The Atypical Appendix
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16/04/2019 1 Sonography of the Appendix • Clinical • Key Anatomy • Sonographic Features - Normal - How to visualise • Abnormal - Typical - Atypical • Mimics Overview 12yo Female – RIF pain • Clinical - Often Unhelpful • Visualisation- Important - Normal/ Abnormal • Non-visualisation - Doesn’t mean normal • “Equivocal Appendix” - Real Workshop: Take Home Messages 12yo Female – RIF pain • Anorexia (likelihood ratio1.26) • Absence of diarrhoea (1.06) • Pain migration (1.82) • Guarding (1.5) • Percussive tenderness (1.78) • Reduced bowel sounds (2.5) • Rovsing’s sign- pushing LLQ ^ pain in RLQ (2.0) • Rebound pain (1.96) • WBC >10000/mm3 (1.89) • One Finger , one spot • 50% Adults , < Children Typical appendicitis: Clinical features Peri-umbilical pain Nausea RLQ pain Vomitting & fever • Common > 5 years (Rosendahl 2004) • Neonatal appendicitis high mortality • < 3 y.o. - Diagnosed after perforation (Nearly 100%) • Most common surgical emergency • Missed appendicitis - 2nd most common medico-legal malpractice ( behind meningitis) • Appendix ruptures > 12 y.o. - 36 hrs (Klein 2007) < 6 y.o. - 6 hrs Appendicitis Clinical: Paediatric Acute Abdomen >50% no anorexia >50% no migration of pain >50% no focal tenderness >50% no rebound • Royal Womens & Childrens : 91.7% visualisation (n= 3799) Visualisation Is Important: The New benchmark Cundy TP, Gent R, Frauenfelder C, Lukic L, Linke RJ, Goh DW. Benchmarking the value of ultrasound for acute appendicitis in children. J Pediatr Surg. 2016.
Transcript of The Atypical Appendix
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Sonography of the Appendix• Clinical
• Key Anatomy
• Sonographic Features
- Normal
- How to visualise
• Abnormal
- Typical
- Atypical
• Mimics
Overview
12yo Female – RIF pain
• Clinical
- Often Unhelpful
• Visualisation- Important
- Normal/ Abnormal
• Non-visualisation
- Doesn’t mean normal
• “Equivocal Appendix”
- Real
Workshop: Take Home Messages
12yo Female – RIF pain
• Anorexia (likelihood ratio1.26)
• Absence of diarrhoea (1.06)
• Pain migration (1.82)
• Guarding (1.5)
• Percussive tenderness (1.78)
• Reduced bowel sounds (2.5)
• Rovsing’s sign- pushing LLQ ^ pain in RLQ (2.0)
• Rebound pain (1.96)
• WBC >10000/mm3 (1.89)
• One Finger , one spot
• 50% Adults , < Children
Typical appendicitis: Clinical features
Peri-umbilical pain
Nausea
RLQ pain
Vomitting & fever
• Common > 5 years (Rosendahl 2004)
• Neonatal appendicitis high mortality
• < 3 y.o.
- Diagnosed after perforation (Nearly 100%)
• Most common surgical emergency
• Missed appendicitis
- 2nd most common medico-legal malpractice
( behind meningitis)
• Appendix ruptures > 12 y.o. - 36 hrs (Klein 2007)
< 6 y.o. - 6 hrs
Appendicitis Clinical: Paediatric Acute Abdomen
>50% no anorexia
>50% no migration of pain
>50% no focal tenderness
>50% no rebound
• Royal Womens & Childrens : 91.7% visualisation (n= 3799)
Visualisation Is Important: The New benchmark
Cundy TP, Gent R, Frauenfelder C, Lukic L, Linke RJ, Goh DW. Benchmarking the value of ultrasound for acute appendicitis in children. J Pediatr Surg. 2016.
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• Technique
• Mindset
• Monash Story
Simple question- How good are you? Criteria: Equivocal Appendix
• Vermiform appendix
- Latin
• “dangling”+“vermis”+‘form”,
• “dangling worm-shaped thing”
• 2cm below- ileocecal junction
• Attached postero-medially
• Note
- Descending Colon
- Terminal ileum/ ileocecal junction
- Cecum
- Vermiform Appendix
Appendix: Key Anatomy
• Located
- McBurney’s Point: Is the point
that is 1/3 along the line drawn
from the ASIS to Umbilics.
Appendix: Surface Anatomy
ASIS
Appendix: Key Anatomy
Blind ending worm like proection of cecum
• Gut signature
• 2-6mm
• Contains gas
• No- mild vascularity
• Compressible
• Surrounded by
- Normal bowel
- Isoechoic fat
Appendix: Sonographic Anatomy
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• Highly variable
• Position
- Note: Retroceacal
Appendix: Highly Variable Anatomy
de Souza SC, et al . Vermiform appendix: positions and length – a study of 377 cases and literature review. J. of Col 2015;35(4):212-6.
• Settings
- Decrease frame rate
- Decrease DR
• Transducers
- Micro-convex
- Linear
Appendix: How to visualise?
• Numerous strategies
• Identify
- Caecum
- Ileocaecal junction
- “Most likely region”
• Alternately
- “One finger test”
Appendix: How to visualise?
ASIS
1. Descending Colon
2. Terminal ileum/ ileocecal junction
3. Cecum
4. Appendix
Appendix: Key Anatomy
Appendix: Descending Colon Identify Caecum
Larger – Haustra
Undulating bumps
Expanded- Gas filledhttp://brownemblog.com/blog-1/2017/3/3/pocus-for-appendicitis
Appendix: Terminal Ileum Identify Caecum
http://www.ultrasoundcases.info/files/Jpg/lbox_26493.jpg
Small bowel no undlations-as no Haustra.
Medial/superior to cecum.
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Caecum Small Bowel
Appendix: Identify Caecum
Smaller mucosal foldsLarger
Taenia Coli – Haustra
Expanded: Gas filled
• Rapid scanning
• Strobe the layers
• Look for the blind ending
“worm”
Appendix: The Scanning
• Retocaecal
• What can we do?
Appendix: How to visualise?
• Retrocaecal
• What can we do?
• Sustained compression
- Caecal
- Fan: Superior- Inferior
• Image-Postero-lateral
• Lat Decubitus
- Fan: Lat- Medial
• Time
Appendix: How to visualise?
• Medial
• What can we do?
Appendix: How to visualise?
• Medial
• What can we do?
• Fan med to lat
• Pressure
- Off & On
• Use psoas / iliac vessels
• Time
Appendix: How to visualise?
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• Medial
• What can we do?
• Fan med to lat
• Pressure
- Off & On
• Use psoas / iliac vessels
Appendix: How to visualise?
• Pelvic
• What can we do?
Appendix: How to visualise?
• Pelvic
• What can we do?
• Graded Compression
• Angle- Use bladder
• Endovaginal- Non-paediatric
• Time
Appendix: How to visualise?
• Royal Womens & Childrens : 91.7% visualisation (n= 3799)
Visualisation: The New benchmark
Cundy TP, Gent R, Frauenfelder C, Lukic L, Linke RJ, Goh DW. Benchmarking the value of ultrasound for acute appendicitis in children. J Pediatr Surg. 2016.
Appendix: : The “Typical” Abnormal Appendix: The “Typical” Abnormal
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Appendix: : What are the features?
14yo Male – “Marked Focal Pain”
Case Review
7.8mm
Normal/ Abnormal?
7yo male RIF pain
Case Review
• Appendix part /not visible
• Variable appearance
- Hypo fluid collection/mass
- Hyperaemic echogenic mass
• Extruded appendicolith
Appendix: : The Very Abnormal- Harder
• More advanced : More difficult
- Words / History
Appendix: : The Abnormal- Harder
• More advanced : More difficult
- Perforated
- Words / History
Appendix: : The Abnormal- Harder
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• Case
• Point tenderness (Yes/ No?)
Appendix: : The “Equivocal”
• Sonographer –Yes
• Radiologist- No
• Surgeon –Yes
• Treated with Abx
Appendix: : The “Equivocal”
• 28 yo female
• RIF pain, dyspareunia, dysuria, discharge
• Hx appendectomy
• ?PID
• Ultrasound
• ?
Atypical appearance: Case Review
• 1:50000
• Pain, nausea, vomiting
• Ultrasound appearance
- Thickened stump, inflammation,
- Faecoliths, FF, inflamed cecum
• Treatment
- Complicated appendicitis
- Laproscopic approach
Atypical appearance: Stump Appendicitis
• 22 yo
• Clinical
- RUQ pain, nausea & vomiting
- ?cholecystitis
• Abdo ultrasound
- normal GB
- focally tender point
• 2% Appendicitis RUQ (fred 2012)
Atypical Location: Case Review
• 70 yo
• Indirect Hernia- Contains normal appendix
- Appendicitis: Amyands Hernia
Atypical location: Case Review
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• ?
Atypical appearance: Case Review
34yo Female – Lower abdo pain ? Ovarian, ? Appendix
• Appendicele/ Appendix mucocele
• Mucous
- Abnormal accumulation
- Dilatation
• Viscous
• Need to exclude malignancy
- Eg Mucinous cystadenoma
- Pseudomyxoma peritonei
Atypical appearance: Case Review
• Pathophysiology
- Partial/recurrent obstruction
• Clinical symptoms
- May be similar to acute
- Normal WCC, no fever
• Criteria
- Symptoms >2/52
- Confirmed on histology ( inflammatory infiltrate, wall fibrosis)
- Relief post-appendectomy
Atypical presentation: Chronic appendicitis
• Appendix invaginated into Caecum
• Rare – 0.01% intussusceptions
And the rare….
• Intussusception
Other differentials- Long List
• Epiploic Appendigitis
Other differentials
Little pouches of peritoneum filled with fat. Can become twisted and torted.
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• Small / Large Rectus abdominis tear
Other differentials
Karen Lee
Peter Coombs
MH:Sonographers
Paediatric Radiologists
Acknowledgements
References
• Akbulut S, Ulku A, Senol A, Tas M & Yagmur Y. “Left-sided Appendicits:Review of 95 Published cases and a Case Report” World Journal
of Gastroenterology. 2010; (16) 14:5598-5602
• Molander P, Paavonen J, Sjoberg, Savelli L & Cacciatore B. 'Transvaginal Sonography in the Diagnosis of Acute Appendicitis' Ultrasound
in Obstetrics and Gynaecology. 2002; 20:496-501
• Becker T, Kharbanda A & Bachur R. “Atypical Clinical Features of Pediatric Appendicits’ Academic Emergency Medicine . 2007; (14)
2:124-129
• Subramandian A & Liand MD. “A 60 Year Literature Review of Stump Appendicitis: thr Need for a Critical View” The American Journal of
Surgery 2012; (203) 4:203-507
• Toprak H, Bilgin M, Atay M & Kocakoc. “Diagnosis of Appendicitis in Patients with Abnormal Position of the Appendix due to Mobile
Cecum” Case Reports in Surgery. 2012; (2012)
• Van Breda Vriesman AC & Puylaert ABCM. “Mimic of Appendicitis: Altnernative Nonsurgical Diagnoses with Sonography and CT”
American Journal of Roentgenology. 2006; 186:1103-1112
• Caspi B, Zbar P, Mavor E, Hagay Z & Appelman Z. ‘The Contributuon of Transvagonal Ultrasound in the Diagnosis of Acute Appendicitis:
an Observational Study’ Ultrasound in Obstetric and Gynaecology. 2003;21:273-276
• Safaei M, Moeinei L & Rasti M. ‘Recurrent Abdominal Pain and Chrinic Appendicitis’ Jounral of Research in Medical Sciences 2004; 1:11-
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IMAGES
http://www.ultrasoundcases.info/Case-List.aspx?cat=611
https://iame.com/online/ovary/ovary.html
http://lookfordiagnosis.com/mesh_info.php?term=mesenteric+lymphadenitis&lang=1
