INDEX
45yo patient with acute onset left lower quadrant pain.
Diagnosis: Epiploic appendagitis
lack of central flow on Doppler due to thrombosis / torsion of the central vessel
Non-compressible hyperechoic mass with hypoechoic margins
Anatomy:
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A case of RIF pain. Shown here is CECT abdo-pelvis.
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.
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ACUTE APPENDICITIS
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
- 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
- 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
- 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
- Acute appendicitis
Differential Diagnosis:
- Crohn's disease
- Terminal ilieitis
- 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)
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
* * * * * * *
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
- RUQ / flank pain
- Rarely, chronic appendicitis is present where patient has been symptomatic for >3weeks
Complication of this condition:
- Perforation
- Abscess formation
- Perforation
- Abscess formation
Rx:
- Appendectomy
- Occasionally conservative with IV antibiotic
- 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.
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.
EPIPLOIC APPENDAGITIS
 |
| Oval shape fat density, note hyperdense ring and hyperdense center |
 |
| Same patient in coronal pain. Hyperdense ring and hyperdense center. |
- Primary - spontaneous venous thrombosis, torsion
- Secondary - due to adjacent inflammation eg diverticulitis, appendicitis
- Oval shape lesion of fat attenuation
- Hyperdense ring - due to thickening of the visceral peritoneum
- Surrounding fat stranding
- +/- central hyperdensity - thought to represent thombosed vessel / fibrous tissue / haemorrhage
- +/- local bowel wall thickening
- CT findings may evolve and persist up to 6 months
lack of central flow on Doppler due to thrombosis / torsion of the central vessel
Non-compressible hyperechoic mass with hypoechoic margins
Anatomy:
- Located along the serosal surface of the colon
- Outpouchings containing fat and vessels
- Commonly on the anterior surface of sigmoid colon along the taenia coli. Appendages are most abundant in the transverse and sigmoid colons.
- 1 - 2 cm thick, 2 - 5 cm long
- ?Risk factor: obesity, heavy exercise
- 2nd - 5th decade
- Acute abdo pain (due to inflammed appendage adhered to the parietal peritoneum).
- Not usually toxic
- No/mild leukocytosis.
- Clinical course: self-limiting, usually resolves by one week
- Omental infarction (lacks hyperdense ring, larger 3-15cm)
- Mesenteric panniculitis
- Acute diverticulitis (lack bowel wall thickening, and different location from epiploic appendagitis)
- If happens on the right side (less commonly), may mimic appendicitis
- Neoplasm eg. liposarcoma
- Trauma
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