Acute appendicitis

   August 30, 2021  Posted in Gastrointestinal Tract, Infection

Case contribution: Dr Radhiana Hassan

Clinical:

  • A 60 years old lady
  • No known medical illness
  • Presented with abdominal pain x 3/7, initially generalised then radiated to right iliac fossa region
  • Associated with vomiting and loss of appetite.
  • No fever, no altered bowel motion, no UTI or URTI symptoms
  • Clinical examination shows mild tenderness at RIF with vague mass. TWBC=18, renal profile normal, liver function test is also normal
Abdominal radiograph AP supine view

X-ray findings:

  • Multiple calcified foci are seen projected over the right hypochondriac region likely gallstones (yellow arrow)
  • A few opacities are also seen within the left pelvic cavity (white arrow)
  • No dilated bowel loops or pneumoperitoneum.
Ultrasound abdomen shows multiple gallbladder calculi

Ultrasound abdomen findings:

  • Liver is not enlarged and shows homogeneous parenchymal echogenicity with no focal lesion within it.
  • The gall bladder is well distended and shows multiple calculi within its lumen. The wall is not thickened and no pericholecystic collection is observed.
  • Intrahepatic and extrahepatic ducts are not dilated.
  • No pelvic mass seen. No collection in RIF seen. There is no free fluid.
CT scan abdomen in axial plane soft tissue window post contrast
CT scan abdomen in coronal plane soft tissue window post contrast
CT scan abdomen in sagittal plane at the region of the appendix

CT scan findings:

  • A blind end tubular structure that is continuous with caecum is identified at retrocaecal region, representing an appendix (red arrows).
  • It appears dilated and  fluid filled, the maximal transverse external diameter measures about 1.1cm at its body.
  • Mucosal wall enhancement is noted, however appears intact with no apparent area of discontinuity.
  • Minimal periappendiceal fat streakiness. No surrounding fluid or collection is detected. No pneumoperitoneum.
  • No evidence of appendicolith.  No dilated bowel.
  • Cholelithiasis is as noted on ultrasound with no evidence of active infection.
  • Uterine fibroids with intralesional calcifications.

Diagnosis: Acute appendicitis with no evidence of perforation.

Discussion:

  • Appendicitis remains the most common acute surgical condition of the abdomen
  • Accurate and timely diagnosis of acute appendicitis is essential to minimize morbidity.
  • The case-fatality rate of appendicitis jumps from less than1 percent in nonperforated cases to 5 percent or higher when perforation occurs
  • The diagnosis of appendicitis traditionally has been based on clinical features found primarily in the patient’s history and physical examination
  • Atypical presentations can result in delays in treatment, unnecessary hospital admissions for observation, and unnecessary surgery.
  • Imagings have been shown to increase diagnostic accuracy and patient outcomes in these cases
  • Diagnostic accuracy of ultrasound ranges from 71-97%.
  • Diagnostic accuracy of CT scan ranges from 93-98%.
Author: radhianahassan