Recognizing appendicitis using ultrasound imaging

Appendicitis can sometimes be quite tricky to pinpoint. What do you do when a patient presents with acute abdominal pain? Whip out your ultrasound probe and go digging! By the end of this video, you'll be able to look at an ultrasound image and distinguish between a normal appendix and an inflamed one so that you can quickly identify and treat a case of appendicitis.

Learn how to perform your own abdominal ultrasounds and interpret your findings with our Abdominal Ultrasound Essentials course. Dr Nikolaus Mayr–the Chief Resident of Radiology at the Hospital of the Brothers of St. John of God in Salzburg–will guide you through the essentials of abdominal sonography.

[00:00:00] Appendicitis is inflammation of the vermiform appendix. It's a very common condition and it's one of the main reasons for abdominal surgery in young patients. Acute appendicitis is typically a disease of children and young adults with a peak incidence in the second and third decades of life. The classical presentation consists of periumbilical pain, which within a day or more can move to the right hypogastrium. It is associated with fever, nausea, and vomiting.

[00:00:30] It also relies on the appendix being in the normal position, which is not the case in the significant number of cases. Be aware that small children can present with nonspecific vague symptoms. Also, choose ultrasound as your first choice of imaging when trying to rule out appendicitis in young patients. We want to avoid using ionizing radiation whenever possible. With a competent user, ultrasound is reliable at identifying abnormal appendices, especially infant patients.

[00:01:00] However, the identification of a normal appendix is much more difficult. In normal appendix, there's a subtle wall and a small diameter under six millimeters. It's also a mobile structure and can shift under pressure from a probe. When the appendix is inflamed, it becomes stylated and attaches itself to the other abdominal structures. The surrounding fat structures show stranding, pinpointing the pathology, pointing you directly toward the inflamed appendix.

[00:01:30] This is a video that will show us the approach to finding the appendix. We need the cecal pole, here, in the right hypogastric region. We need the terminal ileum, here, entering at the valve of Bauhin. And then we will look in this corner, to see if there is another structure that looks like a terminal ileum, entering here. This is the appendix in long section. You can see the typical walling of the appendix. You can also see that this appendix is definitely

[00:02:00] below six millimeters in diameter. Now, we will follow the appendix in its full length to find the appendix pole. This is important, as the inflammation of the appendix can also sit only at the pole and the rest can be normal. The end of the appendix is right here. So, this is the appendix in its full length.

[00:02:30] In this video, we see what appendicitis looks like. You see the cecal pole here. We see that there is a hyperechoic round structure leaving the cecal pole and a dilated tube-like structure ending here. This is the inflamed dilated appendix. You can also see that the fat structures around here are stranding and when we measure the appendix,

[00:03:00] it has 12 millimeters. Now, we go into a long section over the cecal pole and we see the dilated appendix coming out, here and moving behind the cecal pole, here. This is the typical presentation of appendicitis.