Emergency Ultrasound Course For Radiologists.

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

3. Common Uncommon
Acute
appendicitis
Acute uncomplicated appendicitis
Complicated appendicitis
Bowel &
Peritoneum
Mesenteric adenitis
Infectious entero-colitis
Perforated viscus / Pneumoperitoneum
KUB Urolithiasis (obstructive or not)
Acute UTI (PN, pyelitis, cystitis,…)
Gyna CL / Haemorrhagic CL / Hgic CL cyst
Other adnexal cysts : chocolate / dermoid
Complicated / ruptured adnexal cyst
Ectopic pregnancy (disturbed or not)
PID / Post-partum infections
Ovarian Torsion
Unusual Abd. Wall , inguinal , Testicular torsion , Ruptured AAA , …
RLQ

4. 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

5. Introduction to acute appendicitis

6. clinical radiologylaboratory
1 2 3
Any Disease

7. ❑ C/P :-
❑ Periumbilical pain then RLQ pain.
Nausea & vomiting (+ fever).
Acute appendicitis

8. ❑ C/P :-
❑ RLQ tenderness (in~96%, but nonspecific).
Rebound tenderness, rigidity, and guarding.

9. ❑ C/P :-
❑ Rovsing sign >> RLQ pain with palpation of the LLQ.
>> suggests peritoneal irritation in the RLQ.

10. ❑ C/P :-
❑ Psoas sign >> RLQ pain with
extension of the right hip or
flexion of the right hip against
resistance.
>> suggests location along the
course of right psoas muscle.

11. ❑ C/P :-
❑ Obturator sign >> RLQ pain
with internal and external
rotation of the flexed right hip.
>> suggests deeper location in
the right hemipelvis.

12. ❑ C/P :-
❑ In children, an inflamed appendix near U.B cause
irritative voiding symptoms, hematuria, pyuria.
So may be misdiagnosed as cystitis.

13. ❑ C/P :-
❑ In Pregnancy, the appendix migrates upwards,
so right upper quadrant (RUQ pain) or
(right flank pain) must be considered a possible
sign of appendicitis esp. in late pregnancy.
So may be misdiagnosed as cholecystitis or
renal colic.

14. ❑ Lab. Results :-
❑ WBC count >> greater than 10,500-11,000 cells/µL.
❑ Neutrophilia >> greater than 75-78%.
❑ CRP level >> greater than 1-10 mg/dL.
❑ Urine analysis >> to differentiate appendicitis
from urinary tract conditions.

15. ❑ Lab. Results :-
❑ Appendicitis is the most common cause of abdominal surgery in
children.
❑ Perforation rates as high as 50% at the initial visit have been reported
due to delays in diagnosis and late visits to the emergency department.
❑ It has been reported that a CRP value
higher than > 100 mg/L was strongly related
to appendiceal necrosis.

16. ❑ U/S :-
❑ Step ( 1 ) >>> How to catch the appendix.
❑ Step ( 2 ) >>> Signs of acute appendicitis.
❑ Step ( 3 ) >>> Complications of appendicitis.

17. Sonographic approach to acute
appendicitis

18. ❑ Technique :-
❑ First, a low-frequency transducer (3-5 MHz).
❑ Get the right kidney long axis, then ascending colon down to the
cecum.

19. ❑ Positioning :-
❑ If you can not see the appendix on
supine position,
then, left lateral decubitus.
❑ Still you can not see the appendix then
2nd look supine again.

20. ❑ Switch to a high-frequency linear transducer.
❑ Pressure along the psoas muscle.

21. ❑ Followed by graded compression to push out
gas in the distal ileum and get the appendix.

22. Step 1 : Displacing small bowel loops by gentle compression.
Step 2 : Visualization of iliac vessels & psoas muscle.
Step 3 : Visualization of ascending colon, cecum & terminal ileum.
Graded compression ultrasound

23. Step 4 : Identification of appendix Arising from cecum & separate from
terminal ileum.
Step 5 : Appendix followed along its whole length.
Graded compression ultrasound

25. • Small bowel (ileum) vs large bowel (colon/cecum).

26. • Terminal ileum vs appendix.

28. Machine settings
Linear Transducer.
Machine Settings :-
>> Adjust Focus.
>> Increase Frequency.
>> Virtual convex.
>> Panoramic view.

29. • Appendix vs ileum.

30. • Appendix vs ileum.

31. • ?
• Tip appendicitis ? Distal appendicitis ?

32. • ?
• Tip appendicitis ? Distal appendicitis ?

33. • 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.

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

35. ❑ U/S criteria of normal appendix :-
❑ Shape : Oval.
❑ Size (outer to outer diameter) : < 6-8 mm.
❑ Compressibility : compressible.
❑ Wall thickness = Single wall thickness : < 3 mm.
❑ Wall vascularity : no (significant) mural vascularity.
❑ Lumen : Empty or gas-filled or faecal-filled.

36. • Check size.
Diameter 4 mm. Diameter 3 mm.
Without compression. With compression.

37. • Check shape.
Oval shape (with or without compression).

38. • The normal appendix usually has an ovoid appendix appearance,
a round or partly round appendix had a high correlation with
>> appendicitis.
• Non compressible appendix >> appendicitis.

39. • Check compressibility.
The normal appendix should be compressible under transducer pressure.

40. • Non compressible appendix >> appendicitis.

41. • Check vascularity :-
Color Doppler is also contributory, showing hyperemia in the appendiceal
wall in the acutely inflamed appendix
>> appendicitis.

42. • Doppler flow patterns :-
– Type 1 : punctate foci of intramural flow are dispersed within the wall.
– This pattern showed specificity of 85.7% for normal appendices.
– 9-years-old male patient with histopathologically proven lymphoid
hyperplasia and no evidence of acute appendicitis.

43. • Doppler flow patterns :-
– Type 2 : discrete intramural linear or curvilinear signal extends at least
3 mm in long- or short axis views.
– This pattern represents hyperemia, likely owing to vessels with increased
flow, as it showed high specificity (94.9%) for appendicitis.
– Histopathologically proven appendicitis in two patients (5 and 20 years
old).

44. • Doppler flow patterns :-
– Absent flow :
May be noted in normal cases or
in gangrenous appendicitis with mural ischemia.

45. • Color Doppler is, showing hyperemia in the appendiceal wall
>> appendicitis.
9-years-old male patient with histopathologically proven appendicitis.

46. • Color Doppler, showing hyperemia in the appendiceal wall
>> appendicitis.
17-years-old male patient with histopathologically proven appendicitis.

47. • Check Lumen :-
Normal appendix with air-filled lumen.
Appendix with hyperechoic foci of air in its lumen (arrows).
C = Cecum.

48. • Normal appendix with stool-filled lumen.
Echogenic stool filling lumen of mid and distal appendix.
Absence of appendiceal hyperemia & periappendiceal inflammation.

49. • Sonographic visualization of an appendix with an appendicolith, regardless
of appendiceal diameter, should also be regarded as a positive test
>> appendicitis.

50. • Check compressibility : non compressible appendix.
• Check shape : rounded shape.
• Check lumen : fluid-debris level.
>> appendicitis

51. Pitfalls

52. • Air.
Air-filled appendix

54. • Hyperechoic fecal matter in appendiceal lumen.

55. • A faecal-impacted appendix was defined as an appendix containing a non-
compressible echogenic mass without posterior shadowing within the lumen.
• A, B, Echogenic residual stool within normal appendix. A, Note echogenic
nonshadowing luminal contents within appendix, representing retained fecal
matter (long white arrow). Note thickened hypoechoic mucosal layer (short
white arrow) from lymphoid hyperplasia. A, appendix. B, Note distension of
luminal contour of appendix by residual echogenic, nonshadowing stool.
Faecal-impacted appendix

56. • Hyperechoic foci in appendiceal lumen.
• Linear surface.
• With posterior dirty shadowing.

57. • Hyperechoic fecal matter in appendiceal lumen.
• No significant posterior shadowing.
• Normal lamina propria.

58. • Hyperechoic material in appendiceal lumen.
• Filling the lumen +_ layering.
• With posterior enhancement.

59. • Hyperechoic foci in appendiceal lumen.
• Rounded surface.
• With strong posterior shadowing.

60. • A mucus-impacted appendix in 11-years-old girl with cystic fibrosis.
• Normal appendix in cystic fibrosis.
• Enlarged 10 mm & noncompressible appendix (calipers).
• Heterogeneous echogenic mucoid material distending the lumen (L)
Absence of periappendiceal mesenteric fat.
Mucus-impacted appendix /
Appendix in cystic fibrosis

61. • 3-year-old girl with a history of cystic fibrosis who presented to the
emergency department with abdominal pain and decreased appetite.
• An enlarged, non-compressible appendix ( arrow ) measuring 8 mm in
diameter near its tip. The base of the appendix measures 10 mm ( arrows )
and is distended by echogenic material. The girl was tender upon attempted
appendiceal compression. Dilated small bowel is seen anteriorly.

62. • Axial contrast-enhanced CT image shows the mildly dilated appendix (
arrow ) without surrounding fatty edema or free fluid. There are multiple
dilated fluid- and stool-containing small-bowel loops ( asterisks ) consistent
with a small-bowel obstruction.
• The girl improved with conservative therapy for a bowel obstruction and did
not require appendectomy.

63. • Patients with cystic fibrosis might have enlarged appendix
if inspissated mucoid material distends the lumen.
• Appendiceal average diameter 8.3 mm (up to 14.5 mm).
• 80% of patients have diameters ˃ 6 mm.
Diameter of appendix alone may not be a parameter for
diagnosing appendicitis in patients with cystic fibrosis.

64. • Lymphoid hyperplasia.

65. • Hypertrophy in response to gastrointestinal inflammatory diseases, such as
viral gastroenteritis and mesenteric adenitis, leading to thickening of the
lamina propria within the appendiceal wall.
Lymphoid hyperplasia

66. • Lymphoid hyperplasia may result in >>
___ a non-compressible appendix,
___ 6–8 mm in diameter and
___ may be misdiagnosed as appendicitis in pediatric patients.

67. • 5-year-old girl who underwent appendectomy after false-positive sonography.
Sonographic image obtained during compression shows enlarged
noncompressible appendix.
• Pathologic analysis revealed lymphoid hyperplasia with no appendicitis.

68. • True-positive diagnoses of appendicitis can be accurately identified by the
presence of at least two additional findings from the group of :
___ hyperechoic periappendiceal fat,
___ periappendiceal fluid,
___ and mural hyperemia.

69. • 6-year-old girl with lymphoid hyperplasia, appendicitis of appendiceal tip on
histologic examination, and sonography showing both hyperechoic
periappendiceal fat and periappendiceal fluid.

70. • Hyperechoic material inside lumen with no posterior shadowing =
Faecal impaction.
• Thickened hypoechoic lamina propria =
Lymphoid hyperplasia.

71. Air foci Faecal matter Lymphoid hyperplasia
3 Pitfalls

72. 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