{"id":26403,"date":"2022-12-09T21:55:56","date_gmt":"2022-12-10T02:55:56","guid":{"rendered":"https:\/\/www.stepwards.com\/?page_id=26403"},"modified":"2025-03-21T21:11:43","modified_gmt":"2025-03-22T01:11:43","slug":"abdominal-imaging-call-prep-cases-acute-uncomplicated-appendicitis-ct","status":"publish","type":"page","link":"https:\/\/www.stepwards.com\/?page_id=26403","title":{"rendered":"Abdominal Imaging Call Prep Cases: Acute Uncomplicated Appendicitis (CT)"},"content":{"rendered":"<div id=\"toc_container\" class=\"no_bullets\"><p class=\"toc_title\">Page Contents<\/p><ul class=\"toc_list\"><li><a href=\"#OVERVIEW\"><span class=\"toc_number toc_depth_1\">1<\/span> OVERVIEW<\/a><\/li><li><a href=\"#WHAT_IS_IT_EXACTLY\"><span class=\"toc_number toc_depth_1\">2<\/span> WHAT IS IT EXACTLY?<\/a><\/li><li><a href=\"#WHY_IS_IT_AN_IMPORTANT_CALL_CASE\"><span class=\"toc_number toc_depth_1\">3<\/span> WHY IS IT AN IMPORTANT CALL CASE?<\/a><\/li><li><a href=\"#WHAT_CLINICAL_CONTEXT_HELPS_RAISE_SUSPICION_FOR_THIS_DIAGNOSIS\"><span class=\"toc_number toc_depth_1\">4<\/span> WHAT CLINICAL CONTEXT HELPS RAISE SUSPICION FOR THIS DIAGNOSIS?<\/a><\/li><li><a href=\"#WHAT_IS_THE_KEY_TO_MAKING_THIS_DIAGNOSIS_ON_CALL\"><span class=\"toc_number toc_depth_1\">5<\/span> WHAT IS THE KEY TO MAKING THIS DIAGNOSIS ON CALL?<\/a><\/li><li><a href=\"#WHAT_HAPPENS_NEXT_AFTER_THE_DIAGNOSIS_IS_MADE\"><span class=\"toc_number toc_depth_1\">6<\/span> WHAT HAPPENS NEXT AFTER THE DIAGNOSIS IS MADE?<\/a><\/li><li><a href=\"#CASE_ARCHIVE\"><span class=\"toc_number toc_depth_1\">7<\/span> CASE ARCHIVE\u00a0<\/a><\/li><\/ul><\/div>\n<h5><span id=\"OVERVIEW\"><span style=\"text-decoration: underline;\">OVERVIEW<\/span><\/span><\/h5>\n<p>This page is dedicated to covering a very important call case: acute uncomplicated appendicitis. This page will specifically cover this diagnosis in the setting of making the finding on abdomen\/pelvis CT imaging.<\/p>\n<figure id=\"attachment_26426\" aria-describedby=\"caption-attachment-26426\" style=\"width: 710px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-12-at-10.00.25-AM-scaled.jpg\"><img loading=\"lazy\" class=\" wp-image-26426\" src=\"http:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-12-at-10.00.25-AM-scaled.jpg\" alt=\"\" width=\"720\" height=\"334\" srcset=\"https:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-12-at-10.00.25-AM-scaled.jpg 2560w, https:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-12-at-10.00.25-AM-300x139.jpg 300w, https:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-12-at-10.00.25-AM-1024x475.jpg 1024w, https:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-12-at-10.00.25-AM-768x356.jpg 768w, https:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-12-at-10.00.25-AM-1536x712.jpg 1536w, https:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-12-at-10.00.25-AM-2048x949.jpg 2048w\" sizes=\"(max-width: 720px) 100vw, 720px\" \/><\/a><figcaption id=\"caption-attachment-26426\" class=\"wp-caption-text\">An axial (screen left) and coronal (screen right) image of a CT abdomen\/pelvis with contrast showing an inflamed appendix with appendicoliths. Marked adjacent inflammation. This patient will benefit from a quick trip to the operating room before any complications (such as perforation) develop.<\/figcaption><\/figure>\n<p>Many of the cases presented here will be CT scans of the abdomen\/pelvis with contrast however certain cases may present non-contrast imaging (which can have overlapping findings).<\/p>\n<h5><span id=\"WHAT_IS_IT_EXACTLY\"><span style=\"text-decoration: underline;\">WHAT IS IT EXACTLY?<\/span><\/span><\/h5>\n<p>Appendicitis refers to inflammation of the appendix. In many cases this is thought to be related to an underlying infectious process, however other inflammatory\/reactive processes can be possible as well.<\/p>\n<p>It is important to realize that appendicitis can have a few distinct subcategories with specific imaging characteristics (and with implications on treatment. This page will focus <span style=\"text-decoration: underline;\">specifically<\/span> on UNCOMPLICATED appendicitis, however there are separate pages for <a href=\"https:\/\/www.stepwards.com\/?page_id=26405\">perforated appendicitis<\/a> and <a href=\"https:\/\/www.stepwards.com\/?page_id=26404\">appendicitis with abscess<\/a> (both of which are common complications).<\/p>\n<h5><span id=\"WHY_IS_IT_AN_IMPORTANT_CALL_CASE\"><span style=\"text-decoration: underline;\">WHY IS IT AN IMPORTANT CALL CASE?<\/span><\/span><\/h5>\n<p>Appendicitis is typically regarded as a surgical urgency\/emergency as patients can get quite ill (and possibly septic) if it is left untreated too long. While the management of appendicitis has become slightly more nuanced over the years, it is not a self limited condition and requires intervention.<\/p>\n<p>Specifically in the case of acute uncomplicated appendicitis, timely diagnosis and intervention can prevent the development of complications (such as <a href=\"https:\/\/www.stepwards.com\/?page_id=26405\">perforation<\/a> and\/or <a href=\"https:\/\/www.stepwards.com\/?page_id=26404\">abscess<\/a>).<\/p>\n<h5><span id=\"WHAT_CLINICAL_CONTEXT_HELPS_RAISE_SUSPICION_FOR_THIS_DIAGNOSIS\"><span style=\"text-decoration: underline;\">WHAT CLINICAL CONTEXT HELPS RAISE SUSPICION FOR THIS DIAGNOSIS?<\/span><\/span><\/h5>\n<p>Patients who present with clinical signs and symptoms of infection (in the setting of abdominal pain) are commonly the demographic that may have appendicitis.\u00a0Couple clinical details to keep in mind:<\/p>\n<ul>\n<li><strong>Chief complaint:\u00a0<\/strong>abdominal pain (may be in the right lower quadrant however not always).<\/li>\n<li><strong>Relevant medical history:\u00a0<\/strong>the nature of the abdominal pain may be useful to understand (typically at some point patients will have lower quadrant abdominal pain but this may change location and become more generalized).<\/li>\n<li><b>Physical exam:\u00a0<\/b>some patients may have rebound tenderness\/peritonitis.<\/li>\n<li><strong>Unstable vitals:\u00a0<\/strong>while not a requirement, some patients may present with vital signs (tachycardia, hypotension) which may reflect a sepsis type physiology.<\/li>\n<li><strong>Elevated white count: <\/strong>given the inflammatory process most patients with appendicitis should have a white count (however exceptions may occur).<\/li>\n<\/ul>\n<h5><span id=\"WHAT_IS_THE_KEY_TO_MAKING_THIS_DIAGNOSIS_ON_CALL\"><span style=\"text-decoration: underline;\">WHAT IS THE KEY TO MAKING THIS DIAGNOSIS ON CALL?<\/span><\/span><\/h5>\n<p>There are a few imaging features to keep in mind when making this diagnosis. It is important to realize that this is an inflammatory condition, which is reflected in the types of imaging findings we would expect to see.\u00a0The below video playlist summarizes these findings and applies them to various cases from the associated case archive.<\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" title=\"YouTube video player\" src=\"https:\/\/www.youtube.com\/embed\/videoseries?list=PLd9O3REk4a33KJNC_B8NeWH3RFEHHjihx\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p><span style=\"text-decoration: underline;\"><strong>FIRST Find the Terminal Ileum\/Ileocecal valve:<\/strong><\/span><\/p>\n<p>While this may appear simple, it is important to make sure that you first identify the appendix. This is to make sure you are not confusing inflammation of another structure as appendicitis (such as the terminal ileum, which has different implications\/treatment strategies.<\/p>\n<p>The best way to do this is to first make sure you locate the terminal ileum and the ileocecal valve to understand where the small bowel connects to the cecum.<\/p>\n<figure id=\"attachment_26428\" aria-describedby=\"caption-attachment-26428\" style=\"width: 638px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-12-at-10.11.55-AM-scaled.jpg\"><img loading=\"lazy\" class=\" wp-image-26428\" src=\"http:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-12-at-10.11.55-AM-scaled.jpg\" alt=\"\" width=\"648\" height=\"293\" srcset=\"https:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-12-at-10.11.55-AM-scaled.jpg 2560w, https:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-12-at-10.11.55-AM-300x135.jpg 300w, https:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-12-at-10.11.55-AM-1024x462.jpg 1024w, https:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-12-at-10.11.55-AM-768x347.jpg 768w, https:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-12-at-10.11.55-AM-1536x693.jpg 1536w, https:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-12-at-10.11.55-AM-2048x924.jpg 2048w\" sizes=\"(max-width: 648px) 100vw, 648px\" \/><\/a><figcaption id=\"caption-attachment-26428\" class=\"wp-caption-text\">Coronal image showing the location of the ileocecal valve (red arrow) and axial showing the location of the terminal ileum (yellow arrow) which is just proximal to this valve.<\/figcaption><\/figure>\n<p>The ileocecal valve is typically fatty in composition and has a characteristic appearance. Make sure to find this landmark on every case if possible to understand where the ileum connects to the cecum and help locate the appendix.\u00a0<strong>Keep in mind the valve sometimes is not as obvious to see on axial slices, and that you can sometimes see it more easily on coronal\/sagittal reformats.\u00a0<\/strong><\/p>\n<p><span style=\"text-decoration: underline;\"><strong>SECOND Find the Appendix:<\/strong><\/span><\/p>\n<p>Once the terminal ileum\/ileocecal valve has been correctly identified, the next step is to identify the appendix. This will be a tubular structure that arises from the cecum (near the terminal ileum insertion) and is blind ending.<\/p>\n<figure id=\"attachment_26445\" aria-describedby=\"caption-attachment-26445\" style=\"width: 678px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-16-at-10.20.35-AM-scaled.jpg\"><img loading=\"lazy\" class=\" wp-image-26445\" src=\"http:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-16-at-10.20.35-AM-scaled.jpg\" alt=\"\" width=\"688\" height=\"313\" srcset=\"https:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-16-at-10.20.35-AM-scaled.jpg 2560w, https:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-16-at-10.20.35-AM-300x136.jpg 300w, https:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-16-at-10.20.35-AM-1024x465.jpg 1024w, https:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-16-at-10.20.35-AM-768x349.jpg 768w, https:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-16-at-10.20.35-AM-1536x698.jpg 1536w, https:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-16-at-10.20.35-AM-2048x930.jpg 2048w\" sizes=\"(max-width: 688px) 100vw, 688px\" \/><\/a><figcaption id=\"caption-attachment-26445\" class=\"wp-caption-text\">The appendix is shown here arising from the cecum (axial image on screen left, yellow arrow) and is blind ending (coronal image on screen right, red arrow).<\/figcaption><\/figure>\n<p>Keep in mind it may take a few scrolls to find the appendix as it can point in most any direction (i.e. retrocecal, up towards the liver, medially, etc). In same cases if its very hard to find&#8230;consider investigating if the patient has had an appendectomy!<\/p>\n<p><span style=\"text-decoration: underline;\"><strong>THIRD Characterize the Appendix:<\/strong><\/span><\/p>\n<p>Now that the appendix has been properly identified, it is time to characterize its features to see if there is suspicion for appendicitis.<\/p>\n<figure id=\"attachment_26446\" aria-describedby=\"caption-attachment-26446\" style=\"width: 736px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-16-at-10.44.08-AM-scaled.jpg\"><img loading=\"lazy\" class=\" wp-image-26446\" src=\"http:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-16-at-10.44.08-AM-scaled.jpg\" alt=\"\" width=\"746\" height=\"344\" srcset=\"https:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-16-at-10.44.08-AM-scaled.jpg 2560w, https:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-16-at-10.44.08-AM-300x138.jpg 300w, https:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-16-at-10.44.08-AM-1024x472.jpg 1024w, https:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-16-at-10.44.08-AM-768x354.jpg 768w, https:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-16-at-10.44.08-AM-1536x708.jpg 1536w, https:\/\/www.stepwards.com\/wp-content\/uploads\/2023\/02\/Screen-Shot-2023-02-16-at-10.44.08-AM-2048x944.jpg 2048w\" sizes=\"(max-width: 746px) 100vw, 746px\" \/><\/a><figcaption id=\"caption-attachment-26446\" class=\"wp-caption-text\">Common characteristics of acute appendicitis.<\/figcaption><\/figure>\n<p><span style=\"text-decoration: underline;\"><strong>Classic features of appendicitis are:<\/strong><\/span><\/p>\n<ul>\n<li><b>Periappendiceal inflammation:\u00a0<\/b>this may actually be the first finding that is noticed. Periappendiceal fat stranding is often present.<\/li>\n<li><b>Dilated appendix diameter:\u00a0<\/b>classically appendicitis is thought to result in a dilated appendix diameter of over 6 mm. A normal appendix may measure over 6 mm, however it&#8217;s important to always consider if it is possible the a patient has early appendicitis if the appendix is dilated.<\/li>\n<li><b>Hyperemic\/thickened wall:\u00a0<\/b>classically an appendix wall thickness of more than 3 mm raises suspicion for appendicitis (especially in the setting of a hyperenhancing wall).<\/li>\n<li><b>Presence of appendicoliths:\u00a0<\/b>these calcified deposits within the appendix are characteristic of appendicitis (they also help identify the appendix itself as they are &#8220;eye-catching&#8221;).<\/li>\n<\/ul>\n<p>Not every case may have every finding, but the above raise the suspicion for this diagnosis.<\/p>\n<p><span style=\"text-decoration: underline;\"><b style=\"text-decoration-line: underline;\">FINALLY Look for <\/b><b><u>Complications<\/u><\/b><b style=\"text-decoration-line: underline;\">:<\/b><\/span><\/p>\n<p>While this page only covers acute uncomplicated appendicitis, it is good to get into the habit of looking for complications as part of your search pattern. Refer to these pages on <a href=\"https:\/\/www.stepwards.com\/?page_id=26405\">perforated appendicitis<\/a> and <a href=\"https:\/\/www.stepwards.com\/?page_id=26404\">appendicitis with abscess<\/a> (both of which are common complications) to learn more.<\/p>\n<h5><span id=\"WHAT_HAPPENS_NEXT_AFTER_THE_DIAGNOSIS_IS_MADE\"><span style=\"text-decoration: underline;\">WHAT HAPPENS NEXT AFTER THE DIAGNOSIS IS MADE?<\/span><\/span><\/h5>\n<p>While treatment pathways ar evolving, typically in the case of acute appendicitis, the patient is taken to the operating room for an appendectomy. This diagnosis has a very clear surgical implication when it is invoked.<\/p>\n<h5><span id=\"CASE_ARCHIVE\"><span style=\"text-decoration: underline;\">CASE ARCHIVE\u00a0<\/span><\/span><\/h5>\n<p><strong>Use the following login information to access the case archives: USERNAME: user, PASSWORD: password.<\/strong><\/p>\n<p><a href=\"https:\/\/pacsrad.com:3333\/studyList?album=Call%20Prep%20Cases%3A%20Body%20-%20Acute%20Uncomplicated%20Appendicitis%20%28CT%29&amp;sortKey=name&amp;sortOrder=-1\">Click here to open up a case archive of acute uncomplicated appendicitis seen on CT.<\/a><\/p>\n<p>&nbsp;<\/p>\n<p>Page Updated: 02.15.23<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Page Contents1 OVERVIEW2 WHAT IS IT EXACTLY?3 WHY IS IT AN IMPORTANT CALL CASE?4 WHAT CLINICAL CONTEXT HELPS RAISE SUSPICION FOR THIS DIAGNOSIS?5 WHAT IS THE KEY TO MAKING THIS DIAGNOSIS ON CALL?6 WHAT HAPPENS NEXT AFTER THE DIAGNOSIS IS MADE?7 CASE ARCHIVE\u00a0 OVERVIEW This page is dedicated to covering a very important call case: &#8230; <a title=\"Abdominal Imaging Call Prep Cases: Acute Uncomplicated Appendicitis (CT)\" class=\"read-more\" href=\"https:\/\/www.stepwards.com\/?page_id=26403\" aria-label=\"More on Abdominal Imaging Call Prep Cases: Acute Uncomplicated Appendicitis (CT)\">Read more<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"parent":26318,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_mi_skip_tracking":false},"jetpack_shortlink":"https:\/\/wp.me\/P71awf-6RR","_links":{"self":[{"href":"https:\/\/www.stepwards.com\/index.php?rest_route=\/wp\/v2\/pages\/26403"}],"collection":[{"href":"https:\/\/www.stepwards.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.stepwards.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.stepwards.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.stepwards.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=26403"}],"version-history":[{"count":13,"href":"https:\/\/www.stepwards.com\/index.php?rest_route=\/wp\/v2\/pages\/26403\/revisions"}],"predecessor-version":[{"id":26466,"href":"https:\/\/www.stepwards.com\/index.php?rest_route=\/wp\/v2\/pages\/26403\/revisions\/26466"}],"up":[{"embeddable":true,"href":"https:\/\/www.stepwards.com\/index.php?rest_route=\/wp\/v2\/pages\/26318"}],"wp:attachment":[{"href":"https:\/\/www.stepwards.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=26403"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}