ULTRASOUND IN

APPENDICITIS

Daniel Makes
Dept. Of Radiology Faculty Of Medicine
University Of Indonesia / Cipto Mangunkusumo Hospital
Jakarta
 ANATOMY
The appendix is the vermiform continuation of
the caecum and arises from its posteromedial aspect
In the retrocaecal position the appendix
may occasionally be situated retroperitoneally
The average lenght of the appendix is 9 cm, and
if the lumen is collapsed the average diameter is 4.5 mm
 PATHOPHYSIOLOGY
The etiology of acute appendicitis is
obstruction, followed by infection
It is accepted that in 35% of all patients
the presence of a fecolith plays an
important role in the pathological process
Foreign bodies, tumors, parasites and
gallstones are reported as rare causes of
obstruction in appendicitis
 RADIOLOGICAL
EXAMINATIONS
In everyday practice radiological examinations in patients with
suspected appendicitis are mainly used for the exclusion or
detection of other conditions
Nevertheless various radiological examinations may contribute to
the diagnosis of appendicitis and provide vital information
complementary to US
Examination Technique
Essential for US examination
in patients with suspected appendicitis is the use of
high-resolution transducers in combination with
graded compression of the abdomen
 EQUIPMENT
Both 5.0 – 7.5 MHz transducers combine relatively deep penetration, about 10 and 8
cm respectively,
with high image quality. The 5 MHz transducer is
used for survey and the 7.5 MHz transducer for detailed imaging
The examination is started with a global survey of
the upper abdomen with 3-5 MHz sector scanner and more detailed survey with the 5.0
MHz sector
scanner
Graded compression with US should be applied in
a way resembling classic palpation of the abdomen
ACUTE APPENDICITIS
The sonographic hallmark of
appendicitis is direct visualization of
the inflamed appendix
The classic appearance is that of
a concentrically layered, small
sausage like structure found at the
point of tenderness
ACUTE APPENDICITIS
 ACUTE APPENDICITIS
A blind-ended & aperistaltic tube
Appendix diameter greater than
6 mm
Visualization of an appendix with
an appendicolith
COMPRESSION TECHNIQUE IN ACUTE APPENDICITIS
 Abortive Appendicitis and
Recurrent Acute Appendicitis
In about 10%-15% of patients, appendicitis runs an abortive course. The
patients initially have clinical signs of appendicitis, but after a variable period
of time (4-36 h) from the onset of the symptoms, they rather suddenly resolve

If the patient is examined sonographically shortly after such an attack, the

appendix which is still swollen, can easily be demonstrated by US but is no
longer tender on pressure applied with the transducer
The Sensitivity of US decrease
with perforation

Loculated pericecal fluid

Prominent pericecal fat
Circumferential loss of the sub
mucosal layer of appendix
 If an appendiceal abscess is suspected on US scan, CT is
always indicated : it confirms the diagnosis, delineates
the extent of the abscess, and determines the safest access route
for percutaneous drain-age
An appendiceal abscess is mostly anechoic but may show very
small reflectives particles, which may sometimes coalesce to a
diffuse hyperechoic center
 Differential Diagnosis Using
Ultrasound
 Bacterial Ileocaecitis
Bacterial Ileocaecitis is a bacterial infection confined to the terminal
ileum, caecum and mesenteric lymph nodes.
• The mural thickening of the terminal ileum and caecum and the
enlarged mesenteric lymph nodes provide characteristic US features
 Cholecystitis
If the gallblader is in
a relatively caudal position,
cholecystitis may mimic
appendicitis. This may occur in
patients with emphysema or
hepatomegaly but also
occasionally in normal patients,
usually women
Urological Conditions

Stones in the right ureter

may mimic appendicitis
especially it the stone is
located distally and
urinalysis is normal
Gynecological Conditions
Ovarian Cyst
The most frequent gynecological
condition seen is the persistent and /
or hemorrhagic functional cyst, which
occurs not only at or a short time after
the expected ovulation
( intermenstrual pain ) , but also later
on in the menstrual cycle
Adnexal Torsion
Torsion occurs only if the
adnexa is pathologically
enlarged , e.g in
hydrosalpinx, large
functional cyst, or demoid
cyst
Ectopic Pregnancy
Ectopic pregnancy is not
the most frequent but
certainly the most
important gynecological
condition masquerading
as appendicitis
ECTOPIC PREGNANCY
 Caecal Carcinoma
Caecal carcinoma may clinically mimic
appendicitis in a number of different ways. The
tumor itself may present as a painful mass like
an appendiceal phlegmon but also may cause
acute pain, thereby simulating the symptoms of
acute appendicitis. Secondly, a perforated
carcinoma may show the same symptoms as
perforated appendicitis or appendiceal abscess
 CONCLUSION
The US examination is
an important complement to the clinical diagnosis, but it can
never replace it.
If US examination reveals no abnormalities or is considered
not diagnostic or unreliable, the clinical diagnosis remains
the cornerstone in therapeutic decision making