Acute appendicitis

Case contributed by Dr Huy Sruy


An elderly man complains of right lower quadrant pain for 6 hours.

Patient Data

Age: 85 years
Gender: Male

Real time ultrasound reveals non compressibility of the appendix with a 9 mm of diameter and fat stranding surrounding the appendix. An appendicolith is noted.

Case Discussion

Real-time ultrasound signs of acute appendicitis

  1. Direct signs
  • Non-compressibility of the appendix (perforation: appendix might be compressible)
  • Diameter of the appendix > 6 mm
  • Single wall thickness ≥ 3 mm
  • Target sign: hypoechoic (fluid-filled lumen), hyperechoic (mucosa/submucosa), hypoechoic (muscularis layer)
  • Appendicolith: hyperechoic with posterior shadowing
  • Color Doppler and contrast-enhanced US: hypervascularity in early stages of AA, hypo- to avascularity in abscess and necrosis

2.      Indirect signs

  • Free fluid surrounding appendix
  • Local abscess formation
  • Increased echogenicity of local mesenteric fat
  • Enlarged local mesenteric lymph nodes
  • Thickening of the peritoneum
  • Signs of secondary small bowel obstruction


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