Friday, March 25, 2011

Case 2: CECT abdomen-pelvis



A case of RIF pain. Shown here is CECT abdo-pelvis.


Description points:
- Outer diameter of appendix (>6mm in appendicitis)
- Appendiceal wall enhancement (in IV contrast study)
- Surrounding inflammatory changes: Fat stranding, peritoneal fluid
Other associated radiological findings:
- Arrow head sign (made possible by introduction of rectal contrast, or contrasted by air)
- Appendicolith
- Absence of opacification in the appendiceal lumen
- Lymphadenopathy (non-specific)
- Ileocaecal thickening
- Phlegmon
Important findings not to miss:
- Pneumoperitoneum for hollow visceral perforation
- Appendiceal mass
- Gangrenous appendix: presence of loculated air and surrounding fluid
- Peri-appendiceal abscess
- Distal appendicitis: normal looking proximal appendix, but tip/distal appendix demonstrates inflammatory changes
Diagnosis:
- Acute appendicitis
Differential Diagnosis:
- Crohn's disease
- Terminal ilieitis
Clinical features:
Classic:
- Migrating pain: from peri-umbilical region to RIF (score 1)
- Anorexia / Urine Ketones (score 1)
- Nausea & Vomiting (score 1)
- Tender RIF (score 2)
- Rebound tenderness (score 1)
- Elevated temperature (>/= 37.3c) (score 1)
- Leukocytosis (>10 x 10^3) (score 2)
- Shift of leukocytes (neutrophilia) (score 1)
* * * * * * *
Above forms the MANTRELS score (aka Alvorado score): Score 5-6: maybe acute appendicitis Score 7-8: probable acute appendicitis Score 9-10: Highly probable acute appendicitis
* * * * * * *
"Less classic features"
- RUQ / flank pain
- Rarely, chronic appendicitis is present where patient has been symptomatic for >3weeks
Complication of this condition:
- Perforation
- Abscess formation
Rx:
- Appendectomy
- Occasionally conservative with IV antibiotic
Aetiology:
Obstruction of the appendiceal lumen:
- Impacted faecolith
- Lymphoid tissue hyperplasia from infection
- Appendiceal calculi (usually a/w perforation)
- Luminal obstruction due to strictures, adhesions, tumor (primary / secondary), Carcinoid syndrome, parasitic infection.

Anatomy:
- Located at the caecum inferiorly

- Length 5-35cm

- Varying positions:

- Congenital anomaly (rare):

- Supplied by appendicular artery, branch of ileocolic artery. Has own mesentery.

No comments:

Post a Comment