitis, followed by shock, and, if still untreated, death.
The surgical removal of the vermiform appendix is called an appendicectomy (or appendectomy). This procedure is normally performed as an emergency procedure, when the patient is suffering from acute appendicitis. In the absence of surgical facilities, intravenous antibiotics are used to delay or avoid the onset of sepsis; it is now recognized that many cases will resolve when treated non-operatively. In some cases the appendicitis resolves completely; more often, an inflammatory mass forms around the appendix. This is a relative contraindication to surgery.
Use as efferent urinary conduit
The appendix is used for the construction of an efferent urinary conduit, in an operation known as the Mitrofanoff procedure
, in people with a neurogenic bladder