Case 4436

US FINDING FOR APPENDICEAL

PHLEGMON
Published on 05.02.2006

DOI: 10.1594/EURORAD/CASE.4436
ISSN: 1563-4086
Section: Abdominal imaging
Case Type: Clinical Cases
Authors: Antonio Gligorievski
Patient: 25 years, male

Clinical History:

US examinations shows enlarged (diameter 9,2 mm) noncompressible, appendix with periappendiceal inflammation.
Imaging Findings:

A previously healthy 25 year old man presents to the emergency department with acute abdominal pain in the right
lower quadrant of 24 hours' duration. He has no fever, and his examination is remarkable only for right lower
quadrant tenderness without peritoneal signs. The three factors with the highest predictive value for acute
appendicitis are right lower quadrant pain, abdominal rigidity, and migration of pain from the periumbilical region to
the right lower quadrant. US examinations with linear 7,5 Mhz probe, shows enlarged (diameter 9,2 mm)
noncompressible, appendix with periappendiceal inflammation. Enlargement of the appendix is a sign of suppurative
or gangrenous appendicitis. The inflamed appendix can usually be identified medial and inferior to the cecum. It
appears as a sausage-shaped, blind-ending structure on longitudinal, or as a target lesion on transverse sections. In
addition, an irregular hypoechoic mass is identified surrounding the appendix, this represents periappendiceal
inflammation.
Discussion:

Acute appendicitis is the most common indication for emergency laparotomy especialy in children. Perforation,
although still uncommon, occurs with a much greater frequency (approximately 25-35%) in the pediatric and oldery
population. The pathogenesis generally begins with luminal obstruction. The usual initial symptoms are vague
visceral abdominal pain secondary to the distention of the appendix. After 4 to 6 hours, as the inflammation spreads
to the parietal peritoneum, the pain increases in intensity and becomes somatic in nature localized at "McBurney's
Point" in the RLQ. Nausea, vomiting, and anorexia are frequently associated. The typical historical and physical
findings are found in approximately 2/3 of patients eventually determined to have appendicitis. The clinical diagnosis
is not always entirely straightforward especially in children who may not be able to communicate their symptoms
adequately. Imaging methods must be used in patients with indeterminate clinical findings to avoid unnecessary
laparotomies. On the US exam the mucosa, if seen, will appear as a thin hyperechoic line surrounding the lumen.
The wall of the appendix is hypoechoic and is usually <2 mm in thickness with an overall cross-sectional diameter of
less than or equal to 6mm. A recent study has shown that any appendix measuring >6 mm at its greatest point will
be inflamed 93% of the time. Enlargement of the appendix is a sign of suppurative or gangrenous appendicitis. A
cross-sectional diameter measurement of greater than 6 mm along with noncompressibility in a patient with
persistent RLQ pain is considered reliable evidence of appendicitis. It is extremely important that the entire appendix
is visualized because inflammation may be localized to the distal tip. Associated findings include loss of the
echogenic submucosal layer which may reflect extension of the inflammation through the muscularis propria. There
may be a fluid-filled lumen which will be anechoic and/or a hyper echoic appendicolith with acoustic shadowing.
There may also be associated periappendiceal fluid collections or mass which may displace adjacent structures.
These latter findings are more likely to be seen in association with perforation. The lumen of the appendix may be
hyperechoic or, if fluid filled, anechoic. An appendicolith, gas, or inspissated feces can be seen as an intraluminal
hyperechoic structure with or without shadow. The diameter of the lumen is between 3 and 10 mm. When an
appendicolith is detected, the thickness and compressibility are not important in making the diagnosis of
appendicitis. If, in addition, an irregular hypoechoic mass is identified surrounding the appendix, this represents
periappendiceal inflammation.
Differential Diagnosis List: Acute Phlegmonous Appendicitis

Final Diagnosis: Acute Phlegmonous Appendicitis

References:

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(PMID: 8517294)
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(PMID: 1410371)
Siegel MJ. Acute Appendicitis in Childhood: The role of US. Radiology. 1992; 185:341-342. (PMID: 1410335)
Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United
States. Am J Epidemiol 1990; 132:910-25. (PMID: 2239906)
Rao PM, Rhea JT, Novelline RA, McCabe CJ, Lawrason JN, Berger DL, et al. Helical CT technique for the diagnosis
of appendicitis: prospective evaluation of a focused appendix CT examination. Radiology 1997; 202:139-44. (PMID:
8988203)
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Figure 1
a

Description: US finding for appendiceal phlegmon: Coronal view: appendix increased in size, with
thickened wall and widened lumen and surrounding infiltration, it appears as a target lesion on
transverse sections. Origin:
Figure 2
a

Description: US finding for appendiceal phlegmon: b) Saggital view: appendix with thickened wall,
widened lumen and surrounding infiltration, it appears as a sausage-shaped, blind-ending structure on
longitudinal, sections. Origin: