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Acuteappendicitisinadults:Diagnosticevaluation

OfficialreprintfromUpToDate
www.uptodate.com2015UpToDate

Acuteappendicitisinadults:Diagnosticevaluation
Author
RonaldFMartin,MD

SectionEditor
MartinWeiser,MD

DeputyEditor
WenliangChen,MD,PhD

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Oct2015.|Thistopiclastupdated:Jul24,2014.
INTRODUCTIONThediagnosisofacuteappendicitisistypicallybaseduponthefindingsfromthemedical
historyandclinicalexaminationandissupportedbythelaboratoryand/orimagingfindings.
Thistopicwillreviewthediagnosticstudies,includingradiographicstudiesandlaboratoryteststhatcanassistin
establishingthediagnosisofacuteappendicitisintheadult.Theclinicalmanifestationsofacuteappendicitisand
theoperativeandnonoperativemanagementarereviewedasseparatetopics.(See"Acuteappendicitisinadults:
Clinicalmanifestationsanddifferentialdiagnosis"and"Managementofacuteappendicitisinadults".)
DIAGNOSISThediagnosisofacuteappendicitisisgenerallymadefromthehistoryandclinicalexamination
thediagnosisissupportedbythelaboratoryand/orimagingfindings.Thepatientpresentingwithacuteabdominal
painshouldundergoathoroughphysicalexamination,includingadigitalrectalexamination.Womenshould
undergoapelvicexamination.(See"Historyandphysicalexaminationinadultswithabdominalpain".)
Anexperiencedexaminercanmakethecorrectdiagnosisofappendicitiswithoutimaging[1].Severalstudieshave
foundthediagnosticaccuracyofclinicalevaluationalonetobe75to90percent[25].Thediagnosticaccuracyof
theclinicalexaminationmaydependontheexperienceoftheexaminingclinician[611].Patientsinwhom
appendicitisisconsideredtobeextremelylikelyafterassessmentbyanexperiencedclinicianshouldproceed
directlytoappendectomywithoutfurtherradiologictesting.(See"Managementofacuteappendicitisinadults".)
Thediagnosisofacuteappendicitiscanbedifficultandadelaycanresultinperforationratesashighas80
percent[12,13].However,aretrospectivereviewof9048adultswithacuteappendicitisfoundthatthemeantime
frompresentationtooperation(8.6hours)wasnotassociatedwithriskofperforation[14].Factorsassociatedwith
increasedriskofperforationincludedmalegender(RR1.24,95%CI1.081.43),increasingage(RR1.04,95%CI
1.081.43),threeormorecomorbidillnesses(RR2.8,95%CI1.363.49),andlackofmedicalinsurancecoverage
(RR1.43,95%CI1.241.66).
Thechallengingclinicalsettingsinclude[15]:
Childrenlessthan3yearsofage(see"Acuteappendicitisinchildren:Clinicalmanifestationsanddiagnosis")
Adultsolderthanage60years(see"Managementofacuteappendicitisinadults",sectionon'Elderly
patients')
Womeninthesecondandthirdtrimestersofpregnancy,duetothedisplacementoftheappendixbythe
uterusandtheresultingchangesinthephysicalexamination(see"Acuteappendicitisinpregnancy")
Nosinglefeatureorcombinationoffeaturesisahighlyaccuratepredictorofacuteappendicitis,althoughprediction
rulesbaseduponcombinationsoffeaturesmayhavesomeclinicalutility[2,1621].
DiagnosticscoringsystemsSeveralscoringsystemshavebeenproposedtostandardizethecorrelationof
clinicalandlaboratoryvariables.
TheAlvaradoscoreisthemostwidelyuseddiagnosticaidforthediagnosisofappendicitisandhasbeenmodified
slightlysinceitwasintroduced[22,23].However,clinicaljudgmentremainsparamount.Forexample,alow
modifiedAlvaradoscore(<4)islesssensitivethanclinicaljudgement.Inaprospectivestudyof261adultpatients
withclinicallysuspiciousappendicitis,inwhom53patients(20percent)hadafinaldiagnosisofappendicitis,the
lowmodifiedAlvaradoscorewaslesssensitivecomparedwithunstructuredclinicaljudgement(72versus93
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percentsensitivity)[24].Aretrospectivereviewof74patientswithacuteappendicitisfoundthattheAlvarado
scorewaslesssensitiveandspecificthanCTimaging[25].
ThemodifiedAlvaradoscaleassignsascoretoeachofthefollowingdiagnosticcriteria:

Migratoryrightiliacfossapain(1point)
Anorexia(1point)
Nausea/vomiting(1point)
Tendernessintherightiliacfossa(2points)
Reboundtendernessintherightiliacfossa(1point)
Fever>37.5C(1point)
Leukocytosis(2points)

AlowAlvaradoscore(<5)hasmorediagnosticutilitytoruleoutappendicitisthanahighscore(7)doestorule
inthediagnosis.Inasystematicreviewof42retrospectiveandprospectivestudiesthatincludedover8300
patientswithsuspectedacuteappendicitisand/orrightiliacfossapain,overall99percentofpatientswithacute
appendicitishadascoreof5[26].However,ahighscore(7)alonehadpoordiagnosticpredictiveutilityasthe
overallsensitivitywas82percentandthespecificitywas81percent.TheAlvaradoscorewasmostaccuratein
menbutoverpredictedtheprobabilityofacuteappendicitisinwomeninallriskgroups.
Amanagementguidebasedupontotalpointsincludes:
Apatientwithascoreof0to3couldbeconsideredtohavealowriskofappendicitisandwouldbe
dischargedwithadvicetoreturniftherewasnoimprovementinsymptoms,subjecttosocialcircumstances.
Apatientwithascoreof4to6wouldbeadmittedforobservationandreexamination.Ifthescoreremains
thesameafter12hours,operativeinterventionisrecommended.
Amalepatientwithascoreof7to9wouldproceedtoappendectomy.
Afemalepatientwhoisnotpregnantwithascoreof7to9wouldundergodiagnosticlaparoscopy,then
appendectomyifindicatedbytheintraoperativefindings.Thesurgicalmanagementofappendicitisduring
pregnancyisdiscussedseparately.(See"Acuteappendicitisinpregnancy".)
Becauseofthechallengesofdiagnosingacuteappendicitisinwomen,someauthorshaveadvocateddiagnostic
laparoscopytominimizethehighfalsenegativerateinwomenregardlessofscore[23],whileothershave
suggestedusingCTscanstohelpwiththediagnosisofpatientswithanequivocalclinicalpresentationanda
scorebetween4to6[27].(See"Acuteappendicitisinadults:Clinicalmanifestationsanddifferentialdiagnosis".)
Severalotherscoringsystemshavebeendescribedaswell,butnonearetypicallyincommonuse[2830].A
systematicreviewofseveralpublishedscoringsystemsshowedadiagnosticsensitivityof53to99percentand
specificityof30to99percent[31].Asageneralrule,theadditionofthesedecisionaidstoclinicaljudgmenthas
thepotentialtoimprovespecificityandleadtolowerfalsepositiveratesindiagnosisofacuteappendicitis,but
decisionaidscannotdefinitivelydetermineorexcludethepossibilityofappendicitis[31].
DIAGNOSTICEVALUATION
ImagingImagingmodalitiessuchascomputedtomography(CT)andultrasonography(US)areincreasingly
usedtosupporttheclinicaldiagnosisofacuteappendicitis.Althoughsomestudiessuggestthattheincreaseduse
ofimaginghasdecreasedthenontherapeuticappendectomyrate(NAR)foracuteappendicitis[32,33],many
surgeonswillandshouldproceedwithsurgicalexploration,intheabsenceofimaging,ifthereisstrongclinical
supportforappendicitis.(See"Acuteappendicitisinadults:Clinicalmanifestationsanddifferentialdiagnosis",
sectionon'Clinicalmanifestations'.)
Baseduponprospectivetrialsandretrospectivedata,imagingstudiesdonotimprovetheoveralldiagnostic
accuracyforacuteappendicitis(image1andimage2)thediagnosticaccuracyofanexperiencedsurgeonis
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comparabletoCTscanimagingintheassessmentofpatientswithanequivocalpresentationofacuteappendicitis
[2,4,5,7].However,inaretrospectivereview,theCTscanchangedthetreatmentplanin58percentofpatients
[34].Differencesinstudiesmay,inpart,beduetotheexperienceofthesurgeonsandthepopulationsbeing
evaluated.Aprospectivestudyof2763patientsfoundthatthesensitivity,specificity,positivepredictivevalue,
andnegativepredictivevalueofpreoperativeevaluationsincluded[5]:
Ultrasonography
99.1,91.7,96.5,and97.7percent,respectively
Computedtomography
96.4,95.4,95.6,and96.3percent,respectively
Clinicalexamination
99.0,76.1,88.1,and97.6percent,respectively
Diagnosticimagingisunnecessarywhentheclinicaldiagnosisofacuteappendicitisisnearlycertainforeither
presenceorabsenceofappendicitis.Diagnosticimagingshouldbeperformedandismostlikelytoaltertreatment
whenthediagnosisofappendicitisisclinicallysuspectedbutunclear.Diagnosticimagingmaybeusefulin
children,elderadults,orwomenofchildbearingagewithanunclearpresentation.Similarly,patientswith
comorbiditiessuchasdiabetes,obesity,andimmunocompromisemayhaveahigheroccurrenceofatypical
presentationofacuteappendicitis.Thesepopulationsaremorelikelytopresentwithunclearsymptomssuchas
vagueabdominalpain.(See"Acuteappendicitisinchildren:Diagnosticimaging"and"Managementofacute
appendicitisinadults",sectionon'Specialconsiderations'and"Acuteappendicitisinpregnancy",sectionon
'Diagnosis'.)
ComputedtomographyBaseduponretrospectivereviews,adultwomenaremorethantwiceaslikelyas
mentohaveanontherapeuticappendectomyforacuteappendicitis[33,3538],and,therefore,womenmaybenefit
fromapreoperativeCTscanifthediagnosisisuncertain(image3andimage4).Aretrospectivereviewof1425
consecutivepatientsundergoinganappendectomyfoundthatadultwomenevaluatedwithapreoperativeCTscan
hadasignificantlylowernontherapeuticappendectomyrate(NAR)comparedwithadultwomenwithouta
preoperativediagnosticCTscan(21versus8percent)[33].TherewasnoreductioninNARformenorchildren.
PreoperativeCTprotocolsforimaginginclude:
StandardabdominalpelvicCTwithIVandoralcontrast
FocusedappendicealCTwithrectalcontrast
NoncontrastCT
Inmostclinicalsettings,ifthereissufficientdiagnosticconcernanduncertaintytowarrantaCTscantodiagnose
appendicitis,afullabdominalpelvicCTwithIVandoralcontrastshouldbeperformedoradecisionshouldbe
madetoproceedtotheoperatingroomforabdominalexplorationbylaparotomyorlaparoscopy.
StandardCTscanwithcontrastAcommonlyusedprotocolinvolvesastandardabdominalandpelvic
CTscan(16MDCTorhigher)withintravenousandoralcontrast.(See"Principlesofcomputedtomographyofthe
chest".)
AnumberoffindingssuggestacuteappendicitisonstandardabdominalCTscanning[21,39,40]:

Enlargedappendicealdiameter>6mmwithanoccludedlumen
Appendicealwallthickening(>2mm)
Periappendicealfatstranding
Appendicealwallenhancement
Appendicolith(seeninapproximately25percentofpatients)

ThesensitivityandspecificityofCTwithIVandoralcontrastforacuteappendicitisisintherangeof91to98and
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75to93percent,respectively[2,4,19,34,4143].Airintheappendixoracontrastfilledlumeninanormalappearing
appendixvirtuallyexcludesthediagnosis.However,anonvisualizedappendixdoesnotruleoutappendicitis.This
isparticularlyimportanttorememberinpatientswhohavehadsymptomsforashortduration,sinceonlyminimal
inflammatorychangesmaybepresentintherightlowerquadrant.
AnadvantageofacompleteabdominalCTscanisthatitpermitsvisualizationoftheentireabdomen.An
alternativediagnosisisfoundinupto15percentofpatients[34].Furthermore,aCTscancanassistinthe
treatmentplanforpatientswithapalpableabdominalmass,suchasthoseinwhomanappendicealphlegmonor
abscessmayhavedeveloped.Thesefeaturesaremorelikelyinpatientswhopresentafterhavingprolonged
symptoms(fourtofivedays).(See"Managementofacuteappendicitisinadults".)
AdrawbackofthestandardCTprotocolisthatittakesuptotwohourstoadministeroralcontrast.Inaddition,a
CTscaninvolvesradiationexposureandintravenouscontrast,withthepotentialforcontrastinducedrenal
nephropathy.Costandavailabilityarealsoconsiderations,particularlyinresourcepoorsettings.
AppendicealCTAfocusedappendicealCTscancanbeperformedwithrectalcontrastaloneandthin
cutsthroughtherightiliacfossa.Becausefulloralcontrastisnotgiven,thescancanbeperformedwithin15
minutes.Rectalcontrastprovidesgoodvisualizationofthepericecalregionwithouttheneedtowaitfororal
contrasttoreachtherightlowerquadrant,whichmaybeanunpleasantprocedureforthepatient.
InareportusingalimitedappendicealCTscanwithrectalcontrast,thesensitivityofthemostcommonfindings
foracuteappendicitiswereasfollows[21]:
Rightlowerabdominalquadrantfatstranding(100percentsensitivity)
Focalcecalthickening(69percentspecificity)
Adenopathy(63percentsensitivity)
OnestudyreportedthatafocalappendicealCThad98percentaccuracyandsensitivitywithrectalcontrastalong
alimitedarea(15cm)ofthepelviscentered3cmsuperiortothececaltip[17,44].
Therelevanceoffocalappendicealimagingisquestionableoutsideoflargemedicalcenters,asthistechnique
requirespersonneltoadministerrectalcontrastandaradiologistonsitefortheverificationofpositioning.In
addition,anappendicealCTscanonlyevaluatestheappendix,andtheimagesmaybeunrevealinginthe
presenceofotherabdominalpathology.
UnenhancedCTTheadministrationofcontrastforimagingaddstime,expense,andriskofanallergic
reaction.Anumberofstudieshavesuggestedthatadequateimagingcanbeobtainedwithoutcontrast.Invarious
reports,unenhancedCThadasensitivityof88to96percent,specificityof91to98percent,anddiagnostic
accuracyof94to97percentforappendicitis,withtheaddedadvantageoftotalexamtimeof5to15minutes
[7,45,46].
Testcharacteristicsmaydepend,atleastinpart,uponthepatient'sbodyhabitus[2].Someradiologistsmaintain
thatiftheBMIexceeds25thattheCTislessaccurateandthereforeoralcontrastisnecessary.
AnimportantlimitationofunenhancedCTisthediminishedabilitytodiagnoseotherabdominalpathology,
potentiallydiminishingtheroleoftheexaminationinpatientsinwhomthereisdiagnosticuncertainty(eg,elder
patients,women,atypicalpresentation).
UnenhancedCTmaybeofsomevalueinpatientswhohaverenalfailureorclinicalinstability.However,formost
patientswherethereissufficientdiagnosticuncertaintytowarrantaCTscanforappendicitis,afullabdominal
pelvicCTwithIVandoralcontrastshouldbeperformedoradecisionshouldbemadetoproceedtotheoperating
roomforabdominalexploration.
UltrasonographyUltrasound(US)isreliabletoconfirmtheclinicaldiagnosisofacuteappendicitis,butis
notreliabletoexcludethediagnosis(image5andimage6)[47].Accuracyisdiminishedinobesepatients.
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Atleasteightsonographicfindingssuggestiveofinternalinflammatorychangesoftheappendixhavebeen
described[4850].Themostaccurateultrasoundfindingforacuteappendicitisisanappendicealdiameterof>6
mmwithasensitivity,specificity,negativepredictivevalue,andpositivepredictivevalueof98percent[49,50].In
variousreports,thesensitivityandspecificitybyUSinthediagnosisofappendicitisrangedfrom35to98percent
and71to98percent,respectively[2,7,33,36].
AdvantagesofUScomparedwithCTimaginginclude:
Resultsmaybeobtainedmoreefficiently(institutionandpractitionerdependent)
Noradiationexposure
Nouseofintravenousorintestinalcontrastagents
DisadvantagesofUScomparedwithCTimaginginclude:

Lessdiagnosticaccuracy
Lesslikelytorevealanaccuratealternativediagnosis
Accuracyisoperatordependent
Technicalchallenges:Patientswithalargebodyhabitusand/oralargeamountofoverlyingbowelgas

ImagingcostsTheuseofpreoperativeimagingstudiesinthediagnosisofacuteappendicitishasincreased
withtime,from32percent(1995through1999)to95percent(2001through2008),atonerepresentativeacademic
institution[33].TheincreaseintheuseofCTscanningforthediagnosisofappendicitishasbeenlargelyjustified
bytheassumptionthatitdecreasestheratesofperforatedappendicitisaswellasnontherapeuticappendectomies
[51,52].Intwostudiesthatperformedcostanalysis,oneshowedthatthecostofanontherapeuticappendectomy
was16timesmoreexpensivethanafocusedappendicealCTscan,whileanotherreportedthatanappendectomy
was22timesmoreexpensivethannonenhancedCTscanning,implyingcostsavingsifareductionin
nontherapeuticappendectomyratescouldbeachieved[46,53].However,inoneretrospectivereview,most
patientsundergoinganontherapeuticappendectomyhadapreoperativeCTscan,andmorethan50percentof
thosepatientshadCTinterpretationsthatwerepositivefor,orcouldnotexclude,acuteappendicitis[33].
Severalstudieshavefailedtodemonstrateasignificantreductionintheoverallinstitutionalratesfor
nontherapeuticappendectomiesdespitetheincreaseduseofCTscanovertime[19,34,35,37,41,5456].Resultsof
studiesthatincludedanalysisofperforatedappendicitisaremixed.Onestudyshowedanobservedrateof
appendicealperforationof9percentinpatientswhounderwentroutineCTimagingcomparedwith25percentin
patientsinwhomCTscanningwasnotused[37].Otherstudieshavedemonstratedafairlyconstantrateof
perforatedappendixovertimedespitetheincreaseduseofCTscan[33,35,56].
CostanalysisforstudiessuchastheseiscomplicatedbythevalueofCTscanninginpatientsinwhom
therapeuticappendectomywasperformedasaresult,thecostsavingsdependuponanabsoluteratereduction
fornontherapeuticappendectomies[34,57].Additionally,costcalculationsdependuponlocalinstitutionalvariables
andsurgeonvariablesselectedinstitutionalobservationsmaynotbeapplicabletoallpractices.
LaboratorytestsLaboratorytestsserveasupportiveroleinthediagnosisofappendicitis.Nosinglelaboratory
testorcombinationoftestsisanabsolutemarkerforappendicitis[49,54].
Acompletebloodcount(CBC)withadifferentialshouldbeobtained,butcannotbeusedtoconfirmorexcludethe
diagnosisofappendicitis.Amildleukocytosisandaleftshift(increaseintotalwhitebloodcellcount,bands
[immatureneutrophils],andneutrophils)canbepresentinacuteappendicitisaswellasotheracuteetiologiesof
abdominalpain.
Apregnancytestshouldbeperformedforallwomenofchildbearingage.
Althoughmildelevationsinserumbilirubin(totalbilirubin>1.0mg/dL)havebeennotedtobeamarkerfor
appendicealperforationwithasensitivityof70percentandaspecificityof86percent[58],thetestisnot
discriminatoryandgenerallynothelpfulintheevaluationofpatientssuspectedofacuteappendicitis.
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Exploratorylaparotomy/laparoscopyTheacceptablenontherapeuticappendectomyrate(NAR)varies
dependingupontheageandsexofthepatient.Forexample,inyounghealthymaleswithrightlowerquadrant
pain,thenegativeappendectomyrate(NAR)shouldbelessthan10percent,whilearatethatapproaches20
percentisreasonableinyoungwomeninwhomotherpelvicprocessescanmakeaccuratediagnosismoredifficult
(eg,pelvicinflammatorydiseases,tuboovarianabscess)[45,59].
NosignificantdifferenceinNARwasnotedincomparinglaparoscopicandopenappendectomy[33].AlowNAR
hasbeenachievedinsomecentersthatusecloseinhospitalobservation[60].
SUMMARY
Theconstellationoffindingsfromhistory,physicalexamination,andlaboratorystudieswillusuallyleadan
experiencedexaminertothecorrectdiagnosisofappendicitiswithoutdiagnosticimaging(see'Diagnosis'
above).Aclinicaldiagnosiscanbemorechallenginginwomen,whomaybenefitfromtheadditionof
radiologicimagingwhenthediagnosisisunclear.
Thepatientpresentingwithacuteabdominalpainshouldundergoathoroughphysicalexamination,including
adigitalrectalexamination.Womenshouldundergoapelvicexamination.(See'Diagnosis'aboveand
"Historyandphysicalexaminationinadultswithabdominalpain".)
Baseduponprospectivetrialsandretrospectivedata,imagingstudiesdonotimprovetheoveralldiagnostic
accuracyforacuteappendicitis(image1andimage2)thediagnosticaccuracyofanexperiencedsurgeonis
comparabletoCTscanimagingintheassessmentofpatientswithanequivocalpresentationofacute
appendicitis.(See'Imaging'above.)
Diagnosticimagingisadvisedwhenthediagnosisofappendicitisissuspectedbutunclear(eg,elderly
patients,patientswithcomorbidillnesses,womenofchildbearingage).Inthisclinicalsetting,weperforma
standardabdominalCTscanwithintravenousandoralcontrast.(See'StandardCTscanwithcontrast'
above.)
Ultrasound(US)isreliabletoconfirmtheclinicaldiagnosisofacuteappendicitis,butisnotreliableto
excludethediagnosis(image5andimage6).(See'Ultrasonography'above.)
Laboratorytestsserveasupportiveroleinthediagnosisofappendicitis.Nosinglelaboratorytestor
combinationoftestsisanabsolutemarkerforappendicitis.However,acompletebloodcountanda
pregnancytestinpremenopausalwomenshouldbeobtainedinpatientswithacuteabdominalpain,but
cannotconfirmorexcludeadiagnosisofacuteappendicitis.(See'Laboratorytests'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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59. ColsonM,SkinnerKA,DunningtonG.Highnegativeappendectomyratesarenolongeracceptable.AmJ
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GRAPHICS
CTscanequivocalappendicitis

Thepatientisa56yearoldmalewhopresentswithrightlowerquadrantpain.TheCTscan
ofthelowerabdomenintheaxialplane(A)andthemagnifiedviewoftheappendix(B)
showanormalsizedappendixwithsurroundinginduration(redarrow).Theperiappendiceal
indurationraisesthepossibilityofappendicitis.Theassociatedthickeningoftheposterior
peritoneum(orangearrow)suggestsanacuteprocessintherightlowerquadrant.However,
theepicenterofinduration(yellowarrowinAandB)intheregionofthetipoftheliver(L)
andascendingcolon(C)suggeststhattheprocesslikelyoriginatesinthatregion.Thusthe
processaroundtheappendixissecondaryandnotprimarytotheappendix.
Graphic83554Version1.0

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Ultrasoundequivocalappendicitis

Thegrayscaleultrasoundoftheappendixisprojectedinthelongitudinal(A)andtransverse
planes(B).Theappearanceoftheappendixisnearnormalexceptforadiameterthat
measures7.6mminthelongaxis,andadiameterthatmeasuresbetween7and9mmin
thetransverseplane.Sincethisdiametershouldbe6mmorless,thediagnosisof
appendicitisisentertained.Thereisnoloculatedfluidaroundtheappendixandnofreefluid
presentintheperitonealcavity.Theechogeniclineofthemucosaandsubmucosaisintact
andthelumenisdistendedwithcomplexmaterial(arrow).Thefindingsoftheenlarged
diameterwithnootherspecificpathognomonicfeaturesmakethediagnosisofacute
appendicitisequivocal.
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CTscannormalappendix

CTscandepictsanormalappendix.Thefigureontheleftshowsanappendiceallumen
containingairandwallthicknessof3mm(yellowarrow).Thefigureontherightshowsthe
tipofthenormalappendix(greenarrow)thatmeasures6mmandnoassociatedinduration.
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CTscanacuteappendicitis

TheCTscanwasobtainedusingoralandintravenouscontrastfromapatientwhopresented
withrightlowerquadrantabdominalpain.Thesefiguresshowaninflammedappendixthat
measures21mmindiameterandcontainsanappendicolithandfluidthatislikelypurulent.
(A)Showsanappendicolithintheappendixusingawhitearrow.
(B)Showstheappendicolith,anoverlayoforangetoshowfluidinsidetheappendix,anda
yellowarrowindicatesfreefluid.
(C)Showstheenlargedappendixandfluidwithoutanoverlay.
(D)Showsacoloredoverlay:redcircledepictstheenhancingappendicealwallorange
depictstheintraappendicealfluidyellowdepictsthefreefluid.
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Normalappendixonultrasound

Ultrasoundimageofanormalappendix(redarrowandmarkers).The
appendixislocatedattheconfluenceofthetaeniacoli(whitearrows)
andisseeninrelationshiptothececum(COE).Fluidfilledsmall
bowel(DD)andiliacvessels(VI)arealsoindicated.
CourtesyofChristophFDietrich,MD.
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Dopplerultrasoundofappendicitis

Inthisdopplerultrasoundimageofappendicitis,theappendixappears
edematous(9x8mm)andhypervascular.Thelayersofthewallare
stilldetectable.Continuedinflammationmaybefollowedbylocalized
ischemia(whichmaybevisualizedbycolorDopplerimaging)and
necrosis.Sonographicfindingswereconfirmedatsurgery.
CourtesyofChristophFDietrich,MD.
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Disclosures
Disclosures:RonaldFMartin,MDNothingtodisclose.MartinWeiser,MDNothingtodisclose.WenliangChen,MD,PhDNothingto
disclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvettingthrougha
multilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthecontent.Appropriatelyreferenced
contentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy

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