Radiology Case Presentation

By Matt Cole

Clinical Information

• Clinical history: 60 year old white female who presented with a 1 week history of abdominal pain, worse in the RLQ, with recent increased intensity. Some intermittent N/V, no changes in bowel habits, no decreased appetite, no fever/chills.

Clinical Information

• Physical Exam: Afebrile, Vital Signs within normal limits, Abdominal exam revealed tenderness in the RLQ, positive rebound tenderness with pain radiating to the RLQ, minimal rigidity or guarding.

• Lab tests showed a normal white count, normal U/A, normal LFTs, normal lipase

Imaging

• The following imaging studies were obtained:– Chest x-ray– Abdominal series– Abdomen/Pelvis CT

• Both the CXR and the Abdominal series were within normal limits.

• The CT showed the following…

CT Findings

• Abnormally enlarged appendix (9.5 mm) with mild adjacent inflammatory stranding, compatible with appendicitis.

• Appendix lies in the mid and left pelvis and not the RLQ.

Hospital Course

• Based on history, physical exam, and CT findings, she was felt to have appendicitis. She was taken to the OR where a laparoscopic appendectomy was performed. The appendix was noted to be inflamed but not perforated. Final pathology reported the diagnosis to be “acute appendicitis”.

Radiographic features of appendicitis

• Plain Abdominal Radiograph– The presence of a calcified appendiceal fecalith occurs in fewer than 10% of

cases.– Radiographic signs suggesting appendicitis include convex lumbar scoliosis,

obliteration of right psoas margin, right lower quadrant air-fluid levels, air in the appendix, or localized ileus.

– In rare cases, a perforated appendix may produce pneumoperitoneum.

• Ultrasound– Especially useful for pediatric appendicitis.– The finding of a noncompressible dilated appendix is a strong indicator of

nonperforated appendicitis. – After perforation, ultrasound can identify a periappendiceal phlegmon or abscess

formation. – Additional findings that can support the diagnosis of appendicitis include the

presence of appendicoliths, fluid in the appendiceal lumen, focal tenderness over the inflamed appendix, and a transverse diameter of 6 mm or more.

CT diagnosis of Appendicitis

• The most useful features to diagnose appendicitis on CT include enlarged appendix (> 6cm), appendiceal wall thickening, periappendiceal fat stranding, and appendiceal wall enhancement.

• Other features can include appendicolith, appendiceal intraluminal air, intramural air, and abscess.

ACR CODE

ACR CODE: 75.29

References

• Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging, 4th Ed., Copyright © 2001 Churchill Livingstone, Inc.

• www.emedicine.com