A 76-year-old male with a history of coronary artery disease presents with 3 months of abdominal pain. Patient first experienced nausea, vomiting, diarrhea, chills, and severe right lower quadrant abdominal pain approximately 3 months ago. Patient states the pain improved after several days of rest, a bland diet, and hydration. However, patient reported continued decreased appetite and weight loss of 15-20 pounds over the intervening months. The pain recurred approximately one month ago and did not improve with rest prompting patient to see his primary care physician. Patient was placed on oral amoxicillin–clavulanate and instructed to get a CT scan of the abdomen and pelvis. Patient presented to the emergency department following the CT. Vitals include BP 122/69, HR 60, SpO2 98% on RA, T 97.8F. Patient is well appearing with mild tenderness to palpation in the right lower quadrant.
An ultrasound is performed and shown below. What’s the diagnosis? How is the ultrasound performed? What else should you be considering given this patient’s history?
Answer: Appendicitis
Appendicitis Ultrasound:
Technique
- Probe – Linear probe often works best. Can consider curvilinear probe in those with larger body habitus.
- 1) Ask patient to point area of maximal tenderness and place linear probe on this area
- 2) Apply steady but gradually increasing pressure in this area to displace bowel gas and enable visualization
- 3) Appendix is typically anterior to psoas and iliac vessels and is a blind tubular structure that has no peristalsis
- 4) If not visualized over area of maximal tenderness can track up and down along iliac vessels to look for appendix
Pathologic findings
- 1) Dilation > 6 mm in transverse diameter
- 2) Non-compressible
- 3) May have surrounding edema and fecalith within the appendix
Appendicitis Ultrasound Pearls:
- Appendix can be hard to visualize due to body habitus, bowel gas, or because it is retrocecal. Tips to improve visualization:
- Have patient place right leg crossed over left
- Roll patient into left lateral decubitus
- Appendix can be hard to differentiate from terminal ileum
- Terminal ileum does not have a blind ending
- Terminal ileum will show peristalsis
- Always make sure to visualize the blind ending of the appendix
- Ultrasound “Rules In” appendicitis!
Patient ultimately taken to OR by surgery where appendix was removed and sent to pathology. Given patients presentation of chronic appendicitis couple with weight loss there was concern for appendiceal cancer. Pathology has not returned at this time.
Appendiceal Cancer Facts:
- Cancer of the appendix is observed in <2% of appendiceal specimens
- Most patients are asymptomatic but in those who experience symptoms 30% present with acute appendicitis
- History that should raise suspicion for appendiceal cancer include
- Appendicitis in a patient >50 yrs of age
- Chronic symptoms of appendicitis
- Weight loss and anorexia
References:
https://coreultrasound.com/appendicitis/
Uya, A., & Chaiaza, H. (2021, June 24). Appendicitis. ACEP Symbol. https://www.acep.org/sonoguide/advanced/appendicitis
Osueni A, Chowdhury YS. Appendix Cancer. [Updated 2023 Aug 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK555943/
