An 83-year-old woman presentedwith a 2-day history of sharp rightflank and right lower quadrant (RLQ)pain. Previously, she had been healthyand she denied any urinary symptomsor change in bowel habit. She wasafebrile and her vital signs were nor-mal; she had RLQ tenderness but no

peritoneal signs. Plain radiographs (3views of the abdomen) were nonspe-cific. High-resolution, real-time ultra-sonography (US) with graded com-pression was used to assess the patientfor possible appendicitis (Figs. 1, 2, 3and 4).US revealed a blind-ended segment

of bowel in the RLQ that was non-compressible and without peristalsis(Fig. 1), consistent with an inflamedappendix. In the transverse plane, theappendix is seen as a target lesion(Fig. 2). The diameter of the appen-dix was 8.8 mm in the anterior–poste-rior dimension (Figs. 1 and 2). An ap-

Surgical ImagesImagier chirurgical

ULTRASOUND DIAGNOSIS OF ACUTE APPENDICITIS

Section Editors: David P. Girvan, MD, and Nis Schmidt, MD

Submitted by Emma.J. Patterson, MD, and A.R. Jean Buckley, MB, Department of Surgery, Vancouver Hospital and Health Sciences Centre, Vancouver, BC

Submissions to Surgical Images should be sent to Dr. David P. Girvan, Victoria Hospital Corporation, PO Box 5375, Station B, London ON N6A 5A5 or to Dr. Nis Schmidt,Department of Surgery, St. Paul’s Hospital, 1081 Burrard St., Vancouver BC V6Z 1Y6, with a copy of the submitting letter to Dr. Jonathan L. Meakins, Rm. S10.34, RoyalVictoria Hospital, 687 Pine Ave. W, Montreal QC H3A 1A1

© 1997 Canadian Medical Association

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FIG. 2 FIG. 1

pendicolith (white arrows) withacoustic shadowing was demonstratedin the base of the appendix in bothlongitudinal and transverse planes(Figs. 3 and 4). The patient under-went appendectomy that evening andgangrenous acute appendicitis wasconfirmed pathologically.The technique of graded compres-

sion US for the diagnosis of acute appendicitis was first described byPuylaert1 in 1986. Using the ultra-sonographic criterion of visualizationof a noncompressible appendix, Jef-frey, Laing and Lewis2 found that the

sensitivity of US in the diagnosis ofacute appendicitis was 89%, with aspecificity of 95%. In the 90 patientsthey assessed with suspected acute ap-pendicitis, the positive predictive valuewas 89% and the negative predictivevalue was 95%.High-resolution real-time US with

a graded compression technique mayreduce the number of normal appen-dices removed, particularly in ovulat-ing females, in whom up to 40% of ap-pendectomy specimens show nopathognomic evidence of inflamma-tion.3

References

1. Puylaert JBCM. Acute appendicitis:US evaluation using graded compres-sion. Radiology 1986;158:355-60.

2. Jeffrey RB, Laing FC, Lewis RF.Acute appendicitis: high-resolutionreal-time US findings. Radiology1987;163:11-4.

3. Dunn EL, Moore EE, Eldering SC,Murphy JR. The unnecessary laparo-tomy for appendicitis: Can it be de-creased? Am Surg 1982;48:320-3.

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FIG. 3 FIG. 4