AppendicitisJoseph Junewick, MD FACR

05/09/2010

History3 year old with abdominal pain and fever.

DiagnosisAppendicitis

DiscussionThe basic physiology of appendicitis is ischemic necrosis related to luminal obstruction, usually byenteric contents (fecalith)or lymphoid hyperplasia. Because the mucosa is secretory, the appendixbecomes progressively dilated. Appendiceal dilation impedes lymphatic and venous drainage,leading to mural edema which eventually compromises arterial perfusion.The normal appendix measures <6mm although can be larger in patients with chronic constipation(e.g., cystic fibrosis). The central mucosal stripe is echogenic and uninterrupted; fluid is seen in thelumen in about 5% of patients. The mucosal stripe is surrounded by the hypoechoic muscularispropria.If the appendix is compressible, measures <6mmm and the tip is visualized appendicitis can beexcluded. Loss of the echogenic mucosal stripe or focal interruption may reflect early ulceration andnecrosis. Appendicoliths are associted with higher incidence of perforation. Loculatedperiappendiceal fluid is virtually diagnostic of perforated appendicitis. Mural hyperemia on colorDoppler indicates inflammation; lack of color flow with gray-scale findings of appendicitis indicatesgangrenous appendicitis (mural pneumatosis is also associated with gangrenous appendicitis).

FindingsUS-Dilated appendix with appendicolith (right side of longitudinal images) and mural hyperemia. Notethe inflamed hyperechoic mesentery surrounding the appendix.

ReferenceJunewick JJ. Decreasing radiation risks by increasing the use of ultrasound in pediatric imaging.Ultrasound Clin (2009); 4(3):273-284.

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