Perforated acute appendicitis

Posted By Wael Nemattalla
Perforated acute appendicitis

13 years old female. Two appendicoliths are seen. Ileus was seen in this patient.

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  • Wael Nemattalla 2013-12-03 22:49:11

    Acute Pelvic Appendicitis



    Acute appendicitis is the most common surgical cause of right lower quadrant pain. When it presents in a classical manner with pain migrating from the mid abdomen to the right lower quadrant with associated anorexia and fever, diagnosis can be made on clinical grounds alone. This is especially true if the patient is a male. However, presence of atypical symptoms especially in a female patient can make accurate diagnosis much more difficult and can lead to delay in appropriate treatment. High resolution transabdominal sonographic evaluation of the right lower quadrant with graded compression has a proven track record of diagnosis of acute appendicitis in young and thin patients. However, in a considerable number of cases the appendix is located within the pelvis and cannot be evaluated by the traditional transabdominal approach. Therefore, in a female patient, if there is no explanation for the clinical symptoms on a transabdominal ultrasound, then one should proceed to transvaginal pelvic ultrasound.

    Transvaginal ultrasound has proven to be invaluable in diagnosis of gynecologic and obstetric conditions by providing exquisite details with no risks of radiation. During each transvaginal sonographic evaluation, attention must be paid not only to the uterus, ovaries and the adnexa, but also to the surrounding structures, which may be responsible for the patient's presenting symptoms such as acute appendicitis in a pelvic appendix, acute diverticulitis or distal ureteric calculi.

    The sonographic findings of acute pelvic appendicitis on the transvaginal approach do not differ from the traditional transabdominal approach. They include a dilated (greater than 6mm in diameter), blind-ending, tubular structure with gut signature which originates from the base of the cecum. The concentric rings comprising the gut signature (from inner to outer layers) are: echogenic mucosa, hypoechoic muscularis mucosa, hyperechoic submucosa (thick white line), hypoechoic muscularis propria, and finally the hyperechoic serosa. An important limitation of the transvaginal approach in most cases is inability to perform compression. However, direct pressure by the transducer can illicit focal pain, which usually correlates with the patient's symptoms.

    It is important to evaluate the full length of the appendix, including the tip, so as not to miss tip appendicitis. It is important to pay close attention to the sonographic appearance of the appendiceal wall layers. Any disruption of the concentric rings is concerning for ischemia and can either represents perforation or impending perforation.

    Additionally, Doppler ultrasound is helpful. Hyperemia of the wall itself is not a reliable finding, but lack of blood flow within the wall associated with increased blood flow around the appendix is suspicious for complication of ischemic necrosis and perforation. Increased blood flow within the surrounding mesoappendix corresponds to the periappendiceal fat stranding seen on abdominal CT.

    Finally, if an acutely ill patient with acute appendicitis experiences relief of pain symptoms, then one should consider the possibility of perforation and decompression of the obstruction.



    Pearls:



    • Diagnostic features of acute appendicitis are the same on transvaginal ultrasonographic examination as they are on transabdominal examination, but it is not always possible to demonstrate compressibility with the transvaginal probe.

    • Nongynecologic causes of patient's symptoms should be evaluated on transvaginal ultrasonographic examination so that appropriate treatment can be undertaken without delay.

    • Lack of blood flow in the wall with increased surrounding hyperemia is a sign of an advanced stage of acute appendicitis.



    Ref.



    1. Middleton WD, Kurtz AB, Hertzberg BS. Ultrasound: The Requisites. 2nd ed. St. Louis, MO: Mosby 2004.

    2. Haider Z, Condous G, Ahmed S, et al. Transvaginal Sonographic Diagnosis of Appendicitis in Acute Pelvic Pain. Journal of Ultrasound in Medicine. 2006; 25: 1243-1244.

    3. Damani N, Wilson SR. Nongynecologic Applications of Transvaginal US. Radiographics. 1999; 19: S179-S200.

    4. Puylaert JB. Ultrasonography of the acute abdomen: gastrointestinal conditions. Radiologic Clinics of North America. 2003;41:1227-1242.

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