Presentation
Acute right iliac fosssa pain and fever.
Patient Data
In the non-contrast study, there is an obstructing appendicolith, mural thickening of the appendix and terminal ileum, extensive surrounding fat plane smudging, and enlarged reactive lymph nodes. Small gas locules are located within the appendix and interloop fluid.
On contrast-enhanced images, there is mural thickening and enhancement of the appendix with a small mural perforation in the middle segment. Surrounding extensive fat plane smudging, peritoneal thickening and blurring are associated with mild ascites and are compatible with peritonitis. Reactive mural thickening and enhancement of the terminal ileal loops and the sigmoid colon. Proximal dilatation of the jejunal and ileal small bowel loops with the transition point in the terminal ileum with a faeces sign.
Findings indicate acute complicated appendicitis with perforation, peritonitis and ileus.
Case Discussion
The case illustrates the typical clinical presentation of perforated appendicitis with acute right iliac fossa pain, fever, and leucocytosis.
Classic radiographic features include an obstructing appendicolith with distension of the appendiceal lumen by secreted mucus, focal mural perforation with intraperitoneal spillage of its purulent content, peritonitis in the form of peritoneal thickening, fat plane smudging and mild ascites. There is an inflammatory mural thickening of the terminal ileum sigmoid colon and small bowel ileus.
Small gas locules in the appendix and collection are due to necrosis and bacterial overgrowth.
A normal appendix is thin-walled, sharply marginated by normal fat and can contain both gas and fluid. When the appendix is obstructed any intraluminal gas is replaced by secreted mucus and the lumen distends. Distension causes ischaemia and disrupts the mucosal barrier. The reappearance of gas indicates necrosis and bacterial overgrowth and can be seen in the lumen, in the wall and in the periappendiceal fat and fluid.
Case co-author: Dr Fat'h-Allah Awad. MD of radiodiagnosis
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