Acute Appendicitis

Shelley Kraft
DMS 496 Clinical Practicum III

Acute appendicitis is the sudden onset of pain and inflammation of the appendix. The
appendix is located at the distal end of the cecum. This disease is usually diagnosed clinically
through examination and laboratory results without diagnostic imaging before an appendectomy.
When diagnostic imaging is used prior to surgery, computed tomography (CT) is the standard
procedure with ultrasound second, if needed. Although CT is the standard, some professionals
prefer to use ultrasound to reduce the risk of unnecessary radiation exposure to the patient.
Case History
An adolescent patient presented to the emergency room after experiencing right lower
quadrant pain that had persisted for eleven hours. The patient had awaken the previous night
with aching, sharp, cramping, and stabbing pains which over time increased and became more
constant. The patient had rebound tenderness at McBurneys point. The pain was worsened by
palpitation and movement. Symptoms of right lower quadrant pain that radiated to the right
groin, anorexia, and vomiting were present. Lab work was drawn and the results showed a high
white blood cell count, low lymphocytes, and high neutrophils. An ultrasound of the appendix
was ordered.
Sonographic Findings
Before the sonographic exam began the sonographer asked the patient to use one finger
and point to the area of pain. The sonographer placed the probe in that location using
compression and visualized a blind-ended, non-compressible, aperistaltic tubular structure.
While following the tubular structure in gray-scale from the cecum to the appendix, the wall
thickness of the appendix continued to increase. At the distal end of the appendix, an echogenic,
0.8 X 1.1 cm, foci with posterior shadowing was visualized which was confirmed to be an

appendicolith. In the transverse plane of the appendix the diameter exceeded six millimeters
with a gut signature appearance and was surrounded by inflamed perienteric fat. The width of
the appendix at the distal end was documented at 3.5 cm. Color Doppler was also utilized but
there was no increase in blood flow in or around the appendix.
Diagnosis
The diagnosis by the radiologist was acute appendicitis. There were not accessible
records to follow up or support the diagnosis due to patient transport. There was, of course, the
supportive feature of the appendicolith located in the distal end of the appendix. Sonographic
visualization of an appendix with an appendicolith should be regarded as a positive test for acute
appendicitis (1). Acute appendicitis is a sudden onset of rapidly progressing inflammation of a
small part of the large intestine called the appendix (2). This disease is an extremely common
cause of emergency surgery and can occur in any age group or population, but most commonly
teens and young adults (2). This condition can result from a piece of food, stool, or object
becoming trapped in the appendix; also gastrointestinal infections were the bacteria can grow
and cause inflammation (2). Clinically, a patient tends to be presenting with right lower quadrant
pain at McBurneys point radiating to the right groin area, fever, anorexia, and vomiting. Lab
work may indicate elevated WBC, high neutrophils, and low lymphocytes. It is said that the
neutrophil/lymphocyte ratio is an accurate predictor of acute appendicitis when gangrenous
conditions are not present (3). Sonographically, acute appendicitis will demonstrate a blindended, noncompressible, aperistaltic tube in gray-scale. This structure will appear as a gut
signature in the transverse plane and will arise from the base of the cecum. The diameter of the
appendix will be greater than 6mm. Sonographically, one may also see supportive features such
as inflamed, hyperechoic, perienteric fat, pericecal collections, and an appendicolith (1). Using

color Doppler, increased color flow indicating increased vascularity may also be visualized
around the appendix. Not all acute appendicitis cases present with similar symptoms and may be
misdiagnosed due to the overlap of symptoms of other gastrointestinal conditions (1).
Sonographers can learn that detecting the appendix, disease or non-diseased, takes skill and is
operator dependent. It is up to the individual to deliver a truly diagnostic exam with respect to
keep in mind supportive features such as inflamed perienteric fat, pericecal collections and an
appendicolith to guide in an accurate diagnosis of acute appendicitis.

Conclusion
This case had classic symptoms including right lower quadrant pain, anorexia, nausea,
and vomiting. The pain increased with time, movement, and palpitation. Sonographically, the
appendix with acute appendicitis will appear as a noncompressible, blind-ending tubular
structure in the longitudinal axis that measures greater than 6mm in diameter and lacks peristalsis
(4). In the transverse view, the distended appendix has a target-like appearance or gut
signature (4). This was present in the case previously described. Another common finding,
appendicecal wall hyperemia is seen with color Doppler (4). This finding was not present in the
case of the young patient. An appendicolith and hyperechoic pericecal fat was visualized in the
previous case, but there was a lack of pericecal fluid. Appendicoliths, which appear as
hyperechoic foci that have posterior shadowing can also be sometimes found within the lumen of
an inflamed appendix and presence of pericecal inflammatory processes may also be visualized
in the case of acute appendicitis (4).

Acute appendicitis is mainly diagnosed clinically; however, diagnostic imaging plays and
important adjunctive role in confirming the diagnosis when the clinical presentation is
inconclusive (5). In this case, diagnostic imaging was used to determine a definitive diagnosis.
The consequences of missed diagnosis are dire and the common surgical practice has been to
operate on doubtful cases rather than to wait and see until the diagnosis is certain (6). With
diagnostic imaging it is said that computed tomography scanning is more sensitive and specific
than ultrasonography when diagnosing acute appendicitis (7). Once a diagnosis is made,
laparoscopic appendectomy or open surgery of the appendix is the main treatment. Laparoscopic
appendectomy is becoming increasingly common, and clinical evidence suggests that is has
some advantages over open surgery (7).
Important things for the sonographer to remember when encountering this condition are
to apply compression to move excessive bowel gas to diagnostically visualize the appendix,
document inflammation and fluid around the appendix with the use of gray-scale and color
Doppler, and to accurately measure the appendix to evaluate if the diameter exceeds 6mm. It is
also important to remember that this condition is usually diagnosed clinically and when the
doctor orders an ultrasound of the appendix it is important to use all of your knowledge and skill
to provide and accurate and diagnostic study for a clear representation of the condition whether
the study is positive or negative.

REFERENCES
1. Amy Symons Ettore and Bradley D. Lewis. The Peripheral Veins. In: Rumack, C.M.,
Wilson, S.R., & Charboneau, J.W, eds. Diagnostic Ultrasound. 4th ed. Volume I. St.
Louis, MO: Elsevier Mosby; 2010: 285 290
2. Health Grades Inc. Acute Appendicitis. RightDiagnosis.
www.rightdiagnosis.com/a/acute_appendicitis/intro.html. Last updated June 17, 2014.
Accessed July 17, 2014.
3. Mesut Yazici, SEzen Ozkisacik, M. Onur Oztan, Harun Gursoy. Neutrophil/lymphocyte
ration in the diagnosis of childhood appendicitis. Turkish J of Pediatrics. 2010; 52: 400403.
4. ACEP. Focus On: Ultrasound for Appendicitis. ACEP. www.acep.org/continuingeducation-top-banner/focus-on-ultrasound-for-appendicitis
5. Preeyacvha Pacharn, MD, Jun Ying, PhD, Leanna E. Linam, MD, Alan S., Brody, MD,
Diane S Babcock, MD. Sonography in the Evaluation of Acute Appendicitis: Are
negative sonographic findings good enough? J ULTRASOUND MED. 2010; 29: 1749
1755.
6. Mohammad Akbar Ali Mardan, Tariq Saeed Mufti, IrfanUddin Khattak, Nagendra
Chilkunda, Abdulmonem A. Alshayeb, Ahmad Moussa Mohammad, Zia ur Rehman.
Role of Ultrasound in Acute Appendicitis. JAMC. 2007; 19(3).
www.ayubmed.edu.pk/jamc/past/19-3/17%20Akbar.pdf. Accessed July 17, 2014.
7. D J Humes and J Simpson. Acute appendicitis. BMJ. 2006; 333(7567): 530 534.