Ultrasound Findings in Appendicitis

Case 1

Non-perforated appendicitis.

14 year old male presented to the emergency department with right lower quadrant pain. for six hours duration. On physical examination he was febrile. Complete blood count revealed leukocytosis. A right lower quadrant ultrasound, shown below, was requested to evaluate for appendicitis.
Longitudinal graded compression ultrasound image demonstrates a mildly dilated appendix (black arrows) with preservation of the expected multilayered appearance of bowel. Note blind end of the appendix (white arrow). There is no evidence of an appendicolith or adjacent fluid.
At surgery, early non-perforated appendicitis was confirmed.

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Case 2

Perforated appendicitis.

2 year old girl was transferred from an outside hospital with a two day history of bilious vomiting, excessive crying, irritability, and right lower quadrant tenderness. She had no bowel movements during the prior two days. Physical examination revealed a soft, non-distended abdomen with right lower quadrant tenderness. The patient was most comfortable with her hips flexed. An ultrasound examination was performed to evaluate for appendicitis, shown below.
Graded compression ultrasound of the right lower quadrant reveals a non-compressible, enlarged appendix (arrows). Definition of the bowel wall layers, particularly the echogenic submucosa, is lost, suggesting perforation.
At surgery, a perforated appendix was found, without adjacent abscess or purulent fluid.

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Case 3

Perforated appendicitis with free fluid.

5 year old girl with a two day history of nausea, vomiting, fever, and abdominal pain presented to the emergency room. An ultrasound examination was requested to differentiate between appendicitis and ovarian torsion, shown below.
Figure 1. Ultrasound image of the right lower quadrant in transverse plane shows free intraperitoneal fluid (FF) surrounding loops of bowel (B).
Figure 2. Graded compression ultrasound image lower in the right pelvis in transverse plane, demonstrates a calcified appendicolith (small arrows) within the dilated appendix (large arrows)..
At surgery a perforated appendix with adjacent purulent material was removed. Surgical drains were placed in the pelvis and right paracolic gutter.

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Case 4

Perforated appendicitis.

10 year old girl with a three day history of right lower quadrant pain, intermittent nausea, vomiting, fever, and chills presented to the emergency room. Physical examination was significant for abdominal guarding and rebound tenderness in the right lower quadrant. Laboratory evaluation revealed leukocytosis. A graded compression ultrasound examination was performed to evaluate for appendicitis, shown below.
Figure 1. Graded compression ultrasound image of the right lower quadrant in longitudinal plane, shows an enlarged, non-compressible appendix (small arrows), which contains appendicoliths (large arrow). Note that the walls of the appendix are asymmetric, thicker posteriorly than anteriorly, and there is loss of the expected multilayered appearance. These findings may be associated with perforated appendicitis.
Figure 2. Ultrasound image obtained near Figure 1 in an oblique plane shows an echovoid fluid collection (A) representing a small abscess adjacent to a portion of the abnormal appendix (large arrows). As noted above, there is loss of the expected multilayered appearance of the appendix; only a single echogenic layer representing the submucosa (small arrows) is present in its tip.
The diagnosis of perforated appendicitis was made and the patient was treated with intravenous antibiotics for seven days. However fever and abdominal pain persisted, and a CT examination was performed, shown in the CT Findings in Appendicitis section.

Related teaching points can also be found in Primary Treatment

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Case 5

Perforated appendicitis with multiple appendicoliths and ileus.

1 year old girl presented to the emergency room with one day history of abdominal distention and fever. A plain abdominal radiograph was obtained which revealed several calcified appendicoliths in the right lower quadrant, as well as several dilated small bowel loops (refer to Plain Film Findings for additional details). An ultrasound was subsequently performed to evaluate for appendicitis, shown below.
Figure 1. Graded compression ultrasound of the right lower quadrant in transverse plane, reveals a calcified appendicolith (arrow) within the dilated appendix (electronic cursors). Note the well-defined posterior acoustic shadow (small arrows) in relation to the appendicolith.
Figure 2. Transverse ultrasound image of the mid- abdomen demonstrates multiple dilated, fluid-filled bowel loops (B) consistent with an ileus. Small bowel obstruction could produce similar findings.
At surgery, an inflamed, perforated appendix was removed

Return to Atypical Clinical Presentation (C)

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Case 6

Perforated appendicitis associated with shigellosis.

5 year old boy status post meningomyelocele repair and ventriculoperitoneal shunt placement presented to the emergency room with abdominal pain and diarrhea for one day. He was diagnosed and treated for shigellosis. However, abdominal pain persisted, and peritoneal signs developed. Ultrasound examination (shown below) was requested to exclude an abscess.
Figure 1. Longitudinal pelvic sonogram through the right lower quadrant shows a multiloculated fluid collection (FC). One of the loculations contains debris (D) of low-level echogenicity.
Figure 2. Transverse sonogram of the right lower quadrant shows free fluid (arrows) adjacent to bowel loops (B)
Figure 3. Transverse pelvic US image at a lower level than Figure 2 shows an appendicolith (large white arrow) within the dilated appendix (small black arrows). Free fluid (FF) is noted anteriorly. Note posterior acoustic shadow (S) related to the appendicolith.
Figure 4. Longitudinal US image of the mid-lower abdomen demonstrates the ventriculoperitoneal shunt tube (arrows) within free intraperitoneal fluid (FF).
At surgery a perforated inflamed appendix with pus in the peritoneal cavity was found. Patient underwent appendectomy and externalization of the ventriculoperitoneal shunt.

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Case 7

Appendicitis mimicking pelvic inflammatory disease.

18 year old nonpregnant sexually active female who presented to the emergency department with right lower quadrant pain. On pelvic examination, she had cervical motion tenderness. Pelvic ultrasound, shown below, was requested to evaluate for pelvic inflammatory disease. Graded-compression right lower quadrant ultrasound, not shown, did not identify the appendix .
Figure 1. Transverse endovaginal ultrasound image shows a complex cystic right adnexal mass (arrows) thought to represent a tubo-ovarian abscess. The right ovary was not seen. U = uterus.
Figure 2. Transverse endovaginal color Doppler ultrasound image shows increased vascularity to the solid components of the right adnexal mass (M). U = uterus. B = urinary bladder.
The patient was taken to surgery because of clinical deterioration. Perforated appendicitis with abscess extending into the right pelvis was identified.

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