Presentation
Lower abdominal pain.
Patient Data
Subcecal appendix surrounded by free fluid. Proximal appendix not thickened. Appendiceal tip is thickened and measures 8 mm in diameter.
Liver, gallbladder, pancreas, and right kidney appear normal.
Distal part of subcecal appendix surrounded by minute amount of free fluid. Appendiceal tip shows hyperenhancement, contains a small appendicolith, is thickened, and measures 8 mm in diameter; rest of appendix not thickened and not surrounded by periappendiceal fat stranding.
Minimal amount of free fluid in the rectouterine pouch, possibly physiological.
Rest of examination appears normal.
Repeat ultrasound done several days later due to escalating pain, despite conservative treatment.
The appendiceal tip measures 8 mm in diameter (calipers shown were not used accurately for measurements) and contains an appendicolith - unchanged.
Partial regression of free fluid.
Case Discussion
Arrived at the pediatric ER complaining of lower abdominal pain since the previous morning. Right lower quadrant tenderness on palpation, without peritoneal irritation. Blood and urine tests were normal.
Referred for transabdominal gynecological ultrasound (not shown), which was interpreted as normal. Immediately thereafter, had an abdominal ultrasound, where the thickened edematous distal tip of the appendix was demonstrated. The skeptical referring surgeon insisted on a CT abdomen, which showed an appendix surrounded by fluid with a thickened, hyperenhancing tip. It was decided to treat conservatively with ceftriaxone and metronidazole. After several days during which the pain had localized to the right lower quadrant and signs of peritoneal irritation had developed despite antibiotics, she had a repeat ultrasound, which showed that the appendiceal tip still appeared inflamed. Taken to laparoscopic appendectomy.
Surgical report:
Surgical diagnosis: acute appendicitis.
Surgical finding(s): vermiform appendix with signs of inflammation at its tip; minimal amount of turbid fluid in the pelvis.
The histopathology report was laconic: acute appendicitis.
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