Acute appendicitis in pregnancy (MRI)
28/40 pregnant. Right upper quadrant pain and fever. No abnormality detected on ultrasound.
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Intrauterine pregnancy confirmed but not interrogated in detail. The gravid uterus displaces the cecal pole and appendix out of the right iliac fossa, and the cecal pole is tilted posteriorly. An acute inflammatory mass is present posteriorly, with edema of the fat and free fluid throughout the right side of the abdomen. Appendicoliths are seen within the distended edematous appendix. The appearances are consistent with acute appendicitis.
Macroscopic: Appendix covered in fibrinopurulent exudate 60x14mm.
Microscopic: This appendix shows abundant transmural acute inflammation and extensive tissue necrosis. There is no evidence of dysplasia or malignancy.
Conclusion: Appendix - acute gangrenous appendicitis
The MRI findings are consistent with acute appendicitis with an inflammatory mass in the right side of the abdomen, and the findings were confirmed at surgery. Due to a change in the position of the appendix during pregnancy, localization of pain varies. The position as seen here also made an ultrasound diagnosis difficult to make. MRI, where available, is recommended as the second line modality by the ACR Appropriateness Criteria 1,2.
- 1. Page I. Wang, Suzanne T. Chong, Ania Z. Kielar, Aine M. Kelly, Ursula D. Knoepp, Michael B. Mazza, Mitchell M. Goodsitt. Imaging of Pregnant and Lactating Patients: Part 2, Evidence-Based Review and Recommendations. (2012) American Journal of Roentgenology. 198 (4): 785-92. doi:10.2214/AJR.11.8223 - Pubmed
- 2. Smith MP, Katz DS, Lalani T, Carucci LR, Cash BD, Kim DH, Piorkowski RJ, Small WC, Spottswood SE, Tulchinsky M, Yaghmai V, Yee J, Rosen MP. ACR Appropriateness Criteria® Right Lower Quadrant Pain--Suspected Appendicitis. (2015) Ultrasound quarterly. 31 (2): 85-91. doi:10.1097/RUQ.0000000000000118 - Pubmed