As ultrasound involves no ionizing radiation and is a better modality for gynecologic conditions, it is recommended as the initial imaging modality in children, young women and during pregnancy. It has very high sensitivity and specificity for diagnosing appendicitis.

Graded compression technique described by Puylaert is the standard method for US evaluation of acute appendicitis. Slow, gentle maintained pressure at maximum point of pain and tenderness helps to demonstrate appendix easily. If patient is not allowing to compress, we can use Baldisserotto’s technique of changing patient's position to displace bowel loops. It is very important to localize cecum which helps as a guide in search for appendix.

In this case, both techniques were used as the patient was obese. Turning patient to left lateral position immediately demonstrated dilated appendix.

Dilatation of appendix more than 6mm, surrounding fluid and enlarged lymph nodes confirm the diagnosis of appendicitis. Patient also experiences severe probe tenderness on performing US.