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Abstract

Although the radiological features of acute appendicitis have been well documented, the value of plain abdominal radiograph has not been fully appreciated. This article summarizes the role of radiology in acute appendicitis, especially in atypical cases and extremes of age, where there is often delay in diagnosis.

Introduction
Acute appendicitis is one of the commonest surgical emergencies. Although no longer a ‘hot topic' in the medical literature and majority of the time the diagnosis is essentially clinical, acute appendicitis still presents a challenge to the treating surgeon. Several modern series indicate that a preoperative clinical diagnosis of acute appendicitis will be incorrect in 15 of cases and that a significant postoperative complication rate can be e!pected as a result of appendicectomy performed for such a mista"en impression. #lain !$ray of abdomen, %ltrasonography &%S'( and )omputed tomography &)*( scan are used as a combination and of all )* scan has a high diagnostic accuracy. *he role of radiography in the diagnosis of acute appendicitis is poorly appreciated. ,maging tools aid the diagnosis in e-uivocal presentations. .oung children, women of childbearing age, elderly and patients receiving antibiotics present atypically.
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*he value of plain !$ray abdomen is often under appreciated in diagnosing right iliac fossa &0,1( pain. *he radiological signs of appendicitis are well documented but few are aware of them. 2e present a case of acute appendicitis with interesting radiological features.

Case Report
A /+$year$old male, "nown alcoholic presented to the casualty with complaints of pain in the lower abdomen of two days duration with fever and vomiting of one day. *o start with the pain was periumbilical but shifted to 0,1. 3ladder and bowel habits were normal. 4n e!amination, the patient was febrile, had mild tenderness of the 0,1 and at the 5c 3urney's point with no guarding or rigidity. ,nvestigations revealed a leucocytosis &23) 6 117889cu mm( and an %S' of abdomen revealed no evidence of appendicitis. *welve hours later patient developed severe vomiting, increased pain in the right iliac fossa with guarding, rigidity and rebound tenderness. A repeat 23) counts was +/888 9cu mm and %S' showed locali:ed ileus in the 0,1. A plain !$ray abdomen was ta"en which showed; 1( <ocali:ed ileus, +( <oss of lower 19/ of right psoas shadow, /( 'reater than 18 mm distance between right flan" wall and caecum &air9fluid( and =( A strip of free air along the right paracolic gutter, delineating the lower border of liver &1igure, arrow(.

*he patient was subjected to an emergency appendicectomy. *he appendi! was found to be retrocecal, gangrenous and perforated. >e had an uneventful recovery and was discharged on the tenth postoperative day. 2e have seen similar findings &especially no. = as above in the !$ray photograph( in seven of the twenty$three patients admitted with a diagnosis of acute appendicitis and had a perforated appendi! at laparotomy.

Discussion
Acute appendicitis is the most common indication for emergency abdominal surgery. 2hen diagnosed early and treated promptly, the morbidity and mortality from appendicitis is low. >owever, once perforation occurs, morbidity and mortality rates increase dramatically. *he diagnosis of acute appendicitis is usually clinical and straightforward and e!tensive investigations are unnecessary. ,maging studies are useful when the diagnosis is at doubt. Abdominal radiography is indicated for the evaluation of a patient with suspected appendicitis only when the e!istence of a surgical problem is in doubt or when appendicitis is one of the many diagnostic probablities.
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,n order to shorten the interval between the onset of symptoms and surgical intervention, and, hence to decrease the ris" of perforation, various imaging

studies including !$ray, %S', )* scan and laparoscopy may be performed in the evaluation of patients with suspected appendicitis. Although a number of reports have discussed adjunctive testing in patients with suspected appendicitis, their diagnostic value remains uncertain.
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*he original large radiographic series of Steinert et al first evaluated the usefulness of the plain abdominal film in acute appendicitis and developed three categories; 1( normal +( possibly abnormal, such as cases with scoliosis, absence of right psoas margin and air in a nondilated appendi! and /( probable appendicitis or suggestive of appendicitis. ?emonstration of an appendicolith or right lower -uadrant abscess gas justifies the specific diagnosis. 5ost often several signs will be present in cases with positive abdominal films. A combination of findings more strongly suggests a right lower -uadrant inflammatory process than any one alone. 4f the 1/@ positive 3ridgeport >ospital cases, AA &7+ ( had two or more radiographic signs of appendicitis. #atients with perforation or gangrene are more li"ely to have a positive radiographic e!amination &B+ in 3ridgeport >ospital series( . 5ost authors have found that plain film studies are less fre-uently positive when the appendi! is in the retrocecal position, as in our patient.
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Cven if positive, abdominal radiographs add little to the straightforward case of acute appendicitis e!cept e!pense and radiation e!posure. #erhaps +8 of patients with appendicitis present such problems. About half of these patients over B8 years have minimal symptoms, the so$called ‘silent appendi!'. Since the plain film is positive in less than 58 of such cases, further evaluation by barium enema e!amination may be indicated.
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Cllis recommends plain !$ray films of the abdomen in all cases acute abdomen. 3roo"s and Dillen have listed these radiological signs for acute appendicitis; 1( 1luid levels locali:ed to the caecum and terminal ileum, indicating inflammation in the right lower -uadrant, +( <ocali:ed ileus with gas in the cecum, ascending colon and terminal ileum, /( ,ncreased soft tissue density of the right lower -uadrant, =( 3lurring of the right flan" stripe and presence of a radiolucent line between the fat of the peritoneum and tansverus abdominis, 5( 1ecolith in the right iliac fossa, B( 'as filled appendi!, 7( ,ntraperitoneal gas, @( ?eformity of the cecal gas shadow occurring due to adjacent inflammatory mass and A( 3lurring of the psoas shadow on the right side.
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,t is of interest to note that four out of five patients with false$positive radiographs for acute appendicitis have other conditions li"e ruptured ovarian cyst, lea"ing carcinoma of cecum or a low lying gall bladder . *his emphasi:es that radiology reflects all diseases affecting the right lower -uadrant, the commonest being acute appendicitis.
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Although the routine use of adjunctive imaging studies cannot be advocated at the present time, the judicious use of these tests may prove useful in selected

patients such as women of child bearing age, young children, the elderly and patients with systemic disease or who are immunosuppressed, in whom negative appendicectomy and perforation rates remain high. Address for correspondence ?r. 'abriel 0odrigues, 5S., ?E3. Assistant #rofessor of Surgery, 157, D5) Fuarters, 5adhav Eagar, 5anipal G 57B 18=. Darnata"a, ,E?,A. *el; HA1$@+8$+57+B=7 1a!; HA1$@+8$+5788B1 Cmail; gabyrodriguesIe!cite.com

References
1. Da:arian DD, 0oedor 2J, 5ersheimer 2<. ?ecreasing mortality and increasing morbidity from acute appendicitis. Am J Surg 1A78K 11A; B@1$B@5. +. Shim"in #5. 0adiology of acute appendicitis. Am J 0oentgen 1A7@K 1/8; 1888$188=. /. Sarfati 50, >unter '), 2it:"e ?3, 3ebb '', Smythe S>, 3oyan S, 0appaport 2?. ,mpact of adjunctive testing on the diagnosis and clinical course of patients with acute appendicitis. Am J Surg 1AA/K 1BB; BB8$BB5. =. Scher DS, )oil JA. *he continuing challenge of perforating appendicitis. Surg 'ynecol 4bstet 1A@8K 158; 5/5$5/@. 5. Steinert 0, >areide ,, )hristiansen *. 0oentgenolic e!amination of acute appendicitis. Acta 0adiol 1A=/K +=; 1/$+7. B. 'raham A?, Johnson >1. *he incidence of radiographic findings in acute appendicitis compared to +88 normal abdomens. 5ilit 5ed 1ABBK 1/1;+7+$+7B. 7. 3arnes 3A, 3ehringer 'C, 2heeloc" 1), 2il"ens C2. *reatment of appendicitis at the 5assachusetts 'eneral >ospital. JA5A 1AB+K 1@8; 1++$1+B. @. Cllis >, Eathanson <D. Appendi! and appendectomy. ,n; Linner 5J, Schwart: S*, Cllis > &eds(. 5aingot's abdominal operations, 18th ed, Appleton and <ange, Eew .or" 1AA7; pp 11A1$1++7. A. 3roo"s ?2, Dillen ?A. 0oentgenographic findings in acute appendicitis. Surgery 1AB5K 57; /77$/@=.

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