Answer for BIR CoW 12 Aug 2018
Appendicular abcess
Findings
FINDINGS: e/o an well defined collection containing air pockets is noted in right iliac fossa e/o appendicolith noted within the collection e/o extensive fat stranding noted around the collection IMPRESSION: Featues suggestive of appendicular abcess.
Discussion
Appendicitis is inflammation of the vermiform appendix. CT is the most sensitive modality to detect appendicitis. Acute appendicitis is typically a disease of children and young adults with a peak incidence in the 2nd to 3rd decades of life General signs and symptoms include : fever localised pain and tenderness right lower quadrant pain over appendix (i.e. McBurney sign) pelvic pain, diarrhoea and tenesmus (pelvic appendix) flank pain (retrocaecal appendix) groin pain (appendix within an inguinal hernia - Amyand hernia) or a femoral hernia (De Garengeot hernia) leucocytosis nausea and vomiting atypical location: within the pelvis (30%), extraperitoneal (5%) The location of the tip of the appendix is much more variable, especially as the length of the appendix has an extensive range (2-20 cm) . The distribution of positions is described as : behind the caecum (ascending retrocaecal): 65% inferior to the caecum (subcaecal): 31% behind the caecum (transverse retrocaecal): 2% anterior to the ileum (ascending paracaecal preileal): 1% posterior to the ileum (ascending paracaecal retroileal): 0.5% USG FINDINGS Findings supportive of the diagnosis of appendicitis include : aperistaltic, non-compressible, dilated appendix (>6 mm outer diameter) appendicolith distinct appendiceal wall layers echogenic prominent pericaecal and periappendiceal fat periappendiceal hyperechoic structure: amorphous hyperechoic structure (usually >10 mm) seen surrounding a non-compressible appendix with a diameter >6 mm periappendiceal fluid collection target appearance (axial section) periappendiceal reactive nodal prominence/enlargement CT findings include : dilated appendix with distended lumen ( >6 mm diameter) thickened and enhancing wall thickening of the caecal apex (up to 80%): caecal bar sign, arrowhead sign peri-appendiceal inflammation, including stranding of the adjacent fat and thickening of the lateroconal fascia or mesoappendix extraluminal fluid inflammatory phlegmon abscess formation Appendicolith may also be identified periappendiceal reactive nodal prominence/enlargement Complications: perforation: in up to 13-30% of cases abscess formation: appendiceal abscess generalised peritonitis pylephlebitis: infective thrombophlebitis of the portal circulation complicating hepatic abscess Appendicular abscess is considered the most common complication of acute appendicitis, in particular after a perforated appendix. Radiographic features Appendicular abscesses can arise either in the peritoneal cavity or the retroperitoneal space. Ultrasound Ultrasound is the first investigation advised to evaluate a suspected appendicular pathology. Findings of an appendicular abscess include: fluid collection (hypoechoic) in the appendicular region which may be well circumscribed and rounded or ill-defined and irregular in appearance appendix may be visualised within the mass CT Fluid collection is seen in the appendicular region with or without air within. Many times an appendicolith may be visualized. Treatment and prognosis Previously it was believed that early surgical intervention increases the mortality in patients with appendicular abscess and hence the well known Ochsner Sherren regime was followed. But with better antibiotics and expertise of surgeons and anaesthesiologists, now early diagnostic laparoscopy followed by drainage of the abscess is preferred. If the abscess is large (> 4 cm), percutaneous drainage followed by delayed appendectomy is considered the preferred treatment .
Findings
FINDINGS: e/o an well defined collection containing air pockets is noted in right iliac fossa e/o appendicolith noted within the collection e/o extensive fat stranding noted around the collection IMPRESSION: Featues suggestive of appendicular abcess.
Discussion
Appendicitis is inflammation of the vermiform appendix. CT is the most sensitive modality to detect appendicitis. Acute appendicitis is typically a disease of children and young adults with a peak incidence in the 2nd to 3rd decades of life General signs and symptoms include : fever localised pain and tenderness right lower quadrant pain over appendix (i.e. McBurney sign) pelvic pain, diarrhoea and tenesmus (pelvic appendix) flank pain (retrocaecal appendix) groin pain (appendix within an inguinal hernia - Amyand hernia) or a femoral hernia (De Garengeot hernia) leucocytosis nausea and vomiting atypical location: within the pelvis (30%), extraperitoneal (5%) The location of the tip of the appendix is much more variable, especially as the length of the appendix has an extensive range (2-20 cm) . The distribution of positions is described as : behind the caecum (ascending retrocaecal): 65% inferior to the caecum (subcaecal): 31% behind the caecum (transverse retrocaecal): 2% anterior to the ileum (ascending paracaecal preileal): 1% posterior to the ileum (ascending paracaecal retroileal): 0.5% USG FINDINGS Findings supportive of the diagnosis of appendicitis include : aperistaltic, non-compressible, dilated appendix (>6 mm outer diameter) appendicolith distinct appendiceal wall layers echogenic prominent pericaecal and periappendiceal fat periappendiceal hyperechoic structure: amorphous hyperechoic structure (usually >10 mm) seen surrounding a non-compressible appendix with a diameter >6 mm periappendiceal fluid collection target appearance (axial section) periappendiceal reactive nodal prominence/enlargement CT findings include : dilated appendix with distended lumen ( >6 mm diameter) thickened and enhancing wall thickening of the caecal apex (up to 80%): caecal bar sign, arrowhead sign peri-appendiceal inflammation, including stranding of the adjacent fat and thickening of the lateroconal fascia or mesoappendix extraluminal fluid inflammatory phlegmon abscess formation Appendicolith may also be identified periappendiceal reactive nodal prominence/enlargement Complications: perforation: in up to 13-30% of cases abscess formation: appendiceal abscess generalised peritonitis pylephlebitis: infective thrombophlebitis of the portal circulation complicating hepatic abscess Appendicular abscess is considered the most common complication of acute appendicitis, in particular after a perforated appendix. Radiographic features Appendicular abscesses can arise either in the peritoneal cavity or the retroperitoneal space. Ultrasound Ultrasound is the first investigation advised to evaluate a suspected appendicular pathology. Findings of an appendicular abscess include: fluid collection (hypoechoic) in the appendicular region which may be well circumscribed and rounded or ill-defined and irregular in appearance appendix may be visualised within the mass CT Fluid collection is seen in the appendicular region with or without air within. Many times an appendicolith may be visualized. Treatment and prognosis Previously it was believed that early surgical intervention increases the mortality in patients with appendicular abscess and hence the well known Ochsner Sherren regime was followed. But with better antibiotics and expertise of surgeons and anaesthesiologists, now early diagnostic laparoscopy followed by drainage of the abscess is preferred. If the abscess is large (> 4 cm), percutaneous drainage followed by delayed appendectomy is considered the preferred treatment .
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!