DECLARATION

I here by declare that this dissertation entitled “ROLE OF

ULTRASONOGRAPHY IN THE DIAGNOSIS OF

ACUTE APPENDICITIS” is a bonafide and genuine research

work carried out by me under the guidance of Dr.

RAJASHEKAR.D., M.B.B.S., M.D., Professor & HOD of the

Department of Radio Diagnosis.

(Dr. ARUN KUMAR REDDY.Y.S)

Place : B.G. Nagar Date :

ii

CERTIFICATE

This is to certify that this dissertation entitled “ROLE OF

ULTRASONOGRAPHY IN THE DIAGNOSIS OF

ACUTE APPENDICITIS” is a bona fide and genuine

research work done by Dr. ARUN KUMAR REDDY.Y.S in

partial fulfillment of the requirement for the degree of MD in

RADIO DIAGNOSIS for the year 2006.

I have great pleasure in forwarding it to Rajiv Gandhi

University of Health Science, Bangalore, Karnataka.

(Dr. RAJASHEKAR.D) M.B.B.S., M.D.,

Professor & HOD, Department of Radio Diagnosis.

Place : B.G. Nagar

Date :

iii

CERTIFICATE

This is to certify that this dissertation entitled “ROLE OF

ULTRASONOGRAPHY IN THE DIAGNOSIS OF ACUTE

APPENDICITIS” is a bona fide and genuine research work done

by Dr. ARUN KUMAR REDDY.Y.S in partial fulfillment of the

requirement for the degree of MD in Radio Diagnosis under

guidance of Dr.RAJASHEKAR.D.,M.B.B.S.,M.D., in SAH&RC.

I have great pleasure in forwarding it to the Rajiv Gandhi

University of Health Science, Bangalore, Karnataka.

(Dr.RAJASHEKAR.D) M.B.B.S., M.D.,

Professor and Head, Department of Radio Diagnosis

Place : B.G. Nagar Date :

iv

CERTIFICATE

This is to certify that this dissertation entitled “ROLE OF

ULTRASNOGRAPHY IN THE DIAGNOSIS OF ACUTE

APPENDICITIS” is a bona fide and genuine research work done

by Dr. ARUN KUMAR REDDY.Y.S in partial fulfillment of the

requirement for the degree of MD in Radio Diagnosis under

guidance of Dr.RAJASHEKAR.D., M.B.B.S., M.D., in SAH&RC.

I have great pleasure in forwarding it to the Rajiv Gandhi

University of Health Science, Bangalore, Karnataka.

(Dr. M.S.RAJGOPAL) M.B.B.S., M.D.

Principal, AIMS, B.G.Nagara

Place : B.G. Nagar Date :

v

COPYRIGHT

DECLARATION BY THE CANDIDATE

I hereby declare that the Rajiv Gandhi University

of Health Sciences, Karnataka shall have the rights to

preserve, use and disseminate this dissertation/thesis

in print or electronic format for academic/research

purpose.

(Dr. Arun Kumar Reddy.Y.S)

Place : B.G. Nagar Date :

© Rajiv Gandhi University of Health Sciences, Karnataka

vi

Acknowledgements

With deep sense of gratitude, I take this opportunity to express my

regards and respect to my revered teacher and guide Prof. Rajashekar.D.,

M.B.B.S., M.D., Professor & HOD, Department of Radio Diagnosis, Sri

Adichunchanagiri Hospital and Research Centre, B.G.Nagara, for his

constant guidance, supervision and encouragement during the entire period

of the study. I shall always remember his constructive criticism and

valuable advice which has created an everlasting light of inspiration in my

life.

It is an honour and great privilege to express my deepest sense of

gratitude and regards to my respected teachers Prof. D.C.Parthasarathy,

M.B.B.S., M.D., and Prof. B. Prem Kumar, M.B.B.S., M.D., Professors

in Department of Radio Diagnosis, Sri Adichunchanagiri Hospital and

Research Centre , B.G.Nagara for their missionary zeal to impart

knowledge in Radiology. Their valuable advice and guidance have been a

great source of inspiration and courage to me.

I also take the privilege to express my sincere gratitude and

thankfulness to Assoc. Prof. Ravi Prasad Javaji, Asst. Prof. Satish

Prasad.B.S., Department of Radiology, Sri Adichunchanagiri Hospital and

Research Centre, for their guidance, advice and teaching during my study

period which will remain forever in the memory.

It is also a great privilege to express my gratitude and regards to Dr.

Rajesh Gowda Lecturer in the Department of Radiology, SAH&RC, B.G.

vii

Nagara for his untiring efforts to impart knowledge and skill throughout the

study period.

I wish to record my gratitude to all my colleagues and junior

colleagues of Radiology Department for their constant support and advice.

I am also really indebted to all my patients without whom this thesis

would not have been in the present status.

It gives me immense pleasure in expressing gratitude to my parents,

brother, and all the members of my family for their sacrifices, ever

willing love and support in every step of my life.

Last but not the least, I present my appreciation and thankfulness to

my wife Dr. Dhatri for her constant encouragement, love, support and

sacrifices that have immensely contributed to the successful completion of

this thesis and also in my study.

(Dr. Arun Kumar Reddy Y.S.)

Place : B.G. Nagar

Date :

viii

LIST OF ABBREVIATIONS

% - Percentage & - and µci - micro curie AIDS - Acquired Immuno Deficiency Syndrome B.T - Bleeding time C.T. - Clotting time Cm - Centimeter CT - Computed Tomography DC - Differential Count F - Female Fig - Figure FSE - Patent processus vaginalis GRE - Gradient Echo Sequence Hb% - Haemoglobin percentage Hz - Hertz L - Left M/sec - meter per second mBq - Millibequerel MHz - Mega Hertz ml - Milliliter Mm - Millimeter mm3 - Millimeter cube MRI - Magnetic Resonance Imaging R - Right RBS - Random Blood Sugar RIF - Right Iliac Fossa RLQ - Right lower Quadrant SAH&RC - Sri Adichunchanagiri Hospital And Research Centre SE - Spin Echo Sequence SONAR - Sound Navigation and Ranging T1 W - T 1 weighted image T2W - T 2 Weighted image TC - Total Count US - Ultrasound scan

ix

ABSTRACT

Back ground & objectives

Acute appendicitis is the most common surgical abdominal emergency

in India. As this disease is amenable for treatment by surgery, early

diagnosis plays an important role in early treatment and in preventing undue

complications.

This study was undertaken to evaluate the sensitivity, specificity,

positive and the negative predictive values and accuracy of Ultrasonography

in the diagnosis of acute appendicitis.

Methodology

A total of 200 cases were selected ranging in age from 2 years to 67

years admitted in the hospital with suspicion of acute appendicitis which

will be subjected to Ultrasonography, few other tests, followed up and

managed. The data will be used to interpret results.

Results

Among the 200 cases studied, 150 proved surgically were acute

appendicitis. Male: Female ratio was 1.5: 1 for acute appendicitis. The

disease was most common in the 2nd and 3rd decades. Location of appendix

was most commonly Retro caecal (in 75.9% cases). Mean diameter of the

appendix was 9.56 mm. Target sign was the most commonly detected

sonographic sign. Ultrasonographic sensitivity was 96.1% and specificity

was 95.65%. 6 cases were false negative and 2 cases were false positive.

Predictive value of positive test was 98.66% and predictive value of

negative test was 88%.

x

Interpretation & Conclusion

Ultrasonography is a dynamic real time imaging technique without

any hazards of ionization as with that of X-rays. It is cost effective

investigation and not much time consuming. It can be used at bedside for

examining critically ill patients. It can also be used safely in pregnancy.

High resolution sonography with graded compression is a very

promising examination for diagnosis of appendicitis in problem cases and in

women in their reproductive period. Because it is fast and easy to perform

and because of its high accuracy, sonography should be the primary

imaging procedure for patients suspected to have acute appendicitis.

Ultrasonography is also helpful in detecting complications of appendicitis

and for other abdominal diseases that mimic acute appendicitis.

Key words: Acute appendicitis; Appendicolith; Mucocele of

appendix; Ultrasonography; Computed Tomography; Magnetic Resonance

Imaging; Cholecystitis; Appendectomy; Color Doppler Sonography.

xi

LIST OF CONTENTS

Page Nos. 1. INTRODUCTION 1

2. AIMS AND OBJECTIVES 14

3. REVIEW OF LITERATURE 15

4. MATERIALS AND METHODS 62

5. RESULTS AND OBSERVATION 65

6. DISCUSSION 71

7. CONCLUSION 80

8. SUMMARY 82

9. BIBLIOGRAPHY 83

10. ANNEXURES

PROFORMA 90

MASTER CHART 94

KEY TO MASTER CHART 101

xii

LIST OF TABLES

Page No

I. Spectrum of diseases which clincally mimic acute appendicitis 65

II. Sex incidence of acute appendicitis andappendicular mass 66

III. Age incidence of acute appendicitis and appendicular mass 67

IV. Sonographic Findings 68

V. Calculation of Sensitivity & Specificity 68

VI. Comparative Results of Different Studies 69

VII. Position of Appendix in wakeley et al 1933 Study 69

VIII. Position of Appendix 70

xiii

LIST OF FIGURES

Page No 1. Schematic depiction of the layers of Gut wall 13

2. Various positions of the Appendix 13

3. Anatomy of the Appendix 15

4. Normal Appendix on Ultrasonography 52

5. Plain abdomen radiography in Acute Appendicitis 52

6. Acute Appendicitis with netrophil infiltration 53

7. Acute catarrhal Appendicitis 54

8. Obstructive Appendicitis 54

9. Barium enema in Acute Appendicitis 55

10. Mucocele of Appendix 55

11. Acute Appendicitis longitudinal section 56

12. Acute Appendicitis transverse section 56

13. Target sign in Acute Appendicitis 57

14. Appendicolith in Ultrasonography 57

15. Enlarged mesenteric lymph node on Ultrasonography 58

16. Appendicular abscess 58

17. CT in Acute Appendicitis 59

18. MRI in Acute Appendicitis 60

19. Differential diagnosis of Acute Appendicitis 60

20. Tubo-Ovarian mass 61

21. Ovarian cyst 61

22. Spectrum of diseases which may mimic Acute Appendicitis in our series 65

23. Sex incidence of Acute Appendicitis and Appendicular mass 66

24. Age incidence of Acute Appendicitis and Appendicular mass 67

25. Position of Appendix 70

xiv

INTRODUCTION

Acute appendicitis is the most common surgical abdominal emergency in

India. Since adolescents are most prone for acute appendicitis, any mortality in

this age group because of delay in diagnosis or delay in treatment can affect the

wealth of the family and also the wealth of the nation. As this disease is amenable

for treatment by surgery, early diagnosis plays an important role in early

treatment and in preventing undue complications.

Acute appendicitis is the most common cause of ‘Acute abdomen’ in young

adults. Acute appendicitis is relatively rare in infants, and becomes increasingly

common in childhood and early adult life, reaching a peak incidence in teens and

early 20’s 1. In about 30% of patients the signs, symptoms and laboratory findings

of acute appendicitis are atypical 2 often leading to delay in diagnosis and surgical

intervention and consequent increase in rate of perforation.

In addition other diseases produce clinical and laboratory findings similar to

that of acute appendicitis leading to negative appendectomy rate of 20-25% 3, this

rate is particularly high 35-36% for female patients during their reproductive

years because of various gynecologic diseases 4.

Graded compression ultrasound using high frequency linear array

transducers in supine position for diagnosing acute appendicitis was advocated by

Puylaert et al 5.

Ultrasound can diagnose a number of conditions that mimic appendicitis

clinically. If appendicitis can be excluded sonologically and an alternative

diagnosis be made, two benefits will occur. Unnecessary appendectomy can be

1

avoided and appropriate treatment instituted. Ultrasound can be recommended in

children where there is diagnostic doubt, in young women (due to high incidence

of tubal disease), and in patients who are pregnant 6.

Women, in particular, benefit most from preoperative imaging, with a

statistically significant lower negative appendectomy rate than that in women

who undergo no preoperative imaging 7.

HISTORICAL ASPECTS

The history begins in the year 1794 when Spallanzani theorized that bats

flying in the dark are guided by sounds not perceived by human ear. This gave

birth to the concept of Ultrasound. Almost a century later Jacques & Pierre Curie

discovered piezoelectric effect. After Titanic disaster in 1912, efforts began to

develop a method for detecting undersea obstacles. The first attempt to develop a

large practical application of high frequency ultrasound was the effort by Paul

Langevin commissioned by French Government in World War – 1, to detect

submerged enemy submarines. This ultimately led to development of SONAR by

United States Navy in World War -2.

First successful application of ultrasound to medical diagnosis was reported

by Karl Dussik & his brothers Fredrick. During 1947-48 they introduced

hyperphonography. In 1949 George Ludwig et al Naval Military Research

Institute, United States of America experimented with detection of Gall stones

and foreign bodies embedded in tissues. Wild & Reid introduced first handheld

contact scanner. In 1962 Douglas Howry & Coworkers completed construction of

compound contact scanner.

2

Pioneering researchers in various medical specialties began applying

Ultrasound to diagnostics in the early 1950’s. Christian Johann Doppler, while

investigating the colour spectrum of light from stars, described the phenomenon

that today bears his name. In sound the Doppler Effect refers to the apparent

change in frequency (or wave length) associated with the relative motion of the

source and observer. By the end of that decade Ultrasonography has invaded

almost every part of medical specialties. Commercial development of Ultrasound

equipment began during early 1960’s. During past 45 years Ultrasonography

came a long way. Not only have newer clinical uses for ultrasound been

developed, significant advances in equipment have improved image quality and

in turn opened up new vistas in medical diagnosis.

PHYSICAL PRINCIPLES OF ULTRASOUND

Ultrasound is a high frequency mechanical vibration produced by a

transducer made of piezoelectric material which has the property of changing

thickness when a voltage is applied across it. Lead Zirconate Titanate (PZT) is

most widely used material. The vital ingredients of a sonic imaging system are

1. A transducer,

2. A ultrasonic beam, and

3. A display method, usually a Cathode ray tube, or a Television monitor.

Diagnostic frequencies lie in the range of 2.5 MHz to 15 MHz.

The ultrasonic beam is a series of longitudinal waves that transmit energy.

These travel through average body tissue at a velocity of 1540 m/sec. As the

sound beam passes through the body, the beam is attenuated by a combination of

3

diffusion, reflection, refraction and absorption. Reflection occurs at tissue

interfaces. The amount of reflection depends on acoustic impedance of the two

surfaces and on the angle of incidence of the beam. Reflection is greatest where

there is large difference between the acoustic impedance of the two media and

with a small incidence angle of the beam.

Ultrasonic display of image

The ultrasonic image is an electronic representation of data generated from

returning echoes and displayed on a Television monitor or cathode ray tube.

1. A - Mode (Amplitude Modulation) Trace: This single line of

information in space represents the time, or distance, it takes the beam to

strike a particular interface and return its signal to the transducer.

2. B – Mode (Brightness Modulation) Trace: If the trace of the A –

Mode were rotated 90 degree, the spikes would be represented as dots.

The B – Mode is the basis of all static and real time B – Scan images in

ultrasound.

3. Gray – Scale Imaging: Gray - scale imaging was made possible by the

development of the scan conversion memory tube (usually called scan

converter). The scan converter stores the information received from a

transducer and then uses the stored information to generate a signal that

is used to produce a visible image on Television monitor. Two types of

scan conversion memory tubes in use are:

1. The analog scan converter,

2. The digital scan converter.

4

The digital scan converter converts variation in amplitude of the echo signal

received by the transducer into binary numbers. The information is stored into 16

(4-bit) or 32 (5-bit) or more levels of grey that can be displayed on Television

monitor.

M – Mode (Time – Motion Mode) Trace: The M – Mode trace employs

the concepts of A and B – Mode swept across the screen over time. Thus the M –

Mode trace is widely used to depict movement and is especially useful in fetal

heart movement and cardiac studies.

High resolution Ultrasonography: The use of high frequency probes

allow both lateral and axial resolution to be improved. Narrower beams can be

produced as the wavelength decreases (frequency increases) and lateral resolution

improves as the beam width decreases. As these are usually the same numbers of

cycles in a pulse. Regardless of frequency the pulse length will also decrease and

the resolution will be improved. A compromise must be made between resolution

and sensitivity. Attenuation of sounds at diagnostic frequencies is approximately

proportional to frequency, thus higher frequencies are absorbed more strongly by

the tissues so that deeper tissues can not be imaged without using inordinarily

high power levels.

SONOGRAPHY OF GASTROINTESTINAL TRACT

Gastrointestinal sonography is frequently frustrating and always

challenging, gas content with in the gut lumen can make visibility difficult and

even impossible. Intraluminal fluid may mimic cystic masses and fecal material

may create a variety of artifacts and pseudotumours. Nevertheless normal gut has

a reproducible pattern or gut signature and a variety of gut pathologies create

5

recognizable sonographic abnormalities. In addition, in a few conditions such as

acute appendicitis and acute diverticulitis, Sonography may play a major primary

investigative role. Further endosonography performed with high frequency

transducers in the lumen of the gut is an increasingly popular technique for

assessing the esophagus, stomach and rectum8.

Technique

Examination of the intestinal tract usually begins with a systematic

standardized survey using a curvilinear 3.5 to 5 MHz transducer. In patients with

localized abdomen pain, however it may be helpful and time saving to let patients

indicate the position of maximum pain with their fingers on the abdominal wall

and begin the examination there. Incase of diffuse abdominal pain the frame of

colon is identified by its strong gas artifacts and is screened from the caecum to

the sigmoid colon. The rest of the abdomen is examined in an individual

standardized fashion to assess complete coverage of the entire gastrointestinal

tract. If the intestinal wall thickening is found detailed evaluation of the diseased

segment is performed with linear or curved high frequency (7.5 to 13 MHz)

transducer. When the affected bowel segment is far from the abdominal surface

and when the patient is obese a fair amount of pressure must be applied to the

transducer to get acceptable images. For optimal results it may be necessary to

change the patient position several times during the examination. Ideally patients

fast overnight before the examination but at least four – five hours of fasting are

needed to avoid excessive gas in the intestinal lumen.

6

Normal Bowel wall anatomy on sonography

The typical sonographic appearance of the normal bowel wall consists of

five concentric, alternatively echogenic and hypoechoic layers. It is called gut

signature. These layers are described from lumen outwards.

Sonography Histology

1. Echogenic layer superficial mucosa + / - luminal content / mucosal interface

2. Hypoechoic layer Deep mucosa including muscularis mucosa

3. Echogenic layer Sub mucosa + submucosa / muscularis propria

Interface

4. Hypoechoic layer Muscularis propria

5. Echogenic layer Serosa + subserosal fat, marginal interface.

The normal gut wall is uniform and compliant with an average thickness of

3 mm if distended and 5 mm if not. The contents and diameters of the

gastrointestinal lumen and motor activity of the gut are also assessed. Hyper

secretion, mechanical obstruction and ileus are implicated when gut fluid is

excessive. Peristalsis is normally seen in the small bowel and stomach. Activity

may be increased with mechanical obstruction and with some inflammatory

enteritides. Decreased activity is seen with paralytic ileus.

Gut wall pathology

Gut wall pathology creates characteristic sonographic pattern, the most

familiar, the “target” pattern was described by Lutz and Petzoldt in 1976 and later

by Bluth et al who referred to the pattern as a “pseudokidney”. In both

7

descriptions the hypoechoic external rim corresponds to thickened gut wall where

as the echogenic center relates to residual gut lumen or mucosal ulceration. The

“target” and “pseudokidney” are the abnormal equivalents of the gut signature

created by the normal gut.

Gut pathology creating an exophytic mass with or without mucosal

involvement or ulceration may form masses that are readily visualized but are

difficult to assign to a gastrointestinal tract origin because typical gut signatures,

targets or pseudokidneys are not seen on sonography. Consequently

intraperitoneal masses of varying morphology which do not clearly arise from

solid abdominal viscera or the lymph nodes should be considered to have a

potential gut origin. Intraluminal gut masses and mucosal masses may have a

variable appearance and are frequently hidden by gas or luminal content.

Inflammatory bowel disease

Crohn’s disease is suggested by skip areas and involvement of the distal

ileum. The classic sonography feature of Crohn’s disease is the target sign on

transverse images. Which means a strong echogenic center surrounded by a

relatively sonolucent rim of more than 5mm. Strictures are shown as marked

thickening of gut wall with a fixed hyperechoic narrowed lumen, dilatation and

hyper peristalsis of the proximal gut. Periintestinal inflammation leads to

“creeping fat sign”. This appears as a uniform hyperechoic mass seen around the

ileum and caecum. Mesenteric lymphadenopathy is seen as multiple oval

hypoechoic masses usually in the right lower quadrant. Abscesses are seen as

poorly defined mostly hypoechoic focal masses that can contain hyperechoic gas.

Fistulas are seen as hypoechoic tracts with gas inclusions connecting bowel loops

or adjacent structures (Bladder, abdominal wall, vagina, and psoas muscle).

8

Acute terminal ileitis

Acute ileitis is caused by Yersinia species but Campylobacter and

Salmonella species, may also be cultured. The sonographic features are

hypoechoic mural thickening of the terminal ileum and caecum between 6 and 10

mm with hypoechoic swollen ileal folds in the edematous mucosa. Color Doppler

sonography in patients with infectious ileitis shows increased flow centrally

rather than peripherally (as in acute appendicitis).

Tuberculous enteritis and Behcets syndrome also predominantly affect the

Ileocaecal region. Ileocaecal tuberculosis usually associated with enlargement of

the mesenteric lymph nodes.

Appendicitis

The typical findings of acute appendicitis in transverse sonogram are the

target sign with a hypoechoic center, an inner hyperehoic ring and an external

thick hypoechoic ring. In sagittal images, the inflamed appendix is a blind ending,

non compressible tubular structure. In color Doppler examination the presence of

visible hyperemia or increased flow in the mucosal layer of the appendix may be

a marker of appendicitis. Where as increased flow in the mucosal layer most

likely represents enteritis.

Mesenteric Infarction

Mesenteric infarction in its later stages leads to small bowel thickening.

However no bowel wall thickening may be seen. Doppler sonography can aid in

differentiating ischemic and inflammatory bowel wall thickening.

9

Amyloidosis

Amyloidosis is a rare condition in which marked hypoechoic thickening of

the affected bowel segment is seen.

Eosinophilic Enteritis

Eosinophilic enteritis is a rare disease characterized by infiltration of

stomach or bowel wall with eosinophilic leukocytes. In these patients there is

hypoechoic thickening of multiple ileal loops, narrowing of the lumen and loss of

layer structure were described.

Celiac Disease

The sonographic findings of non tropical sprue (or Celiac disease) are

diffuse hypoechoic thickening of the entire small bowel wall that disappears

completely after 3 months of gluten – free diet.

Whipples Disease

Sonographic findings are hyperechoic concentric thickening of the small

bowel with enlarged hyperechoic lymph nodes due to accumulation of fat in these

structures.

Cyto Megalo Virus Enteritis in AIDS Patients

Sonographic findings are small and large bowel wall thickening with

preserved stratification.

Non-Hodgkins Lymphoma of the gastrointestinal tract

The gut is the most commonly involved extra nodal site of lymphoma. The

most common sites in the order of descending frequency are stomach, small

10

intestine, and colon especially caecum. Sonography classically shows transmural

circumferential, profoundly hypoechoic wall thickening up to 4 cm in diameter

with loss of normal stratification.

Tumors of the Small Intestine:

Peritoneal carcinomatosis is the most frequent malignant lesion of the

small bowel and may lead to irregular wall thickening with typical contraction of

several bowel loops to a conglomerate.

Small bowel carcinoids appear as hypoechoic, homogenous predominantly

Intraluminal masses with smooth Intraluminal contour.

Lipomas appear as well circumscribed hyperechoic round or oval masses

with deformation under compression.

Leiomyomas and Schwannomas are seen as hypoechoic intramural round

structure with smooth boundaries.

Leiomyosarcomas are seen as large irregular masses with a heterogeneous

echo pattern.

Adenocarcinomas appear as moderately large Intraluminal masses with

medium echogenecity.

LARGE BOWEL CONDITIONS

Colitis:

Sonographic features of pseudo membranous colitis are thickening of the

colonic wall with a wide inner circle of heterogeneous medium echogenecity

11

surrounded by a narrow hypoechoic muscularis propria, these findings reflecting

the gross sub mucosal edema.

Ischemic colitis cannot be differentiated solely by sonography from

inflammatory or any other form of colonic wall thickening. Duplex and color

Doppler sonography can differentiate these two conditions.

Diverticulitis:

Sonography features are visualization of diverticula, thickening of bowel

wall, inflammatory changes in pericolic fat (typically on the mesenteric side of

the colonic wall), Intramural or pericolic abscesses. And severe local tenderness,

induced by local graded compression. Diverticula are visualized as round or oval

echogenic foci seen in or outside the gut wall, mostly internal acoustic

shadowing.

Colonic Carcinoma:

Colonic Carcinoma has two typical sonographic appearances. The first type

is seen as localized hypoechoic mass up to 10 cm or more with an irregular shape

and a lobulated contour. The Intraluminal gas seen as a cluster of high amplitude

is usually eccentrically located around the mass. Second type shows segmental

eccentric or circumferential thickening of the colon wall. The mural thickening

may be irregular but not as severe as the first type. The central echo clusters are

small because the diseased lumen is usually narrow. This type frequently leads to

colonic obstruction.

12

AIMS AND OBJECTIVES

To study

1. The sonographic pattern of disease in patients with right iliac

quadrant pain.

2. The safety and ease of Ultrasonography in the diagnosis of

acute appendicitis, in patients with right iliac quadrant pain.

3. The sonographic features of probe tenderness, target sign,

free fluid in right iliac fossa, diameter of the appendix,

muscle wall thickness of appendix and appendicolith in

patients of acute appendicitis.

14

REVIEW OF LITERATURE

ANATOMY OF APPENDIX

Embryology:

The appendix is a derivative of the midgut, first appearing around the 8th

week of gestation as an out pouching of the caecum 9. The appendix initially

projects from the apex of the caecum, but the base gradually rotates in a more

medial location towards the Ileocaecal valve.

Fig–3 . Anatomy of the Appendix

Description:

The Vermiform appendix is a narrow, vermian (worm shaped) tube,

arising from the caecal wall 2 cm or less below the end of ileum. It may occupy

one of the several positions:

15

a. Behind the caecum and lower ascending colon (Retro caecal & Retro

colic),

b. Dependant over the pelvic brim (Pelvic/Descending) in females in close

to the right uterine tube and ovary,

c. Lying below the caecum (Sub caecal),

d. In front of the terminal ileum where it may be in contact with the

anterior abdominal wall, and

e. Behind the terminal ileum 10.

The appendix varies from 2 – 20 cm in length, the average being about 9

cm. It is longer in children and may atrophy or diminish after mid adult life. The

main appendicular artery a branch from the lower division the ileocolic artery

runs behind the terminal ileum to enter the mesoappendix a short distance from

the appendicular base. Here it gives a recurrent branch which anastamoses at the

base of the appendix with a branch of the posterior caecal artery.

Histology:

The appendix is lined by columnar cell intestinal mucosa of colonic type.

Crypts are present but are not numerous. In the base of the crypts Klutschitzsky

cells are present which gives rise to carcinoid tumor. The submucosa contains

numerous lymphatic aggregations. So appendix is called abdominal tonsil.

The lymphoid tissue diminishes with increasing age. The muscular coat

consists of two complete layers of smooth muscle, inner circular and outer

longitudinal. The visceral layer of peritoneum envelopes the appendix completely

except for the narrow line of attachment of mesoappendix1.

16

Location:

Mc Burney’s point lies at the junction of the lateral third with the medial

two thirds of a line joining the anterior superior iliac spine and umbilicus. Mc

Burney’s point is the classic site of the greatest tenderness in appendicitis and

also a most useful point to have in mind when a grid – iron incision is made.

The traditional method of locating appendix consists of following one of

the taeniae coli till the appendix is reached. If the organ is still not visible and it is

certain that it has not been removed it will be found adherent to the posterior

caecal wall after the caecum has been mobilized by gentle exploratory

dissection1.

Congenital Abnormalities

Agenesis:

One in 1, 00,000 persons the vermiform appendix is absent.

Duplication:

A few cases of double appendix have been reported. In some instances one

of the twin appendices have been found acutely inflamed and the other

uninvolved.

Left sided Appendix:

Situs inversus viscerum, a congenital abnormality where there is complete

transposition of thoracic and abdominal viscera occurs once in 35,000

individuals, and is more common in males. In such cases the vermiform appendix

is found on the left, and is also the situation in some cases of non rotation of the

midgut.

17

PATHOGENESIS OF ACUTE APPENDICITIS

Acute appendicitis has been attributed to luminal obstruction leading to

distension of the obstructed segment as mucinous secretion accumulates,

followed by vascular compromise of the wall and secondary bacterial invasion by

enteric organisms.

Appendicitis is classically divided into Acute, Suppurative and Gangrenous

stages. Initially the acute reaction is marked by neutrophilic exudation throughout

the thickness of the wall and the lumen may be filled with pus. The subserosal

vessels are congested and often there is a fibrinous exudate covering the serosa

leading to acute appendicitis.

Further after the acute stage, there is more marked neutrophilic infiltration

that causes foci of suppurative necrosis in the wall and with in the mucosa leading

to sloughing necrosis. Later purulent exudate extends to the enveloping omentum

leading to acute suppurative appendicitis.

Acute Suppurative appendicitis if left untreated will develop gross edema

and compromise blood supply to the appendix. Greenish hemorrhagic ulceration

of the mucosa and green – black foci of necrosis in serosa develop leading to

acute gangrenous appendicitis.

Acute Gangrenous appendicitis then ruptures and may cause

periappendiceal abscess or generalized peritonitis11.

CLINICAL ASPECTS OF APPENDICITIS

Etiology of this very common condition is still not clearly known. However

diet (low residue diet), social status (high middle class and upper class), residence

18

(European, American and Australian), familial susceptibility, obstruction of the

lumen of the appendix with appendicolith, foreign body, round worm or thread

worm or a stricture and indiscriminate use of purgatives are all incriminated.

Although no age is exempt, it is rare before the age of 2 years. It becomes

increasingly common during childhood and adolescence and the maximum

incidence is noticed between 20 and 30 years. Thereafter the incidence gradually

drops.

Clinically two varieties are seen:

a. Non-obstructive type and

b. Obstructive type.

Non-obstructive variety progress slowly, whereas obstructive type

progresses very fast, and gangrene and perforation are commonly seen in this

type. A careful history must be taken. If the patient gets pain around the

umbilicus or in the epigastrium in the beginning and later on if this pain shifts to

right iliac fossa, he is undoubtedly suffering from acute appendicitis. The initial

pain is visceral and felt on the midline irrespective of the position of the

appendix, since developmentally the midgut, from which the appendix develops,

is a medial organ. The second pain is due to irritation of parietal peritoneum lying

in close proximity to the appendix.

The pain is dull aching in character in non-obstructive type of appendicitis,

whereas this is of colicky nature in obstructive appendicitis. Pain is followed by

nausea and vomiting along with anorexia depending on the degree of distension

of the appendix. Fever is almost always associated with this condition. So far as

the bowel habit is concerned constipation is the usual accompaniment, but there

may be diarrhea in case of acute pelvic appendicitis or appendicular abscess.

19

Examination reveals presence of hyperaesthesia in Sherren’s triangle,

tenderness at Mc Burney’s point, muscle guard and rebound tenderness over the

appendix. Positive Rovsing’s sign is a definite diagnostic clue and should always

be looked for. Within 2 or 3 days a tender fixed lump develops at the site of

appendix, which is known as ‘appendicular lump’. Sluggish peritoneal sound on

the right iliac fossa is also evident on auscultation.

Should perforation take place, the outlook temporarily improves with

disappearance of pain, but very soon the features of spreading peritonitis appear.

Pain is complained of all over the abdomen, vomiting may become more marked,

but more important is the pulse rate which gradually rises and temperature

becomes subnormal. Restricted movement of the abdominal wall, ‘board-like’

rigidity, spread of tenderness from the right iliac fossa to the left iliac fossa and

‘silent abdomen’ on auscultation has no doubt that the peritonitis is spreading. In

estimating the degree of spread, the pulse rate is an important guide. Variation of

clinical features is observed according to the nature of the disease, the position of

appendix and the age of the patient.

Differentiation between Catarrhal and Obstructive appendicitis:

In catarrhal appendicitis the onset is gradual, the pain is dull and aching,

the patient carries on her usual duties but with discomfort in the abdomen,

nausea, vomiting and even anorexia. In obstructive appendicitis the onset is

sudden. The patient immediately goes back to the bed with severe colicky pain in

the abdomen along with vomiting and rise of temperature.

20

Retro caecal Appendicitis:

When the organ is entirely retroperitoneal, there is hardly any tenderness

and rigidity on the anterior abdomen. There may be some tenderness and rigidity

in the right flank or more posteriorly. To elicit such tenderness the patient should

be rolled to her left side. If the appendix is in close relation to the right ureter, the

patient may complain of hematuria and pain radiating from loin to groin. This

confuses the clinician and the diagnosis of ureteric stone has often been wrongly

made. The history of initial pain around the umbilicus, Rovsing’s sign and psoas

test will guide the clinician to the diagnosis of appendicitis.

Pelvic Appendicitis:

Tenderness and rigidity may not be as prominent on the anterior

abdominal wall as is normal. Moreover the picture becomes more confusing due

to the history of diarrhoea and rise of temperature. Irritation of the bladder

(strangury) and the rectum (passage of mucus per anus and tenesmus) are also

very confusing. Even in this condition a careful history will elicit that pain started

around the umbilicus. Presence of Rovsing’s sign and obturator test will clinch

the diagnosis. Rectal examination is often helpful as tenderness on the right side

of the recto-uterine pouch in females and recto-vesical pouch in males will give

definite clue to the diagnosis. A tender lump or cystic swelling in rectal

examination is diagnostic of pelvic abscess.

Acute Appendicitis in Infancy and Childhood:

The constitutional disturbances are more in children. The temperature is

often high along with the pulse rate, vomiting and diarrhea (instead of

constipation) are the useful features. Elicitation of tenderness is not as easy as in

21

case of adults. A good technique is to palpate the abdomen with the child’s own

hand. At the point of maximum tenderness the child will put its hand away.

Appendicular lump is rarely seen due to short omentum and poor inflammatory

response. For this, early perforation is the rule and the surgeon must diagnose the

case very early and perform appendectomy giving no chance to the appendix to

perforate by itself thereby preventing undue complications that may result from

perforation.

Acute Appendicitis in the elderly

These patients with laxed abdominal wall hardly show any rigidity.

Moreover due to arteriosclerosis of the appendicular artery chance of rapid

gangrene and subsequent perforation becomes obvious. So distension of the

abdomen is the second stage of peritonitis, with constipation and vomiting it

resembles a picture of intestinal obstruction. The clinician, may advice enema

erroneously to make the patient’s condition much worse.

Acute Appendicitis in pregnancy

Acute appendicitis is the most common cause of acute abdomen during

pregnancy, occurring in approximately one in 1500 deliveries 12. A rapid, reliable,

and accurate imaging method is needed to aid in the evaluation of pregnant

women with acute right lower quadrant pain, because clinical and laboratory

findings cannot be used to reliably confirm or dismiss a diagnosis of acute

appendicitis in these patients 13, 14.

The ideal imaging method should be able to aid in the diagnosis of other

possible causes of right lower quadrant pain. Traditionally, Ultrasonography has

been the initial imaging modality of choice in the evaluation of obstetric patients

22

because it is safe and inexpensive and can be performed easily at the bedside. In

pregnant women, graded compression Ultrasonography has been shown to be

accurate in the first and second trimesters but technically difficult in the third

trimester 15, 16. In addition, Ultrasonography is highly operator dependant, and

factors such as intervening bowel gas, the gravid uterus, and obesity may interfere

with the quality and adequacy of images.

Computed Tomography is of limited use in obstetric patients because of

concerns about radiation induced teratogenesis 17. The role of Magnetic

Resonance Imaging in patients presenting with right lower quadrant pain in

pregnant women is discussed later.

Altered anatomic location of the appendix in pregnant women and similarity

of signs and symptoms of normal pregnancy and acute appendicitis are the most

important factors leading to difficulties in diagnosis. Pain in the right lower

quadrant is the most common and reliable symptom of appendicitis in pregnant

women 13.

Delay in the diagnosis of appendicitis occurring in pregnant women is

associated with dangerous complications. The most dreaded being fetal loss. The

incidence of fetal loss is 1.5 % or less if no perforation has occurred. However,

this rate increases to 20 % if the appendix has ruptured 12, 18.

The enlarging uterus will cause upward displacement of the caecum and

thus confuse acute appendicitis with cholecystitis. Careful history with positive

Rovsing’s sign should help to make the diagnosis. Sometimes concealed

accidental hemorrhage or necrobiosis of uterine fibroid may lead to similar pain

as in acute appendicitis.

23

With the patient in supine position the most tender spot is marked with skin

pencil. The patient is now turned to her left and is kept in this position for at least

one minute. The most tender spot is again found out. If there is shifting of

tenderness it indicates uterine pathology. Pyelitis and cystitis are also common

during pregnancy. So, one should be careful to consider these conditions in

differential diagnosis.

INVESTIGATIONS

Temperature

Although in case of advanced appendicitis the temperature is invariably

raised, in 20 % of cases of acute appendicitis the patient may be apyrexial. This

physical sign therefore lacks diagnostic sensitivity.

White Blood Cell Count

The leukocyte count is usually elevated to the range of 12,000 –

18,000/mm3. In addition, an increase in the percentage of neutrophils with a

normal total white blood cell count supports the clinical diagnosis of

appendicitis19.

However, the diagnostic value of this common first-line investigation is

brought in to perspective by the fact that up to 70 % of patients presenting with

other causes of right iliac fossa pain will also have Leukocytosis. On the other

hand many patients with perforated appendix have a normal white blood cell

count. It has been noted that if the test is repeated some hours later in patients

with acute appendicitis, the white blood cell counts tend to remain raised.

24

RADIOLOGICAL DIAGNOSIS

THE PLAIN ABDOMEN RADIOGRAPHY

In their relative order of importance, the radiographic findings of acute

appendicitis follow 20:

1. Appendicular Calculus (Appendicolith, Coprolith or Fecolith):

A nidus of inspissated feces stimulates secretion and precipitation of

calcium phosphate – rich mucus. The resultant calculus has a radiolucent center

(ring shaped). Seventy percent are solitary. 35 % of cases of appendicitis

demonstrate a fecolith 21.

Calcified mesenteric lymph node, concretion in Meckel’s diverticulum,

ureteral calculi, phlebolith, ectopic gallstone, and bone island and buttock

injection granuloma may mimic appendicolith. The average appendicolith

measures about 2 cm and is normally laminated. Because of the mobility of

vermiform appendix the location of the concretion is quite variable.

2. Appendiceal Abscess:

The inflammatory mass is most commonly seen over the right ileum or in

the right paracolic gutter. Scattered gas bubbles may appear in the abscess,

because of the variability in the appendix position, an abscess may develop

anywhere in the peritoneal cavity and occasionally retroperitoneal.

Both Computed Tomography and Ultrasonography can be used to identify

the abscess and the fecolith.

25

3. Periappendiceal Soft Tissue Mass

This is seen in one third of patients. A combination of structures

contribute to formation of the mass including the abscess, the omentum, bowel

wall edema or a loop of ileum distended with fluid.

4. Separation of Caecum from the Right Extraperitoneal Fat

An inflammatory mass in the right lateral paracolic gutter widens this

space.

5. Deformity of Caecum and Ascending Colon

Inflammation and edema widen the haustra of the ascending colon in

about 5% of patients. Submucosal fluid collections may also cause nodular

Intraluminal densities (thumb prints). With retrocaecal appendicitis the lateral

wall of the ascending colon is more likely to be involved.

6. Caecal and Ileal distension

Atony of the caecum and adjacent ileum results in mildly distended bowel

loops usually with short air fluid levels. However a similar appearance occurs in

non specific enteritis, cholecystitis, pancreatitis, salpingo-oophoritis, perforated

ulcer, peritonitis and after enema or cathartics.

7. Gas in the Appendix

Controversy surrounds the significance of this finding. Gas can be found

in the inflamed as well as the normal appendix. A retrocaecal appendix is more

likely to contain gas, since in the upright position gas would rise from the

caecum.

26

8. Increased intraperitoneal fluid:

Fluid exudation follows appendiceal perforation and peritoneal

inflammation.

9. Effacement of Extraperitoneal Fat on the Right:

Effacement of extraperitoneal fat on the right side may follow local

inflammation and edema.

10. Pneumoperitoneum and Pneumoretroperitoneum:

Both are rare but may follow rupture of appendix. The volume of air is

usually small.

11. Small and Large Bowel Obstruction:

This may follow bowel involvement by an abscess.

12. Spinal Tilt to the Right:

Obscuration of the, lower half of the, right psoas muscle, and right

obturator muscle are suggestive but non specific findings.

Plain film abnormalities are seen in about 50 % of patients with

appendicitis. A combination of the above described signs has greater reliability

than any single one. Children and patients with perforation and abscess formation

are more likely to have positive findings.

27

THE BARIUM STUDIES IN THE DIAGNOSIS OF ACUTE

APPENDICITIS

Barium Enema

Barium enema can be used in atypical cases or in patients with underlying

disease. Visualization of a normal, freely mobile and painless appendix with a

well demonstrated distal globular tip should rule out acute appendicitis. Non

filling or partial filling of the appendix by itself does not diagnose acute

appendicitis, however when partial filling is associated with mucosal

irregularities, stenosis, lack of normal motion or pain at palpation. It is highly

suggestive of acute appendicitis.

Non filling or partial filling of the appendix associated with caecal

impression is indicative of appendicitis. Contrast extravasation from the appendix

is very uncommon, but it is highly suggestive of complicated acute appendicitis,

when it does occur. Associated findings such as irritability or mucosal irregularity

of the terminal ileum or recto-sigmoid colon, caecal spasm or a soft tissue mass

are all helpful in supporting the diagnosis of acute appendicitis when other

positive findings are present.

A single-contrast barium enema will show filling in a normal appendix in

all but 10 percent of patients but will not show filling in an appendix obstructed

by inflammation. However, this study, performed on an unprepared bowel, has

many limitations, such as non visualization of the appendix, patient discomfort,

and time consumption and radiation exposure 22.

28

Barium Swallow

This is an alternative to the barium enema and has been reported as having

95% accuracy in children 23.

SONOGRAPHY IN THE DIAGNOSIS OF ACUTE APPENDICITIS

Graded Compression Technique

This technique was described by Puylaert JBCM in 1986. High resolution or

7.5 MHz phased linear array transducer are used to perform the examination.

Usually no preparation is necessary. The patient is asked to point to the area of

maximum tenderness, which is scanned first. If the appendix is not visualized,

scanning of the right lower quadrant is performed in a routine fashion in the

transverse plane. Starting from a point below the tip of the caecum and moving

cephalad to the middle of the transverse colon. Examination in the longitudinal

plane is used to confirm in all findings.

Scanning is done in the supine position while applying graded compression,

which displaces the shadowing gas contents in the caecum and ascending colon,

allowing visualization of the retro caecal area. It also brings the intraabdominal

structures closer to the transducer and its focal zone. So that high resolution

images can be obtained. Another benefit of compression is differentiation of

compressible structures, such as normal caecum and terminal ileum from a rigid

non compressible inflamed appendix. Graded compression is well tolerated by

most patients.

The inflamed appendix is usually located just medial and inferior to the tip

of the caecum. Examining the patient in the right or left posterior oblique position

29

can sometimes be helpful in visualizing an inflamed appendix in this location. If

the inflamed appendix is not identified, pelvic ultrasound examination is then

performed after adequate bladder filling to look for gynecologic or pelvic disease

that mimics acute appendicitis. This is usually done using 3 or 5 MHz sector

transducer. A general survey of the gallbladder, biliary tree, liver and right kidney

is performed.

Graded compression sonography with adjuvant use of posterior manual

compression technique for the sonographic diagnosis of acute appendicitis will

increase the visualization of vermiform appendix. There is a 10 % increase in

visualization of appendix when a combination of the above mentioned techniques

are used as compared to using graded compression technique alone in diagnosing

appendicitis 24.

Normal Sonographic Anatomy of the Right Lower Quadrant

Adequate visualization with recognition of normal structures in the right

lower quadrant is essential for performing and interpreting the examination.

Anterior structures include skin, subcutaneous tissues and abdominal muscle.

Posteriorly, the iliopsoas muscles, is identified, by its large elongated hypoechoic

fibrillar structure, in the longitudinal plane, and punctuate appearance in the

transverse plane. Its central hypoechoic tendon makes recognition easy. The iliac

artery and vein lie medial to the mid inguinal region towards the midline. If

necessary Doppler examination helps determine these two structures from an

inflamed appendix.

The caecum and ascending colon are seen as large oval structures in the

transverse plane with slightly echogenic, or anechoic lumen, depending on their

30

gas, fecal, or fluid content. The mucosa is seen as a hyperechogenic layer of

variable thickness often arranged in large folds (haustra) and surrounded by a 3 –

5 mm hypoechoic muscular wall. The terminal ileum is identified by its medial

relation to the caecum and by it thinner caliber. Its contents are often seen moving

with in as in the caecum, the lumen is surrounded by a thin echogenic mucosa;

however the folds are much smaller and the hypoechoic muscular wall is thinner

(1 – 2 mm). Active peristalsis is seen in the terminal ileum and less frequently in

the caecum. Both are easily compressible by the transducer pressure during

scanning.

Ultrasound is rapid noninvasive, inexpensive, and requires no patient

preparation or contrast material administration. Because ultrasound involves no

ionizing radiation and excels in the depiction of acute gynecological conditions, it

is recommended as the initial study in children, in young women (due to higher

incidence of tubal disease) and during pregnancy 25.

The normal appendix is infrequently demonstrated by ultrasound. If seen it

appears as small, filiform, blind-ended structure, 6 mm or less in diameter with a

collapsed lumen and a very thin (2 mm or less) muscular wall. The appendix can

often be traced to its origin in the caecum 26.

The overall accuracy of sonography performed by emergency physicians in

the diagnosis of acute appendicitis is superior to that of surgeons’ clinical

impression 27.

Ultrasonography of normal Appendix

The normal appendix presents as a small, easily compressible,

concentrically layered, mobile, blind ending, and sausage-like structure. The

31

diameter is usually less than 7 mm, but is incidentally large. The normal appendix

is mobile, may have a collapsed lumen, but also may contain air or some fecal

material, and rarely a little fluid28. Power Doppler reveals scarce or no vascular

signal and there is no hyperechoic, non compressible inflamed fat around the

appendix 29.

Ultrasonography signs in Acute Appendicitis:

1. Blind ending tubular structure at the point of tenderness

- Non compressible

- Diameter 7 mm or greater

- No peristalsis

2. Appendicolith casting acoustic shadow

3. High echogenecity non compressible surrounding fat

4. Surrounding fluid or abscess

5. Edema of caecal pole 30.

The most sensitive sign in diagnosing acute appendicitis is that of a non-

compressible appendix with a diameter of 7 mm or greater 31.

The patterns recognized by sonography reflect the pathologic types of acute

appendicitis, early acute suppurative appendicitis, perforating appendicitis, and

appendiceal abscess.

Early Acute Appendicitis

The patterns of early acute appendicitis seen in about one fourth of patients,

five layers are identified. These layers are described from inside to outside:

32

1. A small echogenic focus that represents the collapsed lumen and the

superficial mucosal lining of the appendix,

2. A thin 2 to 3 mm hypoechogenic layer that represents the edematous

lamina propria and muscularis mucosa,

3. A 2 to 3 mm echogenic layer that represents the submucosa,

4. A hypoechoic, slightly thickened 2 to 3 mm muscular layer, and

5. A thin echogenic layer that represents the serosa.

Lack of luminal distension probably indicates that any obstruction is of

short duration. The total diameter of the appendix ranges from 9.5 to 11 mm 32.

Suppurative Appendicitis

The criteria used for diagnosis of suppurative appendicitis includes fluid

distension of the appendiceal lumen and moderate thickening of the muscular

wall in the range of 3 to 6 mm without an appendicolith or with one. The

muscular wall of the suppurative appendix has less well defined layers. The

appendicolith is identified by sonography as an Intraluminal echogenic focus with

variable degree of shadowing. Its sonographic appearance can be mimicked by

gas, mucus, or debris in the lumen. Appendicolith are found in 30 % of cases of

acute appendicitis. However, only one third of these are seen on abdominal

radiographs. The rest are not visible because of minimal calcification 20, 33, the

diameter of the appendix in suppurative appendicitis ranges from 15 to 19 mm 32.

Perforative Appendicitis and Appendiceal abscess

1. Sonographic signs of appendiceal perforation include:

33

2. Asymmetric thickening of appendiceal wall,

3. Localized fluid collection around the appendix,

4. Free intraperitoneal fluid,

5. Single or multiple interloop abscess, and

6. Lack of or minimal localized tenderness despite demonstration of

suppurative appendicitis 5, 26.

The sensitivity of sonography for the diagnosis of appendicitis decreases

with perforation, but features statistically associated with its occurrence include

loculated pericaecal fluid, phlegmon / abscess, prominent pericaecal /

periapendiceal fat, and circumferential loss of submucosal layer of appendix 34. In

perforative appendicitis the appendiceal lumen may or may not be distended.

Appendiceal abscess is usually seen as a complex hypo or isoechoic

paracaecal mass with through transmission although the typical appearance of an

inflamed appendix may not be seen. Residual appendiceal lumen surrounded the

echogenic mucosa is often seen within the paracaecal mass. Ultrasound may be

useful as a guide for percutaneous drainage of abscess 35.

In the differential on Ultrasonography in a right lower quadrant mass one

must consider a fluid filled small bowel, fluid in small or large bowel

diverticulum, appendiceal / diverticular abscess, mesenteric cyst seroma and

particularly in females of reproductive age group salpingitis and ectopic

pregnancy masses 36.

34

Sonographic findings in Uncommon Disease of the Appendix

Crohn’s Disease:

Appendiceal involvement occurs in 25 % of cases of Crohn’s ileocolitis 37,

although localization to the appendix, is not common. The sonographic

appearance of Crohn’s appendicitis may be similar to that of non granulomatous

acute appendicitis. However the presence of excessive mural wall thickening (less

than 6 mm) with no luminal distension should strongly suggest the diagnosis.

Thickening of the walls of adjacent bowel loops is not a helpful sign, as it can be

seen in non granulomatous appendicitis, but the course is often protracted. Pre-

operative or even intra-operative diagnosis is often difficult. The rate of

recurrence after appendectomy in the form of ileocolitis is low (14 %) and

formation of post operative fistulae is unknown.

Radiation Appendicitis:

This rare condition occurs when the appendix lies in the field of abdominal

and pelvic radiation. Sonographic findings are similar to those of early acute

appendicitis 38. This condition is not associated with pain, fever, nausea, or

leukocytosis and laparotomy is not indicated.

Mucocele of the Appendix

Mucocele of the appendix usually result from mild chronic obstruction or

less commonly from mucinous cystadenoma or cystadenocarcinoma of the

appendix, leading to distension of the appendix by mucin. The mucocele is seen

by sonography as a well defined, oval or round cystic or complex mass 38, nearly

two thirds of patients present with vague right lower quadrant pain but without

35

fever or leucocytosis. Appendectomy is indicated to prevent serious complication

such as pseudomyxoperitonei, resulting from torsion or rupture of mucocele.

Mucoceles of the appendix are rare, appearing in 0.2 - 0.3 % of surgical

appendectomy specimens. They are pathologically divided into 4 categories.

They are:

1. Mucous hyperplasia,

2. Mucinous cystadenoma,

3. Mucinous cystadenocarcinoma, and

4. Secondary to occlusion of the lumen from post-inflammatory scarring,

progenic atrophy, congenital obstruction of Gerlach’s valve or

extraluminal compression 39.

A very important fact to be stressed here is the need for more mucoceles of

the appendix to be diagnosed preoperatively. This makes the surgeon aware of the

need for more careful surgery and consequently reduces the chances of iatrogenic

damage to a mucocele with resultant leakage of the contents in the abdominal

cavity with serious repercussions especially psedomyxomaperitonei 40.

Limitations of the Sonographic Examination:

A technically adequate sonographic study is possible in most patients. In

obese patients it is possible to use a 3 MHz linear array transducer to penetrate

thick layer of fat. However in severely obese patients, patients with marked

tenderness preventing adequate compression, those with considerable fecal or

gangrenous distension and those with massively dilated, fluid filled bowel it may

not be possible to adequately visualize the appendiceal area and obtain good

36

image of the right lower quadrant. In these patients acute appendicitis cannot be

excluded on the basis of non visualization of the appendix by sonography, such

patients should be evaluated on the basis of the clinical and other imaging

modalities.

Pitfalls in the Ultrasound Diagnosis of Appendicitis

False-positive Diagnosis

False-positive diagnoses are less frequently encountered. A false-positive

diagnosis can be made if the normal appendix is mistaken for an inflamed one.

Not infrequently the normal appendix is larger than 7 mm, especially in children

when caused by lymphoid hyperplasia and in adults when caused by fecal

impaction. Appendiceal compressibility, the absence of Doppler signal, and the

absence of inflamed fat are the most important features in deciding if it is normal

or inflamed.

A false positive diagnosis is possible in patients with perforated peptic

ulcer, sigmoid diverticulitis or Crohn’s disease because, in these conditions, the

appendix may be reactively thickened due to adjacent extrinsic inflammatory

disease 41, 42.

Caecal carcinoma may obstruct the appendiceal lumen giving rise to true

appendicitis or to a sterile accumulation of mucus in the lumen. In both cases the

appendix is easily seen by ultrasound and may lead to an erroneous diagnosis of

appendiceal mass 43.

In pregnant women, dilated uterine veins can be mistaken for an inflamed

appendix. However the presence of flow on Doppler examination and the thin

37

wall of the vein should be helpful. Tubo-Ovarian abscess or complicated Ovarian

cysts in close proximate to the caecum may also mimic appendiceal abscess at

sonography.

False-negative Diagnosis

The most important reason for a false-negative ultrasound examination is

overlooking the inflamed appendix. Generalized peritonitis, air-filled dilated

bowel loops and air in the lumen of the inflamed appendix can make it difficult to

identify the inflamed appendix. Another pitfall is demonstration of the normal

proximal part of the appendix while the distal inflamed tip is overlooked, because

it is obscured by bowel gas. Rarely, the inflamed appendix has a maximal

diameter of less than 7 mm. In those cases rigidity, hypervascularity, and

presence of inflamed fat must give the clue.

In advanced appendicitis where there is secondary wall thickening of the

ileum, the ileal thickening is more prominent and conspicuous on Ultrasound than

the underlying inflamed appendix. If In an adult patient enlarged mesenteric

lymph nodes are the sole ultrasound finding, one should be cautious to diagnose

mesenteric lymphadenitis, because these nodes could be secondarily enlarged

because of acute appendicitis.

If in a patient with appendicitis only the fecolith in the appendix base is

visualized and the rest of the appendix is overlooked, this may lead to an

erroneous diagnosis of caecal diverticulitis. If in a woman a relatively large right-

sided Ovarian cyst is found, this is not necessarily the cause of her symptoms and

one should still search for appendicitis 29.

38

If in advanced appendicitis only hypoechoic non compressible inflamed fat

of omentum and mesentery is visualized, and the inflamed appendix is

overlooked, this may lead to an erroneous diagnosis of omental infarction or

epiploic appendagitis 44, 45.

ROLE OF COLOR DOPPLER IN DIAGNOSIS OF APPENDICITIS

Blood flow usually is not demonstrated within the normal appendix.

However when present normal arterial wave forms have high resistance and

normal venous flow shows respiratory variation. In the presence of appendicitis,

vessels within appendix and mesoappendix are increased in size and number and

are more easily demonstrated with Color Doppler. Demonstration of

mesoappendiceal hyperemia is important, since appendiceal vessels traverse the

mesoappendix on their way to and form the appendix. In acute appendicitis the

arterial wave forms have decreased resistance. The venous flow is continuous and

may even be pulsatile.

Color Doppler Ultrasound was performed at the end of grayscale ultrasound

examination by using a low-velocity scale (pulse repetition frequency 1,500 Hz)

and a low wall filter (100 Hz) to detect slow blood flow. Flow in the appendiceal

wall was investigated as follows: Color gain was increased until clutter was

observed and then was reduced just enough to remove clutter from the image of

the appendix 46.

Color Doppler Ultrasonography of non-perforated appendicitis

demonstrates peripheral wall hyperemia reflecting inflammatory hyper-perfusion.

Color flow may be absent in gangrenous appendicitis or early inflammation.

Addition of Color flow Doppler imaging to routine gray-scale imaging can

increase sensitivity of the ultrasound examination for detecting appendicitis to

9547.

39

Color Doppler findings of appendiceal perforation include hyperemia in

the periappendiceal soft tissue or within a well-defined abscess 48.

INDIUM – 111 IMAGING IN APPENDICITIS

Leukocyte Labeling:

This method was developed by Thackur et al and modified by Goodwin et

al. First 50 to 90 ml of the patient’s whole blood is obtained. A leukocyte rich

sample is collected through differential sedimentation. It is then labeled with 250

to 500 µci (9.25 to 18.5 mBq) of Indium oxide and re-injected into the patient.

Imaging

Imaging is performed with a scintillation camera positioned anteriorly over

the abdomen to include the inferior margins of the liver, spleen, remaining

abdomen, and pelvis. Lateral, and left anterior oblique views are obtained if

necessary. Initial scintiphotos are obtained 1.5 to 2 hours after injection, with

delayed images obtained 17 to 24 hours later as clinical outcome is permitted.

Abnormal localized radioactivity in the right lower quadrant is compared

with radioactive uptake by bone marrow and graded as follows;

0 - No activity,

1+ - Radioactivity less than bone marrow,

2+ - Radioactivity the same as in bone marrow,

3+ - Radioactivity greater than in bone marrow,

4+ - Radioactivity equal to that in spleen.

Any localization in the abdomen is considered (abscess) abnormal, other

patterns of abnormal localization are identified and recorded 49.

40

ROLE OF HELICAL CT IN DIAGNOSIS OF APPENDICITIS

The development of helical CT represents the most significant advancement

in imaging patients with abdominal pain. Rapid breath-hold helical CT scans and

improved intravascular opacification using power injector has enabled

radiologists to obtain volumetric data that can be analyzed with multiplanar and

3-dimensional techniques. Although contrast gastro-intestinal studies provide

excellent evaluation of intra luminal and mucosal lesions of the gastro intestinal

tract, they cannot detect mural and extraluminal disease. With its ability to

evaluate the Intraluminal components of the gastrointestinal disease and to

exclude pelvic abnormalities, CT remains the modality of choice. Both CT and

USG can be used in image guided drainage, aspiration of abscess complicating

RLQ pain conditions.

CT has also shown to have high predictive values in acute appendicitis and

can be used in obese patients and doubtful cases. Unenhanced thin section helical

CT is an accurate and effective technique for diagnosis of acute appendicitis. The

normal appendix can be identified in 43-51% of patients with its caliber not

exceeding 6 mm and its wall not more than 3 mm thickness. The CT findings in

appendicitis vary and reflect the stage and severity of the inflammatory process.

An enlarged appendix with periappendiceal fat stranding is found in 93% of

cases. Less common but specific signs include caecal apical changes and

appendicolith (identified in upto 28% of patients). Other signs seen in

appendicitis (adenopathy, fat stranding, adjacent bowel wall thickening and fluid)

are less specific and identification of a normal appendix helps to exclude

appendicitis. An abscess is seen in about 50% of patients. While large abscesses

are generally treated surgically, well localized lesions may be managed with CT

guided percutaneus drainage.

41

ROLE OF MRI IN DIAGNOSIS OF APPENDICITIS

MRI of the acute abdomen is currently limited by its lack of wide

availability and relatively long examination time. However MRI technique

continues to evolve with improvement in both hardware and software, resulting in

faster data acquisition and better images. The use T1W sequence with reduced

artifacts such as breath hold GRE and FSE imaging have improved image quality.

MRI diagnosis of appendicitis depends on demonstration of abnormal

appendix. The inflamed appendix appears on MRI as a curvy-tubular structure

with thickened, markedly enhancing wall on fat suppressed contrast enhanced

T1W images. Detection of periappendiceal abscess will also enhance with

contrast. Disadvantages of MRI include its inability to detect appendicolith or to

visualize a normal appendix due to lack of appendiceal wall enlargement.

Advantages of MRI over US include better visualization of abnormal appendix

and adjacent inflammation, visualization of appendix in a typical location,

operator independence and ease of examining obese patients.

The main advantage of MRI is its ability to depict the organ from which

abdominal pain originates when this organ is not clearly revealed by other

imaging modalities 48. MRI imaging was also found to be accurate and superior to

US in revealing suspected appendicitis in adults. It is reported that an inflamed

appendix demonstrates marked wall enhancement with slight distension 50. On the

other hand accurate diagnosis of acute appendicitis in pediatric patients could be

made even without administration of intravenous contrast material and T2W SE

MR Imaging is the most sensitive sequence 51.

42

MRI of the pelvis allows evaluation of both medically emergent and non

emergent causes of right lower quadrant pain other than acute appendicitis. MRI

helps in accurately diagnosing ovarian torsion, pelvic abscess unrelated to

appendicitis, hemorrhagic cyst, and exophytic fibroid. MRI also helps to

distinguish an abscess from bowel loops or pyosalpinx 52.

Computer aided Diagnosis of Appendicitis

Computer aided clinical diagnosis of patients with RIF pain has been used

since 1972 53. Clinical data are entered into the computer, which composes them

with its database and calculates the likelihood of acute appendicitis.

Scoring System

Many scoring systems have been advocated. The Alvarado score is both

simple to remember and to use, being based on three symptoms, three signs and

two laboratory findings. The total score is 10. Patients with a score of 1 to 4 were

unlikely to have appendicitis. Those with a score of 5 to 6 possibly had

appendicitis and were regularly reassessed. Patients with scores of 7 to 8 had

appendicitis while those with scores 9 to 10 were submitted to surgery 55, 56.

ALVARADO SCORE

Symptoms

- Migratory right iliac fossa pain 1

- Anorexia 1

- Nausea / Vomiting 1

Signs

- Tenderness in the right iliac fossa 2

- Rebound tenderness in right iliac fossa 1

- Elevated temperature 1

43

Labotatory Findings

- Leukocytosis 2

- Shift to left of Neutrophils 1

TOTAL SCORE 10

Fine catheter peritoneal cytology

This technique was first advocated by Stewart and Holloway in 1986.

Intraabdominal fluid is aspirated and analyzed for the presence of neutrophils as

an indication of intraabdominal inflammation. A Peritoneal Neutrophil

Percentage (PNP) of greater than 50 % is considered as positive result. In women

peritoneal aspiration does not differentiate with acute appendicitis and pelvic

inflammatory disease.

Laparoscopy

Laparoscopy increases the accuracy of appendicitis diagnosis in patients

with right iliac fossa pain. In comparison with open appendectomy, it allows

more complete examination of the intraabdominal organs. Conforming pathology

of other sites, that may mimic appendicitis 56.

DIFFERENTIAL DIAGNOSIS

Although acute appendicitis is the commonest abdominal emergency, the

diagnosis at times can be extremely difficult. It is wise to consider carefully,

possible disease of throat, the chest, the abdomen, the pelvis, the genitor-urinary

system, the central nervous system and spine. For these purpose it is helpful to

visualize the body as a house, and compare seven parts of the house to the

appropriate anatomical regions 57.

44

The Attic (The Nasopharynx and Throat)

Tonsillitis: In children abdominal colic may arise from swallowed exudates

from tonsillitis (Tonsil tummy).

Pneumonia and Pleurisy: Pneumonia and pleurisy, especially at the right

base gives rise to right sided abdominal pain. Pleural friction or altered breath

sounds on auscultation, and a chest radiograph may be helpful.

The Upper Storey (Diaphragm to the level of the Umbilicus)

Perforated Peptic Ulcer: History of dyspepsia may be present and a

sudden onset of pain which starts in the epigastrium and passes down the

paracolic gutter. Radiography may show gas under the diaphragm.

Acute Cholecystitis: Murphy’s sign positive, and jaundice may be present.

Cyclical Vomiting: The patient is an infant or a young child and there is a

previous similar attack, rigidity is absent.

The Ground Floor

Enterocolitis: In this condition there is intestinal colic together with

diarrhea and vomiting but localized tenderness does not usually occur.

Nonspecific Mesenteric Lymphadenitis: The patient is usually a child

completely free from pain in between attacks, which last a few minutes and

cervical lymph nodes, may be enlarged.

Intestinal Obstruction: Here there is persisting colicky pain around the

umbilicus with vomiting first of gastric, then of the intestinal contents, the bowel

45

sounds are noisy and a plain erect abdomen radiograph shows multiple fluid

levels.

Terminal Ileitis: in its acute form may be indistinguishable from acute

appendicitis. A history of diarrhea suggests regional ileitis rather than

appendicitis. The ileitis may be nonspecific or due to Crohn’s disease or Yersinia

infection.

Meckel’s Diverticulitis: Is often indistinguishable clinically.

Carcinoma of the Caecum: When obstructed may mimic appendicitis in

patients in the carcinoma age group.

Sigmoid Diverticulitis: In some patients with a long sigmoid loop, the

colon lies to the right of the midline.

The Basement (Pelvis)

It is in women of child bearing age that pelvic disease so often mimics acute

appendicitis.

Salpingitis: The history of a vaginal discharge, of menstrual irregularities

and dysmennorhoea, or burning pain on micturition is all helpful differential

diagnostic points. On rectal or vaginal examination, the enlarged tender fallopian

tubes may be palpable.

Ectopic Gestation: Usually there is a history of a missed period, the cervix

is softened and often severe pain is felt when it is moved on vaginal examination.

Ruptured Ovarian Follicle (syn. Mittelschmerz): Occurs about the 14th to

the 16th day between periods, especially in early womanhood.

46

Twisted Right Ovarian Cyst: On rectal or vaginal examination, the cyst

can be palpable.

Diverticulum of the Caecum (Solitary): This is rare when inflamed. It is

indistinguishable from acute appendicitis.

The Backyard (The Retroperitoneal Structures)

Right Ureteric Colic: in typical Ureteric colic, pain commences in the loin

and passes to the groin. Plain radiography may show a stone in the right Ureteric

line.

Right side Acute Pyelonephritis: The leading features are tenderness

confined to the loin, fever, and pyuria

The Electric Installation

Preherpetic pain of the right 10th and 11th dorsal nerves is localized over the

same as that of appendix.

Spinal conditions of Pott’s disease of the spine, secondary carcinomatous

deposits senile osteoporosis and myelomatous deposits may sometimes give rise

to abdominal pain.

Oil Tank (Blood)

Bleeding into appendicular and related structures can result from blood

dyscrasias or the use of anti-coagulants may manifest as pain abdomen.

Diabetic Abdomen:

Denotes the severe abdominal pain and vomiting which occasionally

precedes coma. The urine should be tested in every abdominal emergency.

47

Acute Pancreatitis

In early cases there may be vomiting and pain in the right iliac fossa.

Rectus sheath Hematoma

Perforation of Gangrenous Appendix

When perforation of gangrenous appendix occurs within 12 to 24 hours

after the commencement of attack, explosive peritonitis is liable to occur. It is

common in acute obstructive appendicitis. In particular in non obstructive type

perforation or gangrene develops after a period of 24 hours. Defense mechanisms

play a role to localize the peritonitis by adherence of greater omentum (abdominal

policemen) to the perforated site.

The Appendicular Mass

On the 3rd day after commencement of an attack of acute appendicitis, a

tender mass can be felt in the right iliac fossa. The mass is composed of greater

omentum, edematous caecal wall and edematous portions of the small intestine.

By the 4th or 5th day the mass becomes more circumscribed. During the ensuing

days (5th to 10th days) the swelling either becomes larger and an appendicular

abscess results, or it becomes smaller and subsides slowly as the inflammation

resolves.

The Appendicular Abscess

Accompanying an abscess there is variable pyrexia, there is an increased

leukocyte count with a relative increase of polymorphonuclear cells. The location

of abscess is determined by the position of appendix. The commonest site of

48

abscess is in the lateral part of the right iliac fossa (extension of retrocaecal

suppuration) second most common is in the pelvis. If an appendix abscess is

accurately diagnosed and defined by Ultrasonography. Percutaneous drainage

under fluoroscopic or ultrasonic guidance is the treatment of choice.

Less Common Pathological Conditions

1. Mucocele of Appendix: The condition may occur when the proximal

end of the lumen is slowly or completely occluded, commonly due to a

stricture and pent-up secretions. The appendix is slowly enlarged.

Rupture of mucocele leads to pseudomyxoma peritonei.

2. Diverticula of the Appendix: Some are congenital (contains all coats)

and most are acquired (no muscularis layer). It can occur in conjunction

with a mucocele.

3. Intussusception of the Appendix: It is a rare condition and occurs

mostly in childhood. It is diagnosed only by operation.

4. Endometriosis of the Appendix: This condition occurs due to ectopic

implantation of the endometrial tissue, and gives rise to monthly

melaena.

5. Primary Crohn’s Disease of the Appendix: It is a rare condition,

appendectomy is indicated. Fistula has not been reported following

appendectomy in this location of the disease.

49

Neoplasms of the Appendix

1. Carcinoid Tumour (Argentaffinoma): It arises in argentaffin tissue

(Kulschitzsky cells of the crypts of Lieberkuhn) can occur anywhere in

the gastrointestinal tract. But commonly it is situated in the vermiform

appendix. These tumors can produce a number of vasoactive peptides,

most commonly 5 – Hydroxy Tryptamine (serotonin). The clinical

syndrome consists of reddish – blue cyanosis, flushing attacks, diarrhea,

asthmatic attacks and sometimes pulmonary and tricuspid stenosis.

Appendectomy is the treatment of choice.

2. Primary Adenocarcinoma: These are mostly of the colonic type and

should be treated by right hemicolectomy.

TREATMENT OF ACUTE APPENDICITIS

Conservative Treatment

The conservative management of appendicitis is usually reserved for cases

where no operating facilities are available. Example: On board ships at sea. It is

claimed that the short term treatment with antibiotics was as effective as surgery.

However, the recurrence rate was high 57.

Surgical Treatment

Open Appendectomy: This is conventionally performed through a muscle

splitting Mc Burney’s incision. Inversion of the appendix stump is now thought to

be unnecessary as it has been shown to make no difference to complication rates

and also has the advantage of not deforming the caecal wall which may

subsequently be mistaken for a caecal neoplasm.

50

Laparoscopic Appendectomy: The first laparoscopic appendectomy for

appendicitis was described by Schreiber in 1987. With the aid of laparoscopy

appendectomy may be performed by making a small incision in the RIF through

which the appendix is removed. The ‘true’ laparoscopic appendectomy uses

staple clips or snares to tie the appendix, which is then delivered through an

appropriately sited port. At no stage does the appendix come in contact with the

abdominal wall. This may account for the low wound infection associated with

this technique.

51

MATERIALS & METHODS

The study was conducted in the department of Radio Diagnosis,

Sri.Adichunchanagiri hospital and research center, B.G. Nagara. All the cases

referred for Ultrasonography with a clinical diagnosis of acute appendicitis for a

period of 18 months starting from April 2004 to September 2005. Examination of

the patient is done using HEWLETT PACKARD IMAGE POINT HX machine

with 7.5 MHz and 3.5 MHz transducers. Graded compression technique was used

to examine the right iliac quadrant for appendix.

Inclusion Criteria

1. All individuals irrespective of age ans sex referred for Ultrasonography

with clinical diagnosis of acute appendicitis,

2. Cases with history of recurrent appendicitis presenting with acute

symptoms, and

3. Cases of acute appendicitis in early pregnancy.

Exclusion Criteria

1. Cases with recurrent appendicitis not presenting with acute symptoms,

2. Patients who are medically unfit for surgery due to other diseases, and

3. Cases of acute appendicitis diagnosed clinically and ultrasonologically but

not willing for admission for further management.

62

After noting the name, age, sex, and address of the patient, clinical

examination of the abdomen was made to elicit tenderness in Mc Burney’s point

in the right iliac fossa.

Ultrasonogarphic examination of the abdomen was made in the following

way:

First general survey of the patients’ abdomen was performed with 3.5 MHz

curvi-linear probe, and then examination of the right lower quadrant by graded

compression technique with 7.5 MHz linear probe was done.

Scanning was done in the supine position while applying gradual

compression, which displaces the shadowing gas contents in caecum and

ascending colon allowing visualization of the retro caecal area. It also brings the

intra abdominal structures closer to the transducer and its focal zone. Scanning

was performed in a routine fashion in the transverse plane, starting from a point

below the tip of caecum and moving cephalad to the middle of the transverse

colon. Examination in the longitudinal plane was used to confirm the findings.

The inflamed appendix was usually located just medial and inferior to the

caecum and anterior and lateral to the iliac vessels, occasionally posterior to the

caecum. If the appendix was not located, scanning the area where the patient

shows maximum tenderness by finger tip was usually the site of appendix. After

visualization of appendix, we have measured the diameter, muscle wall thickness,

appendicolith, and collection of fluid in the right iliac fossa.

63

Investigations

A few routine laboratory investigations were performed:

1. Hb %, TC, DC, ESR, BT, CT

2. RBS,

3. Urine Examination – Sugar, Protein & Microscopy,

4. Chest X-Ray, and

5. Ultrasonography.

Then operative findings of the patients were followed up to determine the

accuracy of the Ultrasonography.

64

RESULTS

Table – I Shows the spectrum of diseases which may

mimi cacute appendicitis in our series.

Disease Male Female Total

Acute Appendicitis Appendicular Mass Right Acute Pyelonephritis Right Ureteric Calculus Pelvic Inflammatory Disease Twisted Ovarian Cyst Ileitis Ileo Caecal Tuberculosis Carcinoma Caecum No Abnormality Detected

90 6 - 6 - - 2 2 4

10

60 2 2 - 8 2 - 2 - 4

150 8 2 6 8 2 2 4 4 14

Total 120 80 200

90

60

60 0 2 2 4

10

60

2 2 08

2 0 2 0 4

AcuteAppendicitis

AppendicularMass

Right AcutePyelonephritis

Right UretericCalculus

Pelvic Inflammatory Disease

Twisted Ovarian Cyst

Ileitis Ileo CaecalTuberculosis

CarcinomaCaecum

No AbnormalityDetected

0

20

40

60

80

100

MALE FEMALE

Fig. 22 - Shows the spectrum of diseases which may mimic acute appendicitis in our series.

65

Table – II : Sex incidence of Acute Appendicitis and Appendicular Mass.

Disease Males Females No. of Patients

Acute Appendicitis Appendicular Mass

90 6

60 2

150 8

Total 96 62 158

90

6

60

2

Acute Appendicitis Appendicular Mass0

20

40

60

80

100

MALE FEMALE

Fig. - 23 : Sex incidence of Acute Appendicitis and Appendicular Mass.

66

Table – III : Age incidence of Acute Appendicitis and Appendicular Mass

Age (years) No. of Patients Percentage

0 – 10 11 – 20 21 – 30 31 – 40 41 – 50 51 – 60 61 – 70

24 66 34 10 14 6 4

15.18 41.77 21.51 6.32 8.86 3.78 2.53

Total 158 100

15.2

41.8

21.5 6.3

8.9

3.82.5

Fig – 24 : Age incidence of Acute Appendicitis and Appendicular Mass

Highest number of patients susceptible to acute appendicitis is in the age

group 11-20 years.

The youngest patient was 2 years old and the eldest patient was 67 years

old in our study.

67

Table – IV : Sonographic findings

Finding No. of Cases

Target Sign Probe Tenderness Free Fluid Appendicolith

152 144 54 20

Table – V : Calculation of Sensitivity and Specificity

Sonographic Diagnosis Patients with Disease

Patients without Disease

Positive Negative

148(a) 6(c)

2(b) 44(d)

Total number of cases - 200

Sonographically positive for appendicitis - 150

Sonographically negative - 50

False Positive - 2

False Negative - 6

Sensitivity = ca

a+

x100 = 6148

148+

x 100 = 96.1 %

Specificity = bd

d+

x 100 = 244

44+

x 100 = 95.65 %

Predictive value of positive test = ba

a+

x 100 = 2148

148+

x 100 = 98.66 %

Predictive value of negative test = cd

d+

x 100 = 644

44+

x100 = 88 %

68

Table – VI : Comparative results of different studies

References Transducer Frequency

(MHz)

Accuracy (%)

Sensitivity (%)

Specificity (%)

Predictive value of Positive

test

Predictive value of Negative

test Puylaert et al (1986)

5 / 7.5 - 75 100 - -

Kastrup et al (1986)

5 87 83 94 96 76

Monzer et al (1987)

5 90 80 95 91 89

RB Jeffrey et al (1987)

5 93.9 89.9 96.2 93 94.3

Wolf et al (1989)

5 95.7 88.5 98 94.5 96.3

Harshada. M. Joshi et al (1996)

6.5 / 10 95 96 93 98 88

Present Study (2004-05)

5 / 7.5 94 96.10 95.65 98.66 88

Table – VII : In 10,000 subjects studied by Wakeley et al 58 in 1993 the

position of vermiform appendix was

Position of Appendix Percentage (%)

Retro Caecal & Retro Colic Pelvic Sub Caecal Pre Ileal Post Ileal

65.28 31.01 2.26

1 0.4

69

Table – VIII : Position of Appendix

Appendix Position No. of Cases Percentage (%)

Retro Caecal Pelvic Sub Caecal Pre Ileal Post Ileal Sub Heaptic

120 28 4 2 2 2

75.9 17.7 2.5 1.26 1.26 1.26

TOTAL 158 100

76.0

17.7

2.5 1.31.3 1.3

Fig - 25 : Position of Appendix

70

DISCUSSION

Ultrasonographic examination of acute appendicitis is the most commonly

used imaging technique. The medical ultrasound is in use since middle 1950’s.

There is an increase in the clinical value in diagnosis of acute appendicitis due to

evolution of graded compression technique by Puylaert JBCM in 1986.

Basically Ultrasonography is a dynamic real time imaging technique

without any hazards of ionization as with that of X-rays. It is cost effective

investigation and not much time consuming. It can be used safely in pregnancy as

well.

For patients with RLQ pain the question has to be answered whether the

pain is really due to acute appendicitis or other diseases which mimic acute

appendicitis.

The clinical presentation of acute appendicitis is typical in more than 70%

of patients. About 30 % of patients have an uncertain preoperative diagnosis.

Consequently the rate of unnecessary laparotomy for acute appendicitis is as high

as 20-25 %. The rate is even higher 35-45 % in women of child bearing age group

because of pelvic inflammatory disease and complicated pregnancies 59, 60. So,

ultrasonographic examination of RLQ pain is necessary for these patients. This is

the basis for the present study.

The present study comprises of 200 selected patients admitted for treatment

to Sri Adichunchanagiri Institute of Medical Sciences, B.G.Nagar with clinical

diagnosis of acute appendicitis. These include 120 male and 80 female patients.

71

Ultrasonography was performed immediately after admission.

Ultrasonography was repeated in a few cases. These patients were treated

surgically or conservatively depending on the condition of the patient. They were

followed up over a period till they were discharged.

Among the 200 cases studied, 150 proved surgically were acute

appendicitis, 8 cases were appendicular mass, 8 cases were pelvic inflammatory

disease, 6 cases were right Ureteric calculus, 4 cases were Ileocaecal tuberculosis,

4 cases were right acute Pyelonephritis, 2 cases were twisted ovarian cyst, 2 cases

were ileitis and no abnormality was detected in 14 cases.

Male: Female ratio in acute appendicitis

In our study among 150 cases of acute appendicitis, 90 patients were male

and 60 patients were female. The male: female ratio was 1.5:1. For appendicular

mass, 6 patients were male and 2 patients were female. According to Bailey and

Love text book of surgery males were affected commonly than females.

Age incidence in acute appendicitis

In our study highest number of patients with acute appendicitis was in the

age group of 11-20 years, and constitutes 41.7 % of cases. The next affected age

group was 21-30 years, and constitutes 21.5 % of total cases. The youngest

patient in our study was 2 years, and the oldest patient was 67 years old. Mean

age of the patient was 23 years.

According to R.B.Jeffrey Jr. et al in their 1988 study mean age was 26

years. According to M.Galindo Lallego et al study mean age was 21.8 years.

72

Location of appendix

In our study we have observed retrocaecal appendix in 120 cases (75.9 %)

of total cases, pelvic in 28 cases (17.7 %), subcaecal in 4 cases (2.5 %), preileal in

2 cases (1.26 %), postileal in 2 cases (1.26 %), and subhepatic in 2 cases (1.26 %)

According to Wakeley et al 54 1933 study the appendix was retrocaecal and

retrocolic in 65.28 %, pelvic in 31.01 %, subcaecal in 2.26 %, preileal in 1 % and

postileal in 0.4 %.

Diameter of appendix

In our study we have taken the maximum outer diameter of the normal

appendix 7 mm as a sonographic criterion. Mean diameter of appendix in our

study was 9.56 mm.

M.M.Abu-Yousef et al in their 1987 study have taken the maximum outer

diameter of normal appendix was 6 mm as a sonographic criterion.

R.B.Jeffrey Jr et al in their 1988 study have taken maximum outer diameter

6 mm as a sonographic criterion for acute appendicitis. Mean diameter of their

study was 8.7 mm.

Muscle wall thickness of the appendix

In our study we have taken hypoechoic muscle wall thickness more than 2.5

mm as a sonographic criterion for acute appendicitis. Mean muscle wall thickness

in our study was 3.01 mm.

R.K.Singh et al study, they have taken muscle wall thickness more than or

equal to 2.5 mm as a criterion for acute appendicitis.

73

Sensitivity

In our study, role of Ultrasonography in diagnosis of acute appendicitis the

sensitivity was 96.1%.

According to R.B.Jeffrey Jr.et al 1988 study sensitivity was 89.9 %.

According to Harshada.M.Joshi et al 1996 study sensitivity was 96 %. In

our study the sensitivity was correlating with the above reported series.

Specificity

In our study, role of Ultrasonography in diagnosis of acute appendicitis

specificity was 95.65 %.

In R.B.Jeffrey Jr. et al 1988 study specificity was 96.2 %, Harshada.M.Joshi

et al 1996 study reported specificity of 93 %, and Puylaert et al 1986 study

reported 100 % specificity.

The specificity in our series was correlating with the above reported series.

False Negativity

In our study false negativity of 3 % was noted. These patients were obese

with thick abdominal wall, so we couldn’t locate the appendix. These were

proved to be retrocaecal appendix at surgery.

In Harshada.M.Joshi et al 1996 study a false negativity of 4 % was reported.

74

False Positivity

In our study false positivity of 1 % was noted. Ileitis of terminal ileum was

mistaken as an inflamed appendix.

In Harshada. M. Joshi et al 1996 study a false positivity of 2 % was noted.

An inflamed Meckel’s Diverticulum was mistaken as an inflamed appendix in

their patients.

Predictive value of Positive test

In our study, role of Ultrasonography in the diagnosis of acute appendicitis

predictive value of positive test was 98.66 %. In R.B.Jeffrey Jr. et al 1987 study it

was 93 %, In Harshada .M. Joshi et al 1996 study it was 98 %. So the predictive

value of positive test in our test was correlating with the above series.

Predictive value of negative test

In our study, role of Ultrasonography in the diagnosis of acute appendicitis

predictive value of negative test was 88 %. In R.B.Jeffrey Jr. et al 1988 study it

was 94.3 %, in Harshada. M. Joshi et al 1996 study it was 88 %. So, predictive

value of negative test in our study is correlating with the above reported series.

Indications for High Resolution Ultrasonography

While patients with typical clinical and laboratory findings of acute

appendicitis (70 %), can go directly to surgery. The following group of patients

should be considered for high resolution Ultrasonography.

Patients with atypical findings : Patients with atypical findings include

those without fever, Leukocytosis, nausea or vomiting and those with pain in

75

atypical location, character or duration. Such uncharacteristic clinical findings

occur in about 30 % of cases of acute appendicitis 2, especially in children, the

elderly and immuno-compromised patients. In our series, few patients examined

by Ultrasonography had atypical presentation.

Those patients that went immediately to surgery on the basis of the

sonographic findings were found to have gangrenous appendicitis. Without the

sonographic findings, surgery might have been further delayed, thus increasing

the risk of perforation and hence, morbidity and mortality.

1. Ovulating women: Ultrasonography is extremely helpful in ovulating

women, as the prevalence of gynecologic diseases that clinically mimic

acute appendicitis may lead to a negative appendectomy rate as high as

35-36 % 4. Pelvic Ultrasonography is very helpful in the diagnosis of tubo-

ovarian abscess, ectopic pregnancy, and ovarian torsion. Patients with non

revealing appendiceal, pelvic and abdominal sonographic examinations

can safely be observed clinically for one or two days, until resolution of

symptoms and return of laboratory findings to normal values.

2. Pregnant women: Clinical findings of acute appendicitis in pregnant

women are different. Besides the usual gynecologic diseases seen in

ovulating women, these patients are also susceptible to certain

complications of pregnancy such as placental abruption, and uterine

rupture, both of which may clinically mimic acute appendicitis. In addition

the appendix, especially in the second half of pregnancy, is usually

displaced from the RLQ to a cephalad and lateral position; thus

appendicitis may produce symptoms and signs that can be confused with

those of other conditions such as Cholecystitis, Pancreatitis or gastritis 26.

76

Delayed diagnosis and perforation in this group are associated with high

maternal and fetal morbidity and mortality rates. We have examined a case of

suspected appendicitis with pregnancy and proved to be acute appendicitis at

surgery. Although helpful, high resolution sonography may be technically

difficult in this group of patients, especially after 30 weeks of pregnancy, because

of the distortion of anatomic landmarks by the gravid uterus.

Role of Ultrasonography in diagnosis of diseases mimicking acute

appendicitis

Many diseases mimic acute appendicitis in their clinical presentation,

including those seen only in women of child bearing age, such as pelvic

inflammatory disease, torsion of ovarian cysts or tumors, endometriosis,

hemorrhagic corpus luteal cysts, and hemorrhagic or necrotic uterine fibroids 60.

In pregnant women, conditions such as ectopic pregnancy, placental

abruption, and uterine wall rupture can clinically resemble acute appendicitis 61.

Conditions such as acute Cholecystitis, diverticulitis, intestinal obstruction,

renal stones and perforated gastric or duodenal ulcers can pose diagnostic

problems in both sexes.

Early and accurate diagnosis of appendicitis is important, both to lower the

negative appendectomy rate and to avoid increased risk of perforation associated

with operative delay. If perforation occurs operative morbidity increases 15- fold,

and mortality increases 50- fold 4.

In a review by Gaensler et al 62, Ultrasonography was found to be 70 %

accurate in detecting nonappendiceal disease in a group of patients without

77

appendicitis in whom a specific diagnosis was made; however, half of their

patients without appendicitis had a nonspecific diagnosis of abdominal pain of

known origin. Ultrasonography was helpful in the diagnosis of various

gynecologic and visceral diseases, but was less accurate in the diagnosis of

urinary tract disease.

Ultrasonography is also helpful in the diagnosis of Campylobacter

ileocolitis and other forms of ileocolitis that can mimic acute appendicitis in their

presentation. Ultrasonography shows mural thickening of the terminal ileum and

proximal colon as well as moderately enlarged mesenteric lymph nodes 5.

Surgical intervention is not indicated in this disease.

In Immuno-compromised patients, neutropenic typhlitis can present with

RLQ pain and fever without Leukocytosis. Ultrasonography can be helpful in

differentiating this condition from acute appendicitis as hypoechoic or echogenic

thickening of the wall of the caecum and ascending colon is seen.

Ultrasonography is also helpful in the diagnosis of mesenteric adenitis,

another condition that can have a similar presentation to that of acute appendicitis 5. The inflammatory process is self limiting, and laparotomy is not indicated.

Recommendations

Patients with suspected acute appendicitis can be divided into four groups.

Patients with typical clinical and laboratory findings of acute appendicitis

constituting the first group should undergo laparotomy without delay.

Ultrasonography will not increase the accuracy of clinical diagnosis, in these

cases and may cause false sense of security with detrimental results because of

false negative results.

78

Patients with atypical clinical diagnosis and most ovulating women should

have high resolution Ultrasonographic evaluation of the RLQ. Those with a

sonographic diagnosis of acute appendicitis, constituting the second group,

should be considered for surgery regardless of their clinical symptoms, as a false

positive rate of sonography is low. With this approach, the diagnosis of acute

appendicitis may be made promptly, thus preventing or decreasing the risk of

perforation and hence the morbidity and mortality of acute appendicitis.

The third group consists of those with atypical clinical symptoms and

adequate negative sonographic examinations. The negative examination is

conclusive if the intraperitoneal structures, such as caecum, terminal ileum, psoas

muscles, and ilial vessels are visualized, and if gas can be displaced from the

colon so that the retrocaecal area may be adequately demonstrated. If the

sonographic examination of the pelvis and abdomen is not revealing, this third

group can be observed clinically until there is resolution of symptoms and signs

and return of laboratory findings to normal values.

The fourth group consists of those with negative, but technically inadequate,

ultrasonographic examinations. Depending on the degree of clinical suspicion,

these patients should be operated on, evaluated by other imaging studies such as

CT, or followed clinically.

In both the third and fourth groups, the pelvic or abdominal USG may

reveal other diseases, and the clinician is then directed to a different course of

treatment.

79

CONCLUSION

The following conclusions were made after studying 200 cases of suspected

acute appendicitis sonographically.

1. More than 63% of cases occur in 2nd and 3rd decade.

2. Males are more affected than females, Male: Female ratio was 1.5: 1.

3. Commonest Ultrasound feature in our study was target sign.

4. Commonest position of appendix in our study was retro caecal appendix.

5. Mean appendicular diameter in our study was 9.56 mm.

6. Mean appendicular muscle wall thickness in our study was 3.01 mm.

7. False negatives in our study were 6, false positives were 2.

8. Sensitivity of our study was 96.1%.

9. Specificity of our study was 95.65%.

10. Predictive value of positive test was 98.66%.

11. Predictive value of negative test was 88%.

Ultrasonography is a dynamic real time imaging technique without any

hazards of ionization as with that of X-rays. It is cost effective investigation and

not much time consuming. It can be used at bedside for examining critically ill

patients. It can also be used safely in pregnancy also.

80

So, High resolution sonography with graded compression is a very

promising examination for diagnosis of appendicitis in problem cases and in

women in their reproductive period. Because it is fast and easy to perform and

because of its high accuracy, sonography should be the primary imaging

procedure for patients suspected to have acute appendicitis. Ultrasonography is

also helpful in detecting complications of appendicitis and for other abdominal

diseases that mimic acute appendicitis.

81

SUMMARY

This study was carried out in 200 patients suspected with acute appendicitis

at Sri Adichunchanagiri Hospital and Research Centre, B.G. Nagar, Mandya from

April 2004 to September 2005.

All the patients in the study were subjected to minimum investigations like

blood for Hb %, B.T., C.T., ESR, Blood Urea, Blood sugar, Urine routine, Chest

X-ray, Plain X-ray erect abdomen, and Ultrasonography.

The age of the patients varied from 2 years to 67 years. The maximum

numbers of cases were in the age group of 11 to 30 year (63.2 %). The mean age

of the patients was 23 years. The Male: Female ratio in our study was 1.5: 1.

Among the 200 cases studied, 150 proved surgically were acute

appendicitis, 8 cases were appendicular mass, 8 cases were pelvic inflammatory

disease, 6 cases were right Ureteric calculus, 4 cases were Ileocaecal tuberculosis,

4 cases were right acute Pyelonephritis, 2 cases were twisted ovarian cyst, 2 cases

were ileitis and no abnormality was detected in 14 cases.

We have observed retro caecal appendix in 120 cases (75.9 %) of total

cases, pelvic in 28 cases (17.7 %), sub caecal in 4 cases (2.5 %), pre ileal in 2

cases (1.26 %), post ileal in 2 cases (1.26 %), and sub hepatic in 2 cases (1.26 %).

Ultrasonography is a dynamic real time imaging technique without any

hazards of ionization as with that of X-rays. It is cost effective investigation and

not much time consuming. It can be used safely in pregnancy as well.

For patients with RLQ pain Ultrasonography helps in most cases to answer

whether the pain is really due to acute appendicitis or other diseases which mimic

acute appendicitis.

82

BIBLIOGRAPHY

1. O’Connell P.Ronan “The Vermiform Appendix”, Chapter 70 Bailey &

love’s – Short Practice of Surgery, Arnold International Students

Edition, 24th edition, London, 2004: 1203-1205.

2. Deal DR “Acute appendicitis”, Sleisenger MH, Ford-tran JS (eds):

Gastrointestinal Disease – Pathophysiology, diagnosis and

management, Philadelphia, Saunders, 1973: 1494-1500.

3. Cantrell JR, Stafford ES, The diminishing mortality from appendicitis,

Ann surgery, 1955; 141: 749-758.

4. Lewis FR, Holcroft JK, Boey J et al. Appendicitis – A critical review of

diagnosis and treatment in 1000 cases, Arch surgery 1975; 110: 677-684.

5. Puylaert JBCM. Acute appendicitis: Ultrasound evaluation using graded

compression, Radiology, 1986; 158: 355-360.

6. Birnbaum BA and Jeffrey RB. CT and Sonographic evaluation of acute

right lower quadrant abdominal pain Am J Roentgen, 1998; 170:361-

371.

7. Sandra E.Benedeck, Matilde Nino-Murica, Gerald J. Bersy and Jeffrey

RB, Jr., Imaging of suspected appendicitis: Negative appendectomy and

perforation rates. Radiological Society of North America, 2002; 225(1):

131-136.

8. Carol M. Rumack, Stephaine R. Wilson, William J. Charboneau.

Chapter 8 The Gastrointestinal Tract.Diagnostic Ultrasound Volume 1.

2nd edition, 1998; 279-327.

83

9. Skandalakis JE, Gray SW, Ricketts R: “The Colon and Rectum”. In

Skandalakis JE, Gray SW (eds): Embryology for Surgeons. Baltimore,

Williams & Wilkins, 1994; 242-281.

10. Peter L. Williams, Mary Dyson; Gray’s Anatomy 37; 1993: pp 223,

1366-1367.

11. Vinay Kumar, Ramzi S.Cortan, Stanley L.Robbins, “The Gastro

Intestinal Tract”, Chapter 15 Basic Pathology, A PRISM Indian Edition,

5th edition, Bangalore, 1992; 520.

12. Babaknia A, Parsa H, Woodruff JD. Appendicitis during pregnancy.

Obstet Gynecol, 1977; 50: 40-44.

13. Mourad j, Elliott JP, Erickson L, Lisboa L. Appendicitis in pregnancy:

new information that contradicts long-held clinical beliefs. Am J Obstet

Gynecol. 2000; 182: 1027-1029.

14. Andersen B, Nielsen TF. Appendicitis in pregnancy: Diagnosis,

management and complications. Acta Obstet Gynecol Scand. 1999; 78:

758-762.

15. Barloon TJ, Brown BP, Abu-Yousef MM, Warnock N, Berbaum KS.

Sonography of acute appendicitis in pregnancy. Abdom Imaging. 1995;

20: 149-151.

16. Lim HK, Bae SH, Seo GS. Diagnosis of acute appendicitis in pregnant

women: Value of sonography. AJR Am J Roentgenol, 1992; 159: 539-

542.

17. Forsted DH, Kalbhen CL. “CT of pregnant women for urinary tract

calculi, pulmonary thromboembolism and acute appendicitis” (letter).

AJR Am J Roentgenol. 2002; 178: 128.

84

18. Firstenberg MS, Malangoni MA. Gastrointestinal surgery during

pregnancy. Gastroenterol Clin North Am. 1998; 27: 73-88.

19. Bongard F, Landers DV, Lewis F: Differential Diagnosis of appendicitis

and Pelvic Inflammatory Disease: A Prospective analysis. Am J Surg

1985; 150: 90-96.

20. Mendelzun RE, Mc Cort JJ: Acute abdomen, in Margulis AR, Burhenne

Hj(eds): “Alimentary Tract Radiology”, Vol 1 (ed 3). St Louis, Mosby,

1983, pp 391-455.

21. Shaw RE: Appendix calculi and acute appendicitis. British Journal of

Radiology, 1965; 52: 452-459.

22. Hoffmann J, Rasmussen OO. Aids in the diagnosis of acute appendicitis.

Br J Surg 1989; 76: 774-779.

23. Schisgall RM: Use of the barium swallow in the diagnosis of acute

appendicitis. Am J Surg. 1983 Nov; 146(5): 663-667.

24. Lee JH, Joeng YK, Hwang A, Macheiner P, et al: Graded compression

sonography with adjuvant use of a posterior manual compression

technique in sonographic diagnosis of acute appendicitis. Am J

Radiology, 2002; 178(4): 863-868.

25. Birnbaum A.Bernard and Wilson R.Stephaine: Appendicitis at the

Millenium, Radiological Society of North America, 2000; 215: 337-348.

26. Abu-Yousef MM, Bleicher JJ, Maher JW, et al: High – Resolution

sonography of acute appendicitis American Journal of Radiology, 1987;

149: 53-58.

85

27. Chen SC, Wang HP, Hsu HY and Lin FY, “Accuracy of Emergency

Department Ultrasonography in diagnosis of Acute appendicitis”,

American Journal of Emergency Medicine, 2000; 18(4): 449-452.

28. Rioux M. “Sonographic detection of the normal and abnormal

appendix”. AJR American Journal of Roentgenology. 1992; 158: 773-

778.

29. Puylaert JBCM. “Ultrasonography – Imaging of Acute Abdomen: Acute

Appendicitis”. Radioiogical Clinics of North America. 2003; 41: 1227-

1242.

30. Field Stuart and Morrison Lain “The Acute Abdomen”, Chapter 22

David Sutton – Text book of Radiology & Imaging, Volume 1, Churchill

livingstone international edition, 7th Edition London, 2003: 683.

31. Yacoe ME and Jeffrey RB, “Sonography of appendicitis and

diverticulitis”, Radiological Clinics of North America, 1994; 32: 899-

912.

32. Takada T., Yasuda H., Uchimaya K., Hasegawa H., Shikata J.I.:

“Ultrasonographic diagnosis of acute appendicitis in surgical

indication”. Int Surgery 1986; 71: 9-13.

33. Kao SCS, Smith WL, Abu-Yousef MM, Franken EA, Sato Y, Kimura K

and Soper RT. “Acute appendicitis in children: Sonographic findings”.

ARJ, 1989; 153:375-379.

34. Borushok KF, Jeffrey RB Jr, Laing FC, et al: “Sonographic diagnosis of

perforation in patients with acute appendicitis”. American Journal of

Radiology, 1990; 154: 275-278.

35. Bagi P, Dueholm S: “Non operative management of the ultrasonically

evaluated appendiceal mass”. Surgery, 1987; 101: 602-605.

86

36. Degani S, Shaprio I, Leibovitz Z et al. “Sonographic appearance of

appendiceal mucocele”. Journal of Ultrasound in Obstetrics and

Gynecology. 2002; 19(1): 99-101.

37. Yang SS, Gibson P, Mc Caughey RS et al: “Primary Crohn’s disease of

the appendix: Report of 14 cases and review of the literature”, Ann

Surgery. 1979; 189: 334-339.

38. Horgan JG, Chow PP, Richter JO, et al: “Computed Tomography and

Sonography in the recognition of Mucocele of the Appendix”. American

Journal of Radiology, 1984; 143: 959.

39. Yadav P, Mukherjee S, Slkarwar JS, and Sharma GL: “High Resolution

Ultrasonographic Diagnosis of Mucocele of the Appendix”. Indian

Journal of Radiology, 2003; 13(1): 33-34.

40. Chen Sc, Chem KM, Wong SCm, et al. “Abdominal Sonography

Screening of Clinically Diagnosed suspected appendicitis before

surgery”. World Journal of Surgery. 1998; 22: 449-452.

41. Pullaert J B C M. Graded compression Ultrasound in acute disease of

right lower quadrant. Semin Ultrasound CT MR 1987; 8: 385-402.

42. Puylaert J B C M, Van der werf S D J, Ulrich C, Veldhuizen R W.

Crohn’s disease of the ileocaecal region: US visualization of the

appendix. Radiology 1988; 166: 741-743.

43. Becking W B, Puylaert J B C M, Feldberg M A M, Van Leeuwen M S.

Appendiceal involvement in caecal carcinoma: Demonstration by

Ultrasound. Gastrointest Radiol 1989; 14: 170-172.

44. Rioux M, Langis P. “Primary epiploic appendagitis: Clinical, US and CT

findings in 14 cases”. Radiology. 1994; 191: 523-526.

87

45. Van Breda Vriesman AC, Lohle PNM, Coerkamp Eg, Puylaert JBCM.

Infarction of omentum and epiploic appendage: Diagnosis,

Epidemiology and Natural History. Eur Radiol. 1999; 9: 1886-1892.

46. Kessler N, Cyteval C, Gallix B, et al. “Appendicitis: Evaluation of

Sensitivity, Specificity, and Predictive values of US, Doppler US, and

Laboratory Findings”. Radiology. 2004; 230: 472-478.

47. Quillin SP, Siegel MJ. “Appendicitis: Efficacy of color Doppler

Sonography”. Radiology. 1994; 191: 557-560.

48. Quillin SP, Seigel MJ. “Diagnosis of appendiceal abscess in children

with acute appendicitis: Vaalue of Color Dopler sonography”. AJR Am J

Roentgenol. 1995; 164: 1251-1254.

49. Navarro DA, Weber PM, Kang IY, et al: Indium – III Leukocyte

imaging in acute appendicitis. AJR 1987; 148: 733-736.

50. Nishino M, Hayakawa K, Iwasuku K, Takasu K. “Magnetic resonance

imaging findings in gynecologic emergencies”. J Comput Assist Tomogr.

2003; 27: 564-570.

51. Incesu L, Coshon A, Selcuk MB, Akan H, Sozubir S, Bernay F. “Acute

appendicitis: MR Imaging and sonographic correlation”. AJR Am J

Roentgenol. 1997; 168: 669-674.

52. Hormann M, Paya K, Eibenberger K, et al. “MR Imaging in children

with nonperforated acute appendicitis: value of unenhanced MR Imaging

in sonographically selected cases”. AJR Am J Roentgenol. 1998; 171:

467-470.

53. Sharp HT. “Gastrointestinal surgical conditions during pregnancy”. Clin

Obstet Gynecol. 1994; 37: 306-315.

88

54. F.T. de Dombal, D.J. Horrocks, J.R. Staniland, and A.P. Mc Cann.

Human and computer-aided diagnosis of abdominal pain: further report

with emphasis on the performance of clinicians. British Medical

Journal, 1974, 4, 376-380.

55. Alvarado A.: A practical score for the early diagnosis of acute

appendicitis. Ann Emerg Med 1986; 15: 557-564.

56. Calder JDF, Gajraj H. Recent advances in the diagnosis and treatment of

acute appendicitis. Br J Hosp Med 1995; 54: 129-133.

57. Charles V. Mann, RCG Russel, Norman S. Williams. “The Vermiform

Appendix”, Bailey & Love’s-Short practice of surgery, 22nd edition,

London, !995; 828-841.

58. Wakeley CPG: The position of vermiform appendix. J Anat 1993; 67:

277-283.

59. Bailey LE, Finley RK Jr., Miller SF, et al: Acute appendicitis during

pregnancy. Ann Surg 1986; 52: 218-221.

60. Dunn EL, Moore EE, Elerding SC, et al: The unnecessary laparotomy

for appendicitis – can it be decreased? Am J Surg 1982; 48: 320-323.

61. Horowitz MD, Gomez GA, Sateisteban R, et al: Acute appendicitis

during pregnancy. Diagnosis and management. Arch Surg 1985; 120:

1362-1367.

62. Gaensler EH, Jeffery RB Jr., Laing FC, et al: Sonography in patients

with suspected acute appendicitis: Values in establishing alternative

diagnosis. AJR 1989; 152: 49-51.

89

PROFORMA OF CASE SHEEET

For

A CLINICAL STUDY OF ACUTE APPENDICITIS

Case No. Inpatient No. : Unit:

Name: Age: Sex:

Address: Occupation :

Socio-Economic Status :

Admitted on :

Operated on :

Discharged on :

Death:

DIAGNOSIS :

COMPLAINTS : HISTORY OF PRESENTING ILLNESS 1. Pain in the abdomen and Local pain

a) Onset b) Duration c) Nature – Dragging/Colicky/Dully aching/burning d) Relation to food or bowel habits if any e) Radiation of pain f) Relieving or aggravating factors

2. Vomiting a) Duration

b) Nature of Vomitus c) Relation to pain d) Relation to food

3. History of Fever a) Onset

b) Duration

90

PAST-HISTORY 1. History of similar complaints in the past 2. History of Hypertension, Diabetes Mellitus, Pulmonary tuberculosis,

Jaundice, Blood transfusion, or Asthma. PERSONAL HISTORY

• Diet • Appetite • Sleep • Bowel • Bladder • Smoking or consumption alcohol • Loss of weight

FAMILY HISTORY

• History of Hypertension, Diabetes mellitus, Tuberculosis, Asthma or any Allergies

EXAMINATION

General Examination

• Built and Nutrition • Pallor • Icterus • Cyanosis • Clubbing • Edema • Lymphadenopathy Vitals

Pulse BP Temperature Respiratory rate

Systemic

• Respiratory system • Cardiovascular system • Gastro Intestinal system • Genito-Urinary system • Central Nervous System

91

Abdomen Examination

Inspection

1. Abdomen

a) Size, b) Shape, c) Distension if any,

2. Umbilicus position,

3. Any visible

a) Peristalsis

b) Pulsations

c) Mass, or

d) Scar

Palpation

1. Local rise of temperature

2. Tone of the abdominal wall musculature

3. Tenderness

4. Any mass per abdomen

5. Any Free Fluid

6. Right iliac fossa

Percussion

1. Free Fluid if any

2. Obliteration of liver dullness if any.

Ausculation Peristaltic sounds heard/not heard PER RECTAL AND PER VAGINAL EXAMINATION: SCROTAL EXAMINATION:

92

INVESTIGATIONS 1. Blood Hb% TC DC P % E % M % N % ESR Blood Urea Blood Sugar 2. Urine Albumin Sugar Microscopy

3. X-ray Chest

4. Plain X-Ray of erect abdomen

5. USG abdomen

Probe tenderness Diameter of the appendix Target sign Muscle wall thickness Free fluid Appendicolith

TREATMENT 1. Conservative 2. Operative

Pre-operative Operative findings Post operative

3. Discharge note Condition at the time of discharge Advise regarding Diet Drugs

Restriction of strenuous activities

4. Follow Up OPERATIVE DIAGNOSIS FINAL DIAGNOSIS

93

MASTER CHARTSl.No. Name Age/Sex I.P.No. Clinical

Diagnosis Sonographic Findings of Appendicitis US.Diagnosis

OperativeDiagnosis

FinalDiagnosis

1 2 3 4 5 61 Chitra 28 / F 30021 Appendicitis + + - 8.4 3.1 - Ac.Appen. Retro.Appen Ac.Appen.2 Shilpa 6 / F 30291 Appendicitis + + + 9.2 3.2 - Ac.Appen. Retro.Appen Ac.Appen.3 Swami 50 / M 30330 Appendicitis + + - 7.6 3.1 - Ac.Appen. Retro.Appen Ac.Appen.4 Kempe Gowda 67 / M 30403 Appendicitis + + + 11.3 3.2 + Ac.Appen. Retro.Appen Ac.Appen.5 Prakasha 27 / M 30705 Appendicitis + + - 8.6 2.9 - Ac.Appen. Retro.Appen Ac.Appen.6 Mohana 23 / M 30919 Appendicitis + + + 10.4 3.2 - Ac.Appen. Pel.Appen. Ac.Appen.7 Harish 10 / M 30944 Appendicitis - + - 6.8 2.8 - Ac.Appen. Retro.Appen Ac.Appen.8 Pavithra 24 / F 31142 Appendicitis - - + - - - FF+P0D PID9 Aslam 9 / M 31244 Appendicitis + + - 8.8 3.0 - Ac.Appen. Retro.Appen Ac.Appen.10 Preethi 21 / F 31302 Appendicitis + + - 9.4 3.1 - Ac.Appen. Pel.Appen. Ac.Appen.11 Javed 32 / M 31376 Appendicitis + + + 11.6 3.0 + Ac.Appen. Retro.Appen Ac.Appen.12 Raju 14 / M 31186 Appendicitis + + - 8.4 2.9 - Ac.Appen. Retro.Appen Ac.Appen.13 Girisha 6 / M 31838 Appendicitis + + - 7.8 2.8 - Ac.Appen. Retro.Appen Ac.Appen.14 Rangamma 26 / F 31544 Appendicitis - - - - - - R.K.Pyelo. R.K.Pyelo.15 Manjula 20 / F 31542 Appendicitis + + + 11.0 3.3 - Ac.Appen. Retro.Appen Ac.Appen.16 Rajanna 27 / M 31622 Appendicitis + + + 8.2 2.9 - Appen.Mass Appen.Mass17 Kumar 21 / M 31556 Appendicitis + + - 9.4 3.0 - Ac.Appen. Retro.Appen Ac.Appen.18 Krupa Shankar 30 / M 31766 Append. Mass - - - - - - I.C.T.B I.C.T.B19 Nanjappa 20 / M 31964 Rec.Appendicitis + + + 12.2 3.1 - Ac.Appen. Retro.Appen Ac.Appen.20 Bhavya Rani 22 / F 31479 Appendicitis + + - 10.3 3.0 - Ac.Appen. Pel.Appen. Ac.Appen.21 Dhananjaya 30 / M 31680 Chr.Appendicitis - - - - - - NAD NAD22 Nandini 17 / F 31687 Appendicitis + + - 9.7 3.0 - Ac.Appen. Retro.Appen Ac.Appen.23 Deepak 15 / M 31700 Appendicitis + + - 8.2 2.9 - Ac.Appen. Retro.Appen Ac.Appen.24 Suresha 20 / M 31798 Appendicitis + + - 10.4 3.1 - Ac.Appen. Retro.Appen Ac.Appen.

94

25 Susheela 11 / F 31581 Appendicitis + + + 11.0 3.0 - Ac.Appen. Pel.Appen. Ac.Appen.26 Srinivas 18 / M 31632 Rec.Appendicitis - - - - - - NAD Retro.Appen Ac.Appen.27 Satish 15 / M 31774 Rec.Appendicitis + + - 7.2 2.9 - Ac.Appen. Retro.Appen Ac.Appen.28 Arundathi 24 / F 31795 Append. Mass + + - - - - Ov.Cyst Ov.Cyst29 Vijay Kumar 18 / M 31862 Rec.Appendicitis - + - 7.2 2.8 - Ac.Appen. Retro.Appen Ac.Appen.30 Raghu 15 / M 32146 Appendicitis - - - - - - NAD NAD31 Swarna 12 / F 32170 Appendicitis + + + 8.6 2.9 - Ac.Appen. Retro.Appen Ac.Appen.32 Nandeesh 20 / M 32634 Rec.Appendicitis + + - 8.3 2.8 - Ac.Appen. Pel.Appen. Ac.Appen.33 Puneeth 17 / M 32289 Rec.Appendicitis + + - 9.9 2.9 - Ac.Appen. Retro.Appen Ac.Appen.34 Huchne Gowda 61 / M 32544 Appendicitis - - - - - - Cae.Mass Cae.Mass Cae.Mass35 Manjunatha 21 / M 32849 Appendicitis - + - 12.2 3.5 - Ac.Appen. Crohn's Ileitis Crohn's Ileitis36 mamatha 27 / F 32852 Appendicitis + + + 10.7 3.1 + Ac.Appen. Post.Ileal.Appen. Ac.Appen.37 Janardhana 20 / M 32158 Appendicitis + + - 8.2 3.0 - Ac.Appen. Retro.Appen Ac.Appen.38 Veena 18 / F 32575 Appendicitis + + + 12.0 3.1 - Ac.Appen. Pel.Appen. Ac.Appen.39 Kapani Gowda 42 / M 32746 Chr.Appendicitis + + - 8.2 2.9 - Ac.Appen. Retro.Appen Ac.Appen.40 Zareena Begum 30 / F 32768 Appendicitis - - - - - - T.O.Mass T.O.Mass T.O.Mass41 Siddarth 28 / M 32759 Appendicitis + + + 9.4 3.2 - Ac.Appen. Retro.Appen Ac.Appen.42 Manjappa 29 / M 32330 Chr.Appendicitis - + - 7.0 2.9 - Ac.Appen. Retro.Appen Ac.Appen.43 Vijaya Lakshmi 25 / F 32328 Chr.Appendicitis - - - - - - NAD Pel.Appen. Ac.Appen.44 Range Gowda 35 / M 32533 Append. Mass + + - 9.2 2.8 - Appen.Mass Appen.Mass45 Chitra Devi 13 / F 32600 Appendicitis + + + 11.6 3.1 + Ac.Appen. Retro.Appen Ac.Appen.46 Yashodha 11 / F 32707 Appendicitis + + - 8.3 3.0 - Ac.Appen. Sub.Cae.Appen. Ac.Appen.47 Mohammad Aslam 52 / M 32782 Appendicitis + + - 10.7 3.0 - Ac.Appen. Retro.Appen Ac.Appen.48 Latha 14 / F 32893 Appendicitis + + - 9.6 3.1 - Ac.Appen. Retro.Appen Ac.Appen.49 Akshaya 40 / M 32945 Appendicitis + + + 11.3 3.0 + Ac.Appen. Pel.Appen. Ac.Appen.50 Shivanna 28 / M 32947 Appendicitis - - - - - - NAD NAD51 Naga Rathna 25 / F 33012 Rec.Appendicitis + + - 7.9 2.8 - Ac.Appen. Retro.Appen Ac.Appen.52 Lalitha 18 / F 33141 Appendicitis + + - 7.6 2.9 - Ac.Appen. Retro.Appen Ac.Appen.53 Ningamma 40 / F 33132 Appendicitis - - - - - - NAD NAD

95

54 Ayesha 17 / F 33033 Appendicitis + + - 10.4 3.1 + Ac.Appen. Pel.Appen. Ac.Appen.55 Raghu Ram 20 / M 33273 Rec.Appendicitis + + - - - - R.UV Cal. R.UV.Cal.56 Jayashree 12 / F 33306 Appendicitis + + + 10.8 3.0 - Ac.Appen. Retro.Appen Ac.Appen.57 Umesh 2 / M 33059 Appendicitis + + - 9.2 3.1 - Ac.Appen. Pre.Ileal.Appen. Ac.Appen.58 Leelavathy 15 / F 33299 Appendicitis + + - 8.9 3.0 + Ac.Appen. Retro.Appen Ac.Appen.59 Shantha Kumar 35 / M 33410 Appendicitis + + - 12.1 3.1 + Ac.Appen. Retro.Appen Ac.Appen.60 Malini 4 / F 33190 Appendicitis + + + 16.6 2.9 - Ac.Appen. Retro.Appen Ac.Appen.61 Gangadhar 32 / M 33842 Appendicitis - - - - - - NAD NAD62 Venkatesh 20 / M 33500 Appendicitis + + - 8.3 2.9 - Ac.Appen. Pel.Appen. Ac.Appen.63 Ramesha 23 / M 33514 Appendicitis + + - 10.4 3.0 - Ac.Appen. Retro.Appen Ac.Appen.64 Rangappa 45 / M 33862 Appendicitis + + + 9.4 3.1 - Ac.Appen. Pel.Appen. Ac.Appen.65 Jayamma 25 / F 33355 Appendicitis - - - - - - NAD NAD66 Ashraf 18 / M 33362 Appendicitis + + + 10.4 3.2 + Ac.Appen. Retro.Appen Ac.Appen.67 Nagaraju 9 / M 33946 Appendicitis + + + 9.5 2.9 + Ac.Appen. Pel.Appen. Ac.Appen.68 Tejaswini 25 / F 34169 Appendicitis - - + - - - PID PID69 Rathnamma 35 / F 34051 Appendicitis - - - 7.4 2.8 - Ac.Appen. Retro.Appen A70 Hameena Begum 35 / F 34240 Appendicitis - - + - - - PID PID71 Nanjundappa 42 / M 34281 Appendicitis + + - 8.3 3.0 - Appen.Mass Appen.Mass72 Rajesh 14 / M 34297 Appendicitis + + - 9.8 2.9 - Ac.Appen. Retro.Appen Ac.Appen.73 Kirthi 7 / F 34753 Appendicitis + + - 9.6 3.0 - Ac.Appen. Sub.Cae.Appen. Ac.Appen.74 Ravali 16 / F 34929 Appendicitis + + + 9.2 3.0 - Ac.Appen. Pel.Appen. Ac.Appen.75 Parvathamma 66 / F 34941 Appendicitis + + - 10.4 2.9 - Appen.Mass Appen.Mass76 Bhavani 3 / F 34451 Appendicitis - + - 7.3 2.8 - Ac.Appen. Retro.Appen Ac.Appen.77 Nagesh 18 / M 34614 Appendicitis - - - - - - R.UV Cal. R.UV.Cal.78 Raghavendra 20 / M 34698 Appendicitis + + + 12.2 3.1 - Ac.Appen. Retro.Appen Ac.Appen.79 Hemavathy 30 / F 34479 Appendicitis - - - - - - NAD Retro.Appen Ac.Appen.80 Lokesh 22 / M 35170 Appendicitis + + - 11.9 3.0 - Ac.Appen. Retro.Appen Ac.Appen.81 Hemanth 9 / M 35274 Appendicitis + + - 6.5 2.8 - Ac.Appen. Retro.Appen Ac.Appen.82 Gunasheela 24 / F 35450 Appendicitis + + - 9.0 3.0 - Ac.Appen. Sub.Hep.Appen. Ac.Appen.

96

83 Manje Gowda 34 / M 35320 Appendicitis - - - - - - R.UV Cal. R.UV.Cal.84 Ganesh 30 / M 35240 Appendicitis + + + 12.0 3.8 - Ac.Appen. Retro.Appen Ac.Appen.85 Prabha 6 / F 35741 Appendicitis + + - 9.1 3.0 - Ac.Appen. Retro.Appen Ac.Appen.86 Saira Bhanu 14 / F 35038 Appendicitis + + - 9.0 3.0 - Ac.Appen. Retro.Appen Ac.Appen.87 Raju 12 / M 35357 Appendicitis + + - 10.4 3.1 - Ac.Appen. Retro.Appen Ac.Appen.88 Shivalinge Gowda 59 / M 35760 Appendicitis + + + 10.8 3.0 - Ac.Appen. Retro.Appen Ac.Appen.89 Manjunatha 13 / M 35728 Appendicitis + + - 9.2 2.9 - Ac.Appen. Retro.Appen Ac.Appen.90 Shivalingamma 31 / F 35421 Appendicitis - - - - - - I.C.T.B I.C.T.B91 Savithramma 45 / F 36128 Appendicitis + + - 10.4 3.0 - Ac.Appen. Retro.Appen Ac.Appen.92 Adarsh 13 / M 36165 Appendicitis + + + 11.0 3.0 - Ac.Appen. Retro.Appen Ac.Appen.93 Devaraju 25 / M 36208 Appendicitis - - - - - - NAD NAD94 Sowbhagya 40 / F 36363 Appendicitis - + - 8.9 3.1 - Ac.Appen. Pel.Appen. Ac.Appen.95 Chandra Shekar 52 / M 36515 Appendicitis - - - - - - Cae.Mass Cae.Mass96 Sanjay 20 / M 36122 Appendicitis + + + 10.2 3.0 - Ac.Appen. Retro.Appen Ac.Appen.97 Shiva Kumar 14 / M 36116 Appendicitis + + - 9.8 2.9 - Ac.Appen. Retro.Appen Ac.Appen.98 Rahamtullah 50 / M 36125 Appendicitis + + + 10.6 3.1 - Ac.Appen. Retro.Appen Ac.Appen.99 Anand 8 / M 36127 Appendicitis + + - 8.2 3.0 - Ac.Appen. Retro.Appen Ac.Appen.

100 Huchaiah 45 / M 36251 Appendicitis + + + 12.8 3.2 - Ac.Appen. Retro.Appen Ac.Appen.101 Kempanna 45 / M 36450 Appendicitis + + + 12.7 3.1 - Ac.Appen. Retro.Appen Ac.Appen.102 Nataraj 8 / M 36771 Appendicitis + + - 8.2 3.0 - Ac.Appen. Retro.Appen Ac.Appen.103 Nanjunde Gowda 50 / M 36781 Appendicitis + + + 10.6 3.1 - Ac.Appen. Retro.Appen Ac.Appen.104 Krishna 14 / M 36929 Appendicitis + + - 9.8 2.9 - Ac.Appen. Retro.Appen Ac.Appen.105 Srikanth 20 / M 36997 Appendicitis + + + 10.2 3.0 - Ac.Appen. Retro.Appen Ac.Appen.106 Puttanna Gowda 52 / M 37003 Appendicitis - - - - - - Cae.Mass Cae.Mass Cae.Mass107 Kempamma 40 / F 37127 Appendicitis - + - 8.9 3.1 - Ac.Appen. Pel.Appen. Ac.Appen.108 Chikkanna 25 / M 37199 Appendicitis - - - - - - NAD NAD109 Ramesh 13 / M 37256 Appendicitis + + + 10.9 3.0 - Ac.Appen. Retro.Appen Ac.Appen.110 Bhagyamma 45 / F 37463 Appendicitis + + - 10.3 2.9 - Ac.Appen. Retro.Appen Ac.Appen.111 Bhageerathi 31 / F 37555 Appendicitis - - - - - - I.C.T.B I.C.T.B

97

112 Shiv Murthy 13 / M 37654 Appendicitis + + - 9.2 3.0 - Ac.Appen. Retro.Appen Ac.Appen.113 Ahmed Kareem 59 / M 37669 Appendicitis + + + 10.8 3.1 - Ac.Appen. Retro.Appen Ac.Appen.114 Osman Basha 12 / M 37785 Appendicitis + + - 10.4 3.1 - Ac.Appen. Retro.Appen Ac.Appen.115 Shivani 14 / F 37845 Appendicitis + + - 9.0 3.0 - Ac.Appen. Retro.Appen Ac.Appen.116 Asha 6 / F 37897 Appendicitis + + - 9.1 3.0 - Ac.Appen. Retro.Appen Ac.Appen.117 Jagadeesh 30 / M 38103 Appendicitis + + + 12.0 3.8 - Ac.Appen. Retro.Appen Ac.Appen.118 Rame Gowda 34 / M 38116 Appendicitis - - - - - - R.UV Cal. R.UV.Cal.119 Vijaya Devi 24 / F 38204 Appendicitis + + - 9.0 3.0 - Ac.Appen. Sub.Hep.Appen. Ac.Appen.120 Harsha 9 / M 38287 Appendicitis + + - 6.5 2.8 - Ac.Appen. Retro.Appen Ac.Appen.121 Shankar 22 / M 38487 Appendicitis + + - 11.9 3.0 - Ac.Appen. Retro.Appen Ac.Appen.122 Chaya Devi 30 / F 38660 Appendicitis - - - - - - NAD Retro.Appen Ac.Appen.123 Lakshman 20 / M 38784 Appendicitis + + + 12.2 3.1 - Ac.Appen. Retro.Appen Ac.Appen.124 Manju 18 / M 38923 Appendicitis - - - - - - R.UV Cal. R.UV.Cal.125 Baby 3 / F 38956 Appendicitis - + - 7.3 2.8 - Ac.Appen. Retro.Appen Ac.Appen.126 Sujathamma 66 / F 39302 Appendicitis + + - 10.4 2.9 - Appen.Mass Appen.Mass127 Rama Devi 16 / F 39410 Appendicitis + + + 9.2 3.0 - Ac.Appen. Pel.Appen. Ac.Appen.128 Aruna 7 / F 39763 Appendicitis + + - 9.6 3.0 - Ac.Appen. Sub.Cae.Appen. Ac.Appen.129 Babu 14 / M 39894 Appendicitis + + - 9.8 2.9 - Ac.Appen. Retro.Appen Ac.Appen.130 Hucche Gowda 42 / M 39940 Appendicitis + + - 8.3 3.0 - Appen.Mass Appen.Mass131 Fatima Begum 35 / F 40134 Appendicitis - - + - - - PID PID132 Puttamma 35 / F 40324 Appendicitis - - - 7.4 2.8 - Ac.Appen. Retro.Appen Ac.Appen.133 Suchitra 25 / F 41387 Appendicitis - - + - - - PID PID134 Malik 9 / M 41985 Appendicitis + + - 9.5 2.9 + Ac.Appen. Pel.Appen. Ac.Appen.135 G.Hegde 18 / M 42357 Appendicitis + + + 10.4 3.2 + Ac.Appen. Retro.Appen Ac.Appen.136 Renuka 25 / F 42578 Appendicitis - - - - - - NAD NAD137 Rangappa 45 / M 42857 Appendicitis + + + 9.4 3.2 - Ac.Appen. Pel.Appen. Ac.Appen.138 Rama Krishna 23 / M 42907 Appendicitis + + - 10.4 3.0 - Ac.Appen. Retro.Appen Ac.Appen.139 Yesudas 20 / M 43266 Appendicitis + + - 8.3 2.9 - Ac.Appen. Pel.Appen. Ac.Appen.140 Bala Krishna 32 / M 18 Appendicitis - - - - - - NAD NAD

98

141 Gnanashree 4 / F 76 Appendicitis + + + 16.6 2.9 - Ac.Appen. Retro.Appen Ac.Appen.142 Kamal 35 / M 97 Appendicitis + + + 12.1 3.1 + Ac.Appen. Retro.Appen Ac.Appen.143 Lakshmi 15 / F 146 Appendicitis + + - 8.9 3.0 - Ac.Appen. Retro.Appen Ac.Appen.144 Arjun 2 / M 167 Appendicitis + + - 9.2 3.1 - Ac.Appen. Pre Ileal Appen. Ac.Appen.145 Gayathri 12 / F 186 Appendicitis + + + 10.8 3.0 - Ac.Appen. Retro.Appen Ac.Appen.146 Muralidhar 20 / M 207 Appendicitis + + - - - - R.UV Cal. R.UV.Cal.147 Savithri 17 / F 236 Appendicitis + + - 10.4 3.1 - Ac.Appen. Pel.Appen. Ac.Appen.148 Mariamma 40 / F 276 Appendicitis - - - - - - NAD NAD149 Shobha 18 / F 294 Appendicitis + + - 7.6 2.9 - Ac.Appen. Retro.Appen Ac.Appen.150 Praveena 25 / F 387 Appendicitis + + - 7.9 2.8 - Ac.Appen. Retro.Appen Ac.Appen.151 Amarnath 28 / M 395 Appendicitis - - - - - - NAD NAD152 Vijay Kumar 40 / M 406 Appendicitis + + + 11.3 3.0 - Ac.Appen. Pel.Appen. Ac.Appen.153 Sunitha 14 / F 453 Appendicitis + + - 9.6 3.1 - Ac.Appen. Retro.Appen Ac.Appen.154 Devappa 52 / M 483 Appendicitis + + - 10.7 3.0 - Ac.Appen. Retro.Appen Ac.Appen.155 Devika 11 / F 511 Appendicitis + + - 8.3 3.0 - Ac.Appen. Sub.Cae.Appen. Ac.Appen.156 Rani 13 / F 548 Appendicitis + + + 11.6 3.1 - Ac.Appen. Retro.Appen Ac.Appen.157 Dharmendra 35 / M 581 Appendicitis + + - 9.2 2.8 - Appen.Mass Appen.Mass158 Padmavathy 25 / F 603 Appendicitis - - - - - - NAD Pel.Appen. Ac.Appen.159 Chandru 29 / M 639 Appendicitis - + - 6.9 2.9 - Ac.Appen. Retro.Appen Ac.Appen.160 Bhaskar 28 / M 674 Appendicitis + + + 9.4 3.2 - Ac.Appen. Retro.Appen Ac.Appen.161 Sivani 30 / F 712 Appendicitis - - - - - - T.O.Mass T.O.Mass162 Zameer 42 / M 739 Appendicitis + + - 8.2 2.9 - Ac.Appen. Retro.Appen Ac.Appen.163 Sheela 18 / F 763 Appendicitis + + + 12.0 3.1 - Ac.Appen. Pel.Appen. Ac.Appen.164 Ashok 20 / M 799 Appendicitis + + - 8.2 3.0 - Ac.Appen. Retro.Appen Ac.Appen.165 Bharathi 27 / F 823 Appendicitis + + + 10.7 3.1 + Ac.Appen. Post Ileal Appen. Ac.Appen.166 Dinesh 21 / M 843 Appendicitis - + - 12.2 3.5 - Ac.Appen. Crohn's Ileitis Crohn's Ileitis167 Javare Gowda 61 / M 869 Appendicitis - - - - - - Cae.Mass Cae.Mass Cae.Mass168 Anil Gowda 17 / M 894 Appendicitis + + - 9.9 2.9 - Ac.Appen. Retro.Appen Ac.Appen.169 Arun Kumar 20 / M 932 Appendicitis + + - 8.3 2.8 - Ac.Appen. Pel.Appen. Ac.Appen.

99

170 Ganga 12 / F 980 Appendicitis + + + 8.6 2.9 - Ac.Appen. Retro.Appen Ac.Appen.171 Vasu 15 / M 1023 Appendicitis - - - - - - NAD NAD172 Umesha 18 / M 1085 Appendicitis - + - 7.2 2.8 - Ac.Appen. Retro.Appen Ac.Appen.173 Indiramma 24 / F 1145 Appendicitis + + - - - - Ov.Cyst Ov.Cyst174 Gopi Nath 15 / M 1197 Appendicitis + + - 7.2 2.9 - Ac.Appen. Retro.Appen Ac.Appen.175 Harish Gowda 18 / M 1219 Appendicitis - - - - - - NAD Retro.Appen Ac.Appen.176 Prashanthi 11 / F 1537 Appendicitis + + + 11.0 3.0 - Ac.Appen. Pel.Appen. Ac.Appen.177 Kalyan 20 / M 1873 Appendicitis + + - 10.4 3.1 - Ac.Appen. Retro.Appen Ac.Appen.178 Vishwanath 15 / M 2093 Appendicitis + + - 8.2 2.9 - Ac.Appen. Retro.Appen Ac.Appen.179 Ragini 17 / F 2319 Appendicitis + + - 9.7 3.0 - Ac.Appen. Retro.Appen Ac.Appen.180 Krishna Chaithanya 30 / M 2587 Appendicitis - - - - - - NAD NAD181 Deepika 22 / F 2777 Appendicitis + + - 10.3 3.0 - Ac.Appen. Pel.Appen. Ac.Appen.182 Pradeep 20 / M 2934 Appendicitis + + + 12.2 3.1 - Ac.Appen. Retro.Appen Ac.Appen.183 Nanda Kumar 30 / M 3245 Appendicitis - - - - - - I.C.T.B I.C.T.B184 Mallikarjun 21 / M 3689 Appendicitis + + - 9.4 3.0 - Ac.Appen. Retro.Appen Ac.Appen.185 B.Shetty 27 / M 3889 Appendicitis + + + 8.2 2.9 - Appen.Mass Appen.Mass186 Roopa 20 / F 3996 Appendicitis + + + 11.0 3.3 - Ac.Appen. Retro.Appen Ac.Appen.187 Lakshmamma 26 / F 3872 Appendicitis - - - - - - R.K.Pyelo. R.K.Pyelo.188 Praveen 6 / M 4320 Appendicitis + + - 7.8 2.8 - Ac.Appen. Retro.Appen Ac.Appen.189 Nagendra Prasad 14 / M 4429 Appendicitis + + - 8.4 2.9 - Ac.Appen. Retro.Appen Ac.Appen.190 Sudarshan 32 / M 4598 Appendicitis + + + 11.6 3.0 + Ac.Appen. Retro.Appen Ac.Appen.191 Vani 21 / F 4881 Appendicitis + + - 9.4 3.1 - Ac.Appen. Pel.Appen. Ac.Appen.192 Naveen 9 / M 4982 Appendicitis + + - 8.8 3.0 - Ac.Appen. Retro.Appen Ac.Appen.193 Sapna 24 / F 4992 Appendicitis - - + - - - FF+P0D PID194 Kishore 10 / M 5005 Appendicitis - + - 7.0 2.8 - Ac.Appen. Retro.Appen Ac.Appen.195 Lakshmi Kanth 23 / M 5132 Appendicitis + + + 10.4 3.2 - Ac.Appen. Pel.Appen. Ac.Appen.196 Manoj 27 / M 5167 Appendicitis + + - 8.6 2.9 - Ac.Appen. Retro.Appen Ac.Appen.197 Srinivasa Murthy 67 / M 5375 Appendicitis + + + 11.3 3.2 + Ac.Appen. Retro.Appen Ac.Appen.198 Shafiq Muhammad 50 / M 5398 Appendicitis + + - 7.6 3.1 - Ac.Appen. Retro.Appen Ac.Appen.

100

199 Madhuri 6 / F 5400 Appendicitis + + + 9.2 3.2 - Ac.Appen. Retro.Appen Ac.Appen.200 Vijayamma 28 / F 5493 Appendicitis + + - 8.4 3.1 - Ac.Appen. Retro.Appen Ac.Appen.

101