0:00

Okay, so now we have an additional

0:02

ultrasound of the right lower quadrant.

0:04

Notice that our ultrasound technologist has

0:07

labeled this as right lower quadrant plus

0:09

rebound tenderness, which is pretty dramatic.

0:12

When the technologist says there's rebound tenderness,

0:14

let me tell you, there's rebound tenderness.

0:15

They're accustomed to these examinations all day long.

0:18

So that should be an indication that probably this

0:20

is not going to be a normal study, one might say.

0:23

On the first images, you can just

0:24

see that this is an echogenic mass.

0:27

It's so bright, and that is all because

0:30

of so much fluid within those fatty

0:32

layers of the right lower quadrant.

0:35

Hard to know what this is.

0:36

Is this a free collection?

0:37

Is this the cecum?

0:39

Hard to know, but either way, we have a lot of edema.

0:42

And then when you look over here in

0:44

the right side of the image, you'll see

0:46

that there are some shadowing elements

0:48

within this blind-ending tube. You can

0:50

see that shadowing posterior here as well.

0:53

And this is the appendix over in the corner.

0:56

Let's take up the next frame as well.

0:58

Maybe we can see it a little bit better.

0:59

And you will see that this is a patient who

1:02

has a very large appendix with appendicolith

1:06

within it, consistent with appendicitis.

1:08

Now the degree of inflammation is

1:10

pretty dramatic.

1:12

This patient did receive a CT scan as well.

1:15

I think that at this point it probably would've

1:16

been diagnostic of appendicitis, but the

1:19

question was here, is that a drainable fluid

1:21

collection or is this a patient who has a simple

1:24

appendicitis that can be resected. So, frequently

1:27

we'll go on from these just really edematous

1:30

cases, and we'll still get imaging because

1:32

we wanna determine whether or not the

1:33

patient would be more safely treated

1:36

with tube drainage and antibiotics, or if they

1:39

should go on to appendectomy straight away.

1:43

So as we come down, we're going to see again

1:45

that very thickened cecum, just a lot of

1:48

inflammation looking to the contralateral side.

1:50

No inflammation there.

1:51

Lots of fluid, just extensive fluid.

1:54

And then when we look at the appendix

1:55

itself, where we find it coming off

1:58

of the cecum, it barely even attaches.

2:01

There's those appendiceal lips, and as you come up,

2:04

you'll actually see holes in the wall of the appendix.

2:07

So this is frankly perforated appendicitis with a lot

2:11

of free fluid and phlegmon down in the lower quadrant.

2:15

Could I measure a drainable fluid collection?

2:17

Probably not at this point.

2:19

Let's look at the coronals as well.

2:21

You'll see the just blown-out

2:23

appendix there from the wall.

2:24

Maybe even the whole appendix

2:26

is free-floating at this point.

2:27

There is some fluid down here and all around the

2:30

appendix, so it was chosen that this patient would

2:32

go on to antibiotic therapy and then potentially

2:35

re-image in three days to see if any of this

2:37

fluid had organized into a nice drainable fluid

2:40

collection. Here with some gigantic lymph nodes.

2:42

So sometimes we have to make choices of

2:44

whether or not a patient's going to go to

2:45

surgery or not, and we will get a CT image

2:48

in those cases.

2:49

We think the radiation dose outweighs the risks

2:52

at this point because we know this patient has

2:54

a pretty high-acuity perforated appendicitis.