0:00

All right, so now we're onto right lower quadrant pain.

0:03

And really the big player in the

0:04

right lower quadrant is the appendix.

0:06

It is the moodiest of the organs.

0:08

I think it realizes it doesn't have a lot of

0:09

function, and it just tries to cause problems.

0:12

So, you know, appendiceal imaging is a large

0:14

part of what we do in the emergency room.

0:17

Here's a 27-year-old, um,

0:18

just a hammer at home who has.

0:21

Fever and chills and right lower quadrant pain.

0:23

Again, a mash of, uh, inflammatory

0:25

changes down in the right lower quadrant.

0:27

Lots of enlargement of that appendix.

0:30

You can even see a nice target with that edema

0:32

within the submucosal location on this axial image.

0:36

Some very large appendicoliths as well.

0:38

So this would be just, um, beautiful

0:41

intern surgery level appendicitis.

0:43

You could go in and just snap that right off.

0:45

I think even one of my residents

0:46

could probably take that off.

0:48

I think we would be good.

0:48

So that is a beautiful image of appendicitis, but

0:53

appendicitis, you know, it's not always that easy,

0:55

but in general there are some very typical frameworks

0:58

for what makes, uh, appendicitis a diagnosis.

1:01

The patient usually comes in with that periumbilical pain radiating to McBurney's point.

1:03

30 00:01:05,865 --> 00:01:07,995 And then migrating down to the right lower quadrant.

1:08

So appendiceal dilation greater than six

1:10

millimeters makes the diagnosis for appendicitis.

1:13

That will catch a few people who have an

1:15

abnormally large appendix, but is actually normal.

1:18

But I think that we've chosen six

1:19

millimeters 'cause it's a conservative

1:21

management, it's a conservative measurement.

1:23

It, we wouldn't want to have patients

1:25

leave who have potential appendicitis.

1:27

So anyone with an appendix over six

1:29

millimeters, there are a few exceptions such

1:31

as cystic fibrosis and some other things.

1:33

But in general, anyone with a six-millimeter

1:35

appendix should be at least examined by the surgeon.

1:38

They'll have thickening of the cecal wall, they

1:40

may have the appendicoliths as in R two cases

1:43

here, and some periappendiceal fat stranding.

1:46

Now there may be perforation, not in this

1:47

case, but you always want to measure the size of

1:50

the perforation as well, because that can be

1:52

an indication for drainage prior to surgery.

1:55

I wanted to bring up just some fun appendiceal cases.

1:58

On the side here is a 7-year-old with abdominal

2:01

pain, and you know, our pediatric population

2:03

still gets a fair number of KUB because I think

2:06

they're always trying to exclude constipation in

2:07

these patients as the cause for abdominal pain.

2:10

Let me tell you, always look for an appendicolith

2:12

because if you see an appendicolith or an appendicolith,

2:16

whichever you prefer, on a KUB, that is an indication

2:19

that this patient with pain has appendicitis.

2:22

Um, you can see this beautiful appendicolith there.

2:24

This patient did go on for ultrasound showing

2:26

that appendicolith at the base of the appendix.

2:29

That is very dilated.

2:31

The presence of an appendicolith is 30% of kids

2:34

with appendicitis may have this on imaging, and

2:37

if it's seen and there is abdominal pain, it's

2:39

about 90% probability of having appendicitis.

2:42

If they have an appendicolith because it

2:43

obstructs the ostium of the appendix,

2:45

they're at higher risk for perforation.

2:47

So if you are looking at KUB in kids, always

2:50

make sure you have that on your search pattern.

2:52

I always do abnormal calcifications

2:54

as one of my latest things.

2:56

Appendiceal ultrasound is a great way to

2:59

evaluate appendicitis in your thin, young

3:02

patients or your pediatric patients.

3:04

We really try not to CT scan our younger population

3:08

because of concerns with radiation dose. On ultrasound,

3:11

the appendix will be non-compressible with the

3:13

probe when you're going in for the ultrasound.

3:15

Again, it should be greater than six

3:17

millimeters in size, similar to CT scan.

3:21

Sometimes you'll see an appendix that looks like this.

3:23

It's very large.

3:24

It has that target appearance, and you may

3:25

see a lot of echogenic fat around it as well.

3:28

That's just fluid within that

3:30

fat, increasing the echogenicity of the normal fat.

3:34

What happens if you get an ultrasound

3:36

in a kid and you can't see the appendix?

3:38

What do we do next?

3:40

So there are various options.

3:41

Obviously, if the patient has a

3:42

high risk of appendicitis, they may

3:44

just take this patient to surgery.

3:46

But for us at Mass General,

3:48

we tend to go next to an MRI.

3:51

Again, I want you to feel

3:52

comfortable looking at these MRIs.

3:53

They're just not that hard.

3:55

Um, you wanna look for the T2 sequences

3:58

in the coronal plane, and in the right lower

4:00

quadrant here, you see a lot of fluid that is

4:02

disproportionate to the contralateral side.

4:05

You also have enlargement of that appendix.

4:07

This is a slam dunk of MRI appendicitis.

4:10

I have to say, sometimes you're looking

4:11

for a normal appendix for a very

4:13

long time, and you may not find it.

4:15

Which is an indication that it is normal, but in the cases

4:17

that are positive, they're usually pretty positive.

4:19

It's well used for us in MRI appendicitis

4:23

in our pediatric and pregnant populations.

4:25

It's part of the ACR appropriateness criteria to

4:27

decrease, uh, radiation dose, and it has a high

4:30

sensitivity and specificity for acute appendicitis.

4:33

And it's gonna have the same level of

4:34

appearance of what you're accustomed

4:35

to on CT; you're just using MRI.

4:36

So I think if you look at those T2

4:38

coronal images, you will find the

4:41

appendix, and these are the money shot.

4:43

You wanna make sure that if the patient

4:44

moved during these images, you just have

4:46

the technologist repeat those images.

4:48

So MRI appendicitis is fairly easy to diagnose, and

4:52

it is useful in the patients who may be younger

4:55

and/or you wouldn't want radiation doses for.