This document provides an overview of emergency ultrasound for acute appendicitis. It discusses the post-appendectomy status, including the appearance of the appendiceal stump at various time points after surgery. It also reviews complications of appendicitis and appendectomy such as abscesses. The document presents several case studies demonstrating ultrasound findings for acute appendicitis and unusual cases, including appendicitis in hernias. It concludes with a discussion of conditions that can mimic the symptoms of appendicitis.

1. Emergency Ultrasound Course
Acute Appendicitis (Part-3)
By:
Dr/ Ismail Sayed Ismail
Radiologist
is
Great doctor

2. Acute appendicitis
1. Introduction
2. Approach
3. Normal appendix
4. Pitfalls
5. Inflam. signs
6. Phases
7. Locations
8. Complications
9. Post-appendectomy
10. Recommendation
11. Case discussion
12. Unusual cases
• Summary
Part 1 Part 2 Part 3

3. Post-appendectomy status

4. • Post-appendectomy stump.

5. • Post-appendectomy stump.
• Remnant stump lengths of greater than 5 mm are considered to have a
higher risk of leading to stump appendicitis, acting as a potential reservoir for
a faecolith.

6. • Post-appendectomy stump.
• 1 day post-operative.

7. • Post-appendectomy stump.
• 1 day post-operative.

8. • Post-appendectomy stump.
• 1 day post-operative.

9. • 13 days after undergoing laparoscopic appendicectomy for histologically
confirmed suppurative appendicitis without perforation. The patient had
experienced renewed right iliac fossa (RIF) pain for six days.
• Post-appendectomy stump and mild post-operative inflammatory changes,
managed conservatively.

10. • Post-appendectomy stump.
• LS view of the ileocecal valve region. A normal inverted appendiceal stump.

11. • Post-appendectomy stump.
• TS view of the ileocecal valve region with the inverted appendiceal stump
centrally positioned ("pseudo-intussusception").

12. • Linear echogenicities noted in the region of surgery, each approximately10
mm in length, in keeping with titanium endoclips used at surgery to achieve
haemostasis.

13. • Post-appendectomy subcutaneous and abdominal wall echogenic foci
(surgical emphysema / sutures). Early post-operative period.

14. • Post-appendectomy minimal free fluid.
• Early post-operative period.

15. • Post-appendectomy echogenic edematous mesenteric fat.
• Early post-operative period.

16. • Post-appendectomy echogenic / edematous mesenteric fat.
• Early post-operative period.

17. • Post-appendectomy abdominal wall hyperaemia.
• Early post-operative period.

18. Complicated appendicitis :
• Gangrenous appendicitis.
• Appendiceal perforation.
• Periappendiceal abscess.
• Periappendiceal inflammatory mass
/ phlegmon.
• Peritonitis.
• Appendiceal mucocele.
Complications of appendectomy :
• Abdominal/pelvic abscess.
• Wound infection, abscess.
• Fistula formation.
• Bowel obstruction.
• Rarely, stump appendicitis

19. • Post-appendectomy large amount of turbid intra-peritoneal fluid collection
and distended bowel loops. Early post-operative period.

20. • Postappendectomy loculated fluid collection without a wall, with a lot of
internal diaphragms.

21. • Post appendectomy abscess with thick hyperaemic wall. Free fluid, thick-
walled adjacent bowel loop (right) and hyperechogenic mesentery.

22. • Wound infection.

23. • Postappendectomy fistula.

24. • Another Postappendectomy enterocutaneous fistula.

25. • 46 y old female with pain at right iliac fossa & vomiting.
History of appendectomy 40 days ago.
• Stump appendicitis & correlated with CT .

26. • 23 yrs female c/o pain in RIF. Probe compression tenderness was present.
H/O appendicectomy 3 yrs.
• Reported as stump appendicitis (courtesy of Arun Gupta).

27. Post-appendectomy
Appendiceal stump Peritoneum Wound

28. Recommendation & Report

29. 1. Ultrasound imaging should be a
routine procedure in every patient
with suspected appendicitis.
2. In any case of suspected
appendicitis, an “ultrasound first”
strategy should be used in both
children and adults.
3. Routine sonography in all patients
with suspected appendicitis halves
rate of unnecessary surgery
(negative laparotomy).
4. Graded compression technique
should be used for visualization of
the appendix.
EFSUMB recommendations 2019
European Federation of Societies for Ultrasound in Medicine and Biology
5. Atypical positions of appendix are the
most frequent cause of false-negative
results.
6. Systematic search for signs that suggest
differential diagnoses of appendicitis
should be implemented.
7. Complementary CT or MRI limited to
inconclusive findings & difficult
conditions (very obese patients, pregnant
women).
8. Sensitivity & specificity of US in acute
appendicitis similar to CT & MRI for
trained operators & adequate
equipments.

30. How to report ❑ Clinical data:-
Acute abdomen, …..
❑ Findings:-
The right iliac fossa shows:
_ A non-compressible blind-ended tubular structure,
arising from the cecum, directed medially.
_ It shows mural thickening and hyperemia.
_ Its lumen is distended with fluid /debris in as well
as 1 cm echogenic appendicolith.
_ It measures 12 mm (outer-to-outer diameter).
_ Surrounded by echogenic and hyperemic fat.
_ Few small reactive mesenteric lymph nodes with
minimal free fluid around.
_ Unremarkable surrounding bowel loops.
❑ Opinion:-
_ Picture is consistent with
Acute obstructive appendicitis.
Acute appendicitis

31. Case discussion

32. Clinician :-
Appendicitis ?
Lab. results :-
Borderline TLC.
C / P :-
Child presented to ER with recurrent low grade
vague abdominal pain, no vomiting, no fever.
Case (01)

34. Normal Appendix

35. Appendicitis or ?
Single wall ?
Echogenic fat ?

36. Clinician :-
Appendicitis ?
Lab. results :-
Showed borderline results (inconclusive).
C / P :-
Adult patient. Presented to ER with acute
right iliac fossa and tenderness.
Case (02)

38. T.I
App

40. Early / Acute
Catarrhal
Appendicitis

41. Clinician :-
Appendicitis vs hgic cyst
Lab. results :-
Showed TLC = 10.500 & -ve pregnancy test.
C / P :-
24y female patient presented to ER with mild
lower abdominal pain and tenderness.
Case (03)
LMP ?

43. Appendicitis or ?
Free fluid ?
Mittelschmerz ?

44. Appendicitis or ?
Luminal linear
Echogenic focus ?

46. Acute catarrhal
Appendicitis
On F / U
Spontaneous
resolving Appendicitis

47. Clinician :-
Appendicitis ?
Lab. results :-
Showed high leukocytosis.
C / P :-
14y child, presented to ER with acute right iliac
fossa pain and tenderness.
Case (04)

48. TS RIF

49. LS RT
lumbar

53. Appendicitis or ?
Echogenic fat ?

54. Rerto-cecal /
Subhepatic
Acute
Catarrhal
Appendicitis

55. Clinician :-
Acute cholecystitis ?.
Lab. results :-
Showed high TLC and CRP.
C / P :-
Adult female patient, presented to ER with acute
right hypochondrial pain and tenderness.
Case (05)

63. • Subhepatic appendicitis may present with RUQ pain.
May be mistaken as cholecystitis due to
reactive GB wall thickening.
• Appendicitis in pregnancy may present with RUQ pain.
May be mistaken as cholecystitis due to
reactive GB wall thickening.

64. Subhepatic
Appendicitis

65. Clinician :-
Appendicitis ?
Lab. results :-
Are pending.
C / P :-
Adult patient. Presented to ER with acute right
lower abdominal pain and tenderness.
Case (06)

67. Appendix not seen
On Supine > Next ?
Echogenic fat ?

70. • To enhance the detection of Retrocecal appendicitis :
>> Decubitus position.
>> Trace the psoas muscle.

71. Retro-cecal
Appendicitis

72. Clinician :-
Appendicitis ?
Lab. results :-
Showed high TLC.
C / P :-
28y male patient presented to ER with acute RIF
pain and tenderness.
Case (07)

77. Acute obstructive
Appendicitis

78. Clinician :-
Appendicitis vs ureteric stone ?
Lab. results :-
Still pending.
C / P :-
33y male patient, presented to ER with acute
right iliac fossa and right lumbar region pain and
tenderness.
Case (08)

79. Value of X-ray ?

85. Acute obstructive
Appendicitis

86. Clinician :-
Appendicitis vs mesenteric adenitis
Lab. results :-
Showed TLC = 10.500.
C / P :-
10y child presented to ER with lower abdominal
pain with significant abdominal distension.
No vomiting, no fever.
Case (09)

92. Acute obstructive
Appendicitis
DD
Appendiceal mucocele

93. Clinician :-
Appendicitis vs mesenteric adenitis ?
Lab. results :-
Showed high TLC and CRP.
C / P :-
7y child, presented to ER with acute right iliac
fossa pain and tenderness.
Case (10)

94. Hypoperistaltic
bowel ?

95. Value of free fluid ?

96. LS view
RT paramidline

98. Gut signature ?
Value ??

99. Acute gangrenous
Appendicitis

100. C / P :-
4y child, sent form ER, with acute pelvic pain,
suprapubic / right iliac fossa pain and tenderness
associated with 2 episodes of vomiting. …. UTI ?
Clinician :-
Acute appendicitis ? Cystitis ?
Lab. results :-
High TLC and CRP with mild anaemia.
Case (11)

104. • In children, an inflamed appendix near U.B
(pelvic appendicitis), may cause irritative voiding
symptoms, hematuria, pyuria ….
with consequent UB wall thickening, so
incorrectly diagnosed as cystitis.

105. Acute appendicitis
> Obstructive type
> Gangrenous phase

106. TS epigastrium
Acute abdomen
In child, what else ?

107. Acute abdomen
In child, what else ?
What to do next ?

108. Catarrhal
Appendicitis
Suppurative
Appendicitis
Gangrenous
Appendicitis
3 Phases

109. Clinician :-
Appendicitis ?
Lab. results :-
Showed high TLC and CRP.
C / P :-
33y generally unwell patient presented to ER with
generalized abdominal pain, mainly pelvic with
rigidity.
Case (12)

110. Fat echogenicity
Epicenter ?

111. Wall integrity ?

113. Is it mass ?
Value ?

114. Complicated /
perforated Appendicitis
With
Appendiceal mass /
phlegmon formation

115. Clinician :-
Acute cholecystitis ?
Lab. results :-
Showed high TLC and CRP.
C / P :-
29y female patient, presented to ER 5 days after
normal vaginal delivery with acute right
hypochondrial pain and tenderness.
Case (13)

117. If Pregnant /
Postpartum?
What is your DD ?

118. Adnexae / Ovaries ?
Size, Vessels, Fat ?

121. RIF & RT Lumbar region LS

122. RIF LS

127. Complicated
Appendicitis
With
Abscess formation

128. Complications
Appendiceal
Perforation
Appendiceal
Mass / phlegmon
Appendiceal
Abscess

129. Uncommon cases

130. Clinician :-
Acute appendicitis ?
Lab. results :-
Not available.
C / P :-
18y male patient, presented to ER with
pain in the right lower abdomen.
Case (14)

131. • .

132. • .

133. • Patient with Crohn's disease with pain. An ultrasound examination was
requested to rule out an appendicitis.
• Thickened base of the appendix in a patient with Crohn's disease. The
thickening is reactive and does not indicate an appendicitis..

134. Reactive (2ry)
appendiceal
thickening in a
patient with
Active Crohn’s
disease
Thanks, Dr. Taco Geertsma

135. Clinician :-
Acute appendicitis ?
Lab. results :-
Not available.
C / P :-
60y male patient, presented to ER with
pain in the right lower abdomen.
Case (15)

136. • .
Old age with ???
appendicitis
What to do next ?

137. • .
Are sure this is
collection ?
Or mass ???
What to do next ?

138. • .

139. Thickened
appendix in a
patient with cecal
carcinoma
Thanks, Dr. Taco Geertsma

140. • 56-years-old female with pain at RIF.
• Appendicitis caused by an obstructing cecum tumor.

141. • 82-years-old male with pain at RIF.
• Villous adenoma at the base of the appendix causing an appendicitis.

142. Clinician :-
Acute appendicitis ?
Lab. results :-
Not available.
C / P :-
23y female patient, presented to ER with
pain in the pelvis. LMP ?
Case (16)

143. • .

144. • .

145. • Typical opinion skin sign.

146. Appendiceal
mucocele

147. Clinician :-
Acute abdomen for investigation ?
Lab. results :-
TLC 7500
C / P :-
59y female patient, presented to ER with
Right iliac fossa pain and tenderness.
She had history of appendectomy 27 years ago
Case (17)

148. • .

149. • TS view : 9.4 mm in diameter. LS view : tubular blind-ended structure with
surrounding with free fluid.

150. Stump
appendicitis

151. Clinician :-
Acute appendicitis ?
Lab. results :-
Not available.
C / P :-
29y male patient, presented to ER with
Right iliac fossa pain and tenderness.
Case (18)

152. • .

153. • .

154. • .

155. Appendicitis with
diverticulosis
Thanks Dr.
Mohamed Adel Sherif

156. Case (19)
Clinician :-
Exclude appendicitis ?
Lab. results :-
Mildly elevated WBCs.
C / P :-
25-years-old male patient, presenting with
diffuse abdominal pain more at RIF.

157. • Exam. started at RIF.

159. • Pneumoperitoneum.

160. • Perforated gastric ulcer
with an air filled crater in
the gastric wall and a
small effusion around.

161. Valentino
Appendix
Seen with
Perforated
peptic ulcer

162. Case (20)
Clinician :-
Rule out complicated hernia ?
Lab. results :-
Showed no signs of inflammation.
C / P :-
64-years-old male patient, presenting to ER with
intermittent abdominal pain during the past 10 days.
Clinical examination demonstrated tenderness in the
right iliac fossa towards the inguinal region.

163. • A direct inguinal hernia protruding anteromedially and inferiorly to the
inferior epigastric vessels.

164. • A small tubular structure compatible with the appendix
was present within the hernia sac.

165. • The appendix diameter was at the upper normal range,
and the surrounding fat was hyperechoic (asterisk).

166. • Complementary CT confirmed Amyand’s hernia.
• Whether the inflammation was caused by some degree of incarceration or as
a result of acute appendicitis remained unclear.
• There were no signs of complications such as perforation or abscess.

167. Amyand’s hernia
/
Direct inguinal
hernia containing
appendix

168. Case (21)
Clinician :-
Rule out complicated hernia ?
Lab. results :-
Showed no signs of inflammation.
C / P :-
72-years-old male patient, presenting to ER with 5
days history of right groin swelling and a 1-day history
of acute pain at that region.
Clinical examination demonstrated firm irreducible
tender right groin swelling.

169. • Noncompressible blind ending tubular cystic mass with a diameter of 0.8 cm
seen herniating through right lower abdominal defect with an adjacent
hyperechoic omental fat .

170. • Complementary CT showed herniation of omental fat and a blind ending
tubular structure through a narrowed neck defect, medial to the common
femoral vessels.

171. De Garengeot's
hernia
/
Femoral hernia
containing
appendix

172. Mimics
Appendicitis

173. • 28y male patient, presented to ER feverish with acute right iliac fossa pain &
tenderness, vomiting & diarrhea. ? history of contaminated food intake.
• Infectious entero–colitis.
• DD : Acute Crohn’s disease.
Bowel mimics

174. • 6y child, presented to ER with lower abdominal pain mainly at the right iliac
fossa, with nausea, vomiting and 2 episodes of diarrhea.
• 1ry mesenteric adenitis.
Mesenteric mimics

175. • 6y child, sent from ER with acute right iliac fossa pain and tenderness for
two days.
• Omental infarction.
Peritoneal mimics

176. • 18y old patient, presented to ER with severe right lumbar and right iliac fossa
pain.
• Ureteric stone.
Urological mimics

177. • 5y child with severe lower abdominal pain and vomiting.
High TLC.
• Acute pyelonephritis of ectopic / pelvic kidney.
Urological mimics

178. • 14y female patient, sent from ER, with mild pelvic pain of acute onset.
No fever or tenderness. LMP ?
• Haemorrhagic corpus leuteum cyst.
Gynecological mimics

179. • 9y female child, presented 2 hours ago to ER with severe lower abdominal
pain, now NO pain on ultrasound examination (on & off).
• Ovarian tortion.
Gynecological mimics

180. • 29y female child, presented to ER with right lower abdominal pain. No fever
History of CS 2 years ago
• Scar endometrioma.
Abdominal wall mimics

182. • Do not do things by halves
• Entire appendix should be examined
from cecal orifice to apex.
• Segmental appendicitis vs mimics
may occur.
Definite exclusion of acute appendicitis requires visualization of
normal appendix in its entire length.

183. The most important ultrasound signs of appendicitis :-
1. Maximum diameter of appendix > 6 mm.
2. Maximum thickness of single wall > 3 mm.
3. Maximum pain and tenderness over the appendix.
4. Echogenic fat / periappendiceal mesenteric fat.
5. Echogenic submucosal layer thickness and hyperaemia.

184. The most important ultrasound signs of gangrenous appendicitis :-
1. Loss of normal echogenic submucosal layer.
2. Lack of vascularization on color flow mode.
Loss of normal echogenic submucosal layer is indicative of
gangrenous appendicitis.

185. The most important ultrasound signs of sealed perforation :-
1. Localized collections of periappendiceal fluid.
2. Extraluminal gas.
3. Extraluminal appendicolith.
4. Abscess.
Peri-appendiceal extra-luminal fluid / air foci / appendicolith are
highly indicative of sealed perforation.

186. Ileo-cecal valve External iliac Vs Psoas muscle
3 Landmarks

187. Air foci Faecal matter Lymphoid hyperplasia
3 Pitfalls

188. Appendix Mesentery Bowel
Inflammatory signs
Shape
Size
Site
Comp.
Type
Lumen
Wall

189. Catarrhal
Appendicitis
Suppurative
Appendicitis
Gangrenous
Appendicitis
3 Phases

190. Medial to cecum
Pre-ileal/post-ileal
Lateral to cecum
Retrocecal
Near kidney & liver
Subhepatic/Pregnancy
Locations

191. Complications
Appendiceal
Perforation
Appendiceal
Mass / phlegmon
Appendiceal
Abscess

192. Post-appendectomy
Appendiceal stump Peritoneum Wound

193. ‫هللا‬ ‫بحمد‬ ‫تم‬