Appendicitis - target sign

Case contributed by Dr FC Lugo

Presentation

Crampy diffuse periumbilical pain.

Patient Data

Age: 30 years
Gender: Male
CT

CT scan shows an enhancing tubular structure with wall thickening suggesting a peri-appendiceal inflammatory stranding with no evidence of rupture.

Case Discussion

A 30-year-old male presents to the emergency department with a 2-day history of abdominal pain accompanied by anorexia, nausea and diarrhea. Pain started as a crampy diffuse periumbilical discomfort that later migrated as a constant right lower quadrant pain. Walking or bending forward aggravated the pain. Physical examination revealed an afebrile (97.7 °F; 36.5°C) patient with increased pain at palpation on right lower quadrant. A complete blood count showed, white blood cell of (12,000/microliters).

Emergency laparoscopic appendectomy was performed with findings of posterior perforation, not visible in CT.

The vermiform appendix is annexed to the cecum, varying in size and positions. The appendiceal artery, a branch of the ileocolic artery, provides its blood supply, lying within the mesoappendix.  This can be clearly seen in Netter's human anatomy atlas. 

It usually presents with an increase in white blood cell count over 10,000/microliters. Sometimes it might be accompanied by a "left shift" (ratio of immature to mature neutrophils). It is possible to see afebrile patients with no increase in white blood cell count.

At physical examination you might find a combination of positive signs, like McBurney's, Psoas, Rovsing's, or heel strike, also it might be possible for them not to present. This occurring secondary to peritoneal irritation, depending on severity and time of evolution.

After a 12 hour shift at the emergency department, you'll probably notice that 1 in 20 patients presents with symptoms of acute appendicitis.  

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Case information

rID: 29712
Published: 19th Jun 2014
Last edited: 9th Oct 2018
Inclusion in quiz mode: Included

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