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This is Pediatrics week 3 case 3.

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The diagnosis under consideration is appendicitis and

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you'll notice we're looking at an ultrasound image perhaps

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that's unfamiliar to you because you use CT

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to diagnose appendicitis and that's not wrong. However, the

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American College of radiology in its

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appropriateness criteria has indicated that where there

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are technologists trained for the

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diagnosis of

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Appendicitis with ultrasound it is the first line

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Imaging modality if there are no

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technologists at your institution or nearby who are

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comfortable with this examined in CT is also an appropriate

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Imaging study, but we're going to look at ultrasound because it's

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a good thing to be familiar with in the diagnosis

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of appendicitis.

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Both the grayscale appearance and also the Doppler signal

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so I'm going to scroll through these still images

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of the right lower quadrant.

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Here. We are.

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Looking at a magnified image of the right lower quadrant.

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We can see the echogenic appearance of the mesentery and

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omentum and then we see this very focal tubular hypoechoic

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structure.

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Notice that it's very difficult to delineate any.

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tissue layers within this it just appears rather disorganized

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but predominantly hypoechoic

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And the failure to distinguish different tissue planes

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can be a sign of inflammation. We're already thinking

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about the appendix. This has the rough morphology of

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the appendix. So we're intrigued and there's this echogenic Focus.

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Which has just a very faint amount of posterior acoustic

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shadowing. So wearing intrigued we're going

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to keep looking but possibly we're looking at the appendix here. You can

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see someone has measured the length of this structure. It appears to be

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blind ended. It's quite a bit darker which suggests edema

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and inflammation.

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And we don't really see those cell layers here.

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We are in a cross-sectional view of

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that same structure. Now. We at least can barely make out a

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anechoic central Lumen and maybe

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a little bit of mucosa here, which is thickened itself.

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So not only is the appendix dilated, but

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the wall is thickened and we don't want to see our appendix

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Beyond six seven millimeters in diameter. We

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don't want to see the wall Beyond three millimeters in diameter.

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We do see some echogenicity in

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this wall of this demetus structure suggesting that

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there may be some increased flow to it. You can see it

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almost circumferentially around the structure and you

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can see heterogeneous materials in the Lumen which suggests sludge

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and with this bit of posterior acoustic shadowing.

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There may be some calculus some fecaliths or

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a Pentacles. If you prefer that are causing some of the obstructing

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process. Here's a very focal echogenic structure

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with very obvious shadowing that's

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quite convincing for an appendico lift. And I'm

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just going to go over to this cine series that's been obtained and

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scroll through we're looking at this structure. We're

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seeing this hypochoic structure. It's tubular part

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of it. We're seeing in longitudinal View and

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part of it in cross-sectional view. It's dilated and at the tip

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it's expanded and there is this suspected appendicolith.

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This is classic for non perforated acute

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appendicitis, and the diagnosis can

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be confidently made here. We don't need to perform any other

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Imaging

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The surgeons can get involved. We don't see signs of an

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abscess. We don't see signs of anything that would cause us to pause before

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surgery. So ultrasound can be a very effective tool

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to make the diagnosis. But what if you don't have ultrasound let's

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go ahead and just take a look at the CT appearance in

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this.

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Same diagnosis. I'm just going to magnify our

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case just a little bit and Center it over here and

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let's take a look down in this right lower quadrant. Here's

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our cecum. You can see stool filling the

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ascending colon. Here's the soas muscle passing

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by here are the vessels the great vessels after their

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bifurcation.

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And that's right in the area where we want to look not every case

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but often in cases, we can see acute appendicitis

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and we can look for inflammatory changes as

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well. So the first thing we'd want to do is scroll around

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this area. But on our first past we didn't see that so where

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else could the appendix be could be retro SQL

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and it could be as high as the liver. In fact in children.

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The number one cause of hepatic abscess is an inflamed

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appendix lying on the liver capsule. So let's

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look over here where at the posterior abdomen as evidenced by

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these vertebral bodies. Let's look at this posterior colon posterior

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cecum and sure enough here is a dilated tubular

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structure blind ending fluid filled and with

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a density that's very suspicious for

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an obstructing appendicolith. So we have acute appendicitis demonstrated

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here on

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CT very similar to the findings. We saw

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on ultrasound. I'm scrolling through on the axial images to

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show that same thing. Here's our structure retro-secal just

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a tiny focus of gas. That doesn't really

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prove anything either way clearly, it's too big in

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size. It's obstructed. It's inflamed and it's going

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to require surgery. That's the end of the case.