Acute appendicitis
Anatomy
• Blind muscular
tube that arises
from the caecum
• variable in
length, ranging
between 2 to 20
cm
• Evaluation of
appendicitis →
outer diameter
of the appendix
Agenesis appendix
• extremely rare
• non-formation of the vermiform appendix.
• people without appendices avoid the risk of
developing acute appendicitis.
Horseshoe appendix
• extremely rare
• appendix arises from the
caecum and curves back
on itself to re-insert into
the caecum,
Duplex appendix
• usually discovered incidentally
during surgery for appendicitis.
• Cave-Wallbridge classification
:
- type A: single caecum with one
normally localised appendix
exhibiting partial duplication
- type B: single caecum with two
completely separate appendices
and divided into two further
subgroups
- type C: double caecum, each
bearing its own appendix
evaluation of appendicitis is the
outer diameter of the appendix →
<6-7mm
Appendicitis
acute inflammation of the vermiform appendix
• CRP and WBC as well as
clinical impression, play an
important role in choosing
between complementary
CT scan and watchful
waiting.
First US, than CT.
• suspected appendicitis
→ relatively young
• In this 11-week pregnant
woman, US confirmed
an intact intra-uterine
pregnancy as well as
acute appendicitis.
Ultrasound
• Aperistaltic, non-compressible, dilated appendix (>6
mm outer diameter) → round when compression is
applied
• Hyperechoic appendicolith with posterior acoustic
shadowing
• Echogenic prominent pericaecal and periappendiceal
fat
• Periappendiceal fluid collection
• Target appearance (axial section)
• Periappendiceal reactive nodal
prominence/enlargement
• Wall thickening (3 mm or above) : mural hyperemia
with color flow Doppler, vascular flow may be lost
with necrotic stages
CT if inconclusive US
• In most patients with an inconclusive US and a high
suspicion of appendicitis, CT is the next step.
• CT is principally performed with i.v. contrast.
CT Scan
• appendiceal dilatation (>6 mm diameter)
• wall thickening (>3 mm) and enhancement
• thickening of the cecal apex: cecal bar sign, arrowhead
sign
• periappendiceal inflammation
• fat stranding
• thickening of the lateroconal fascia or mesoappendix
• extraluminal fluid
• phlegmon (inflammatory mass)
• abscess
• focal wall non-enhancement representing necrosis
(gangrenous appendicitis) and a precursor to perforation
• Less specific signs may be associated with appendicitis:
- appendicolith
- periappendiceal reactive nodal enlargement
Differential diagnosis
Mesenteric lymphadenitis
• second most common cause of RLQ pain
• clinical suspicion of appendicitis
• benign self-limiting inflammation of right-sided
mesenteric lymph nodes without an identifiable
underlying inflammatory process, → > children
than in adults
• Sonography and CT show clustered adenopathy
Bacterial ileocecitis
• Infectious enterocolitis → mild symptoms
resembling a common viral gastroenteritis,
but it may also clinically present with
features indistinguishable from
appendicitis
• Imaging studies show mural thickening of
the terminal ileum and cecum without
inflammation of the surrounding fat, and
moderate mesenteric adenopathy.
Epiploic appendagitis
• Epiploic appendages are small adipose
protrusions from the serosal surface of the
colon
• may undergo torsion and secondary
inflammation → abdominal pain that
simulates appendicitis when located in the
right lower quadrant
• Sonography and CT : inflamed fatty mass
adjacent to the colon, containing a
characteristic hyperattenuating ring of
thickenend visceral peritoneal lining on CT
Right-sided colonic diverticulitis
• may clinically mimic appendicitis or
cholecystitis
• outpouchings of the colonic wall
containing all layers of the wall.
• Sonography and CT findings consist of
inflammatory changes in the pericolic
fat with segmental thickening of the
colonic wall, at the level of an
inflamed diverticulum
Crohn disease
• one third of patients with ileocecal
Crohn disease present with initial
symptoms so acute that they are
misdiagnosed as appendicitis
• Acute active phase of ileocecal Crohn
disease, imaging shows transmural
bowel wall thickening, often
predominantly of the submucosal
layer, with frequent inflammatory
changes of the surrounding fat
Urolithiasis
• right lower quadrant pain when
obstruction is caused by a distal
ureteral stone.
• Unenhanced CT >> sonography,
Rectus sheath hematoma
• A rectus sheath hematoma may be
easy to diagnose in patients
presenting with a painful palpable
mass under anticoagulant therapy
• Sonography and CT show a
hemorrhagic mass within the
sheath of the rectus abdominis
muscle
Right ovarian cyst
• In this young woman, a
conspicuous hemorrhagic right
ovarian cyst (arrowheads) was
visualized and held responsible
for her RLQ symptoms.
• US → lace-like reticular echoes
or an intracystic solid clot, thin
wall, no internal blood flow
Elargement, well defined cytic lesion with irregular
(collapsing) wall, low level echoes, fine internal septation
Free fluid in the douglas pouch
Acute pancreatitis
• CT scan revealed acute
pancreatitis with retroperitoneal
fluid descending to the RLQ,
explaining the patient’s symptoms
mimicking appendicitis.
• The pancreatic exudate (*)
approaches the appendix (arrow)
closely
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