Acute Appendicitis

Valerie L Ward, MD
Peter M Doubilet, MD, PhD

October 10, 1996

Presentation

A 50-year-old woman presented with right lower quadrant (RLQ) pain.

Imaging Findings

Transverse ultrasonography of the RLQ

Sagittal ultrasonography of the RLQ

Transverse and sagittal sonograms demonstrate a thick-walled, noncompressible appendix (arrows). A hyperechoic appendicolith (black arrows) is visible within the lumen of the appendix and demonstrates acoustic shadowing (white arrows). The appendix measures 25 (transverse) x 21 (anteroposterior) x 20 (sagittal) mm.

Differential Diagnosis

Given the sonographic findings, acute appendicitis is the most likely diagnosis. Crohn's disease with ileocecal and appendiceal involvement, acute typhlitis, cecal diverticulitis, and appendiceal neoplasm are other possible, but less likely, diagnoses.

Diagnosis

Acute transmural necrotizing appendicitis with impacted fecal material at the proximal end of the appendix (by histopathology)

Discussion

Acute appendicitis commonly presents with periumbilical pain, nausea, and vomiting. Within days, the pain localizes to the right lower quadrant and is accompanied by peritoneal signs on physical examination. A clinical diagnosis is often difficult to make, as a variety of other disorders can have a similar clinical presentation. For example, gynecological disorders such as ovarian torsion, rupture of an ovarian cyst, ectopic pregnancy, or acute pelvic inflammatory disease may mimic appendicitis in women.

Compression sonography is a readily available and efficient examination for detection of acute appendicitis. A high resolution (5-7.5 MHz) linear array transducer is used to compress the patient's right lower quadrant. Maximal compression is used in the area that the patient identifies as the point of maximal tenderness to measure the anteroposterior (AP) diameter of the appendix. The reported sensitivity and specificity of compression sonography are 78 to 96% and 85 to 98%, respectively.

An inflamed appendix is identified as a blind-ended, aperistaltic and noncompressible tube arising from the cecum and exceeding 6 mm in AP diameter. An appendicolith (or fecalith) may be visible within its lumen. The presence of an appendicolith, even without visualization of an inflamed appendix, suggests acute appendicitis. The finding of an echogenic periappendiceal mass, representing inflammation of the surrounding fat, suggests perforation of the appendix. Compression sonography can expedite diagnosis and surgical intervention, thereby decreasing the morbidity of the condition.

References

1. Rumack CM, Wilson SR, Charboneau JM. Diagnostic ultrasound. St Louis:Mosby-Yearbook, 1991; 181-207.

2. Yacoe ME, Jeffrey RB. Imaging of the acute abdomen: sonography of appendicitis and diverticulitis. In: Balthazar EJ, editor. Radiologic Clinics of North America 1994; 32(5):899-912.

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