Acute appendicitis: transverse retrocaecal appendix

Case contribution: Dr Radhiana Hassan

Clinical:

  • A 63 years old lady
  • Underlying DM on treatment
  • Presented with sudden onset of severe, dull aching abdominal pain at right side
  • No aggravating or relieving factor
  • Associated with vomiting 4-5 times since having pain
  • No loose stool, no altered bowel habit, no PR bleed
  • BP=128/84 mmHg, HR= 88 bpm, T=36.8
  • Pain score 7/10
  • Clinically there is tenderness and guarding at right iliac fossa with vague mass
Abdominal radiograph shows no significant finding
CT scan of abdomen in axial plane soft tissue window post contrast

CT scan findings:

  • Transverse retrocecal appendix is noted (yellow arrows).
  • Appendix is dilated measuring up to 1.2 cm in diameter. Its wall appears thickened and irregular.
  • The surrounding fat is streaky. No obvious collection at right iliac fossa region.
  • No pneumoperitoneum. No free fluid.
  • The rest of bowel loop is neither thickened nor dilated. No pelvic free fluid.
  • Uterus is normal. No adnexal lesion is seen.

Intra-operative findings:

  • Laparoscopic appendicectomy done
  • Suppurative appendicitis
  • Minimal hemoserous fluid at right iliac fossa and pelvis
  • No pus. Base of caecum healthy
  • HPE: acute appendicitis

Diagnosis: Acute appendicitis

Discussion:

  • Transverse retrocaecal appendix comprise about 2% of all appendix location.
  • CT is highly sensitive (94-98%) and specific (up to 97%) for the diagnosis of acute appendicitis
  • CT findings include:
    • appendiceal dilatation (>6 mm diameter)
    • wall thickening (>3 mm) and enhancement
    • thickening of the cecal apex
    • periappendiceal inflammation
    • focal wall nonenhancement representing necrosis (gangrenous appendicitis)¬†and a precursor to perforation
    • appendicolith
    • periappendiceal reactive nodal enlargement

Reference:

  • https://radiopaedia.org/articles/appendicitis-2

Acknowledgement:

  • Dr Siti Kamariah Che Mohamed
Author: radhianahassan