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