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This is a transabdominal ultrasound

0:03

in a pregnant patient presenting

0:05

with right lower quadrant pain.

0:07

The patient had already had a transabdominal

0:10

and transvaginal pelvic ultrasound, which

0:13

demonstrated a viable first-trimester

0:16

pregnancy without acute pathology.

0:19

Because the pelvic ultrasound was normal,

0:21

but the patient was having persistent

0:23

pain, the referring clinicians also

0:26

ordered a limited right lower quadrant

0:28

ultrasound to evaluate for appendicitis.

0:32

We can see that some of the first images

0:34

obtained by the sonographer are not of the right

0:37

lower quadrant, but of the right upper quadrant.

0:40

In patients who are presenting with acute

0:43

abdominal pelvic pathology, particularly

0:46

in the context of early pregnancy, it's

0:48

important to examine the upper abdominal

0:50

quadrants to make sure that there's not a

0:52

large volume of free fluid within the abdomen.

0:56

These are transabdominal ultrasound

0:58

images of the right lower quadrant.

1:00

And we can see that the sonographer is panning

1:03

back and forth and is showing us an elongated,

1:06

thickened, hypoechoic tubular structure.

1:10

It has a gut signature about it

1:12

when we turn on this structure and

1:14

can view it in the axial plane.

1:17

And so what I'm focusing on in these

1:18

images is this ring-like, concentric,

1:23

hypoechoic, and hyperechoic structure

1:25

in the right lower quadrant.

1:27

If we pan through these images, we can see

1:29

that this structure disappears and is blind

1:32

ending. We can also trace it back to the

1:35

cecum, which is on this side of the screen.

1:37

And so this was identified

1:39

as the patient's appendix.

1:41

This was extremely tender

1:42

to transducer palpation.

1:44

We can see a small amount of free fluid

1:46

adjacent to the appendix, and the sonographers,

1:49

when they identify the appendix, will

1:51

attempt something called graded compression,

1:54

which is where they'll apply pressure to the

1:56

appendix with the abdominal ultrasound probe

1:59

along the length of the appendix to attempt

2:01

to elicit pain and also try to collapse the

2:04

appendix to show that it is not obstructed.

2:08

So in patients who have acute appendicitis,

2:10

often there is some obstructing lesion

2:13

or stone near the appendiceal orifice, and

2:15

the appendix will not compress and will be

2:18

extremely tender on transducer palpation.

2:22

These are additional transabdominal

2:24

ultrasound images of the right lower quadrant.

2:26

We can see in better detail the

2:29

stool and fluid-filled cecum here

2:32

on the left side of the screen.

2:35

And we can see this tubular structure

2:37

that is arising from the cecum.

2:41

We can see a gut signature here, that

2:44

kind of three-layered appearance.

2:46

And this appendix is distended and filled

2:49

with fluid and debris and was extremely tender

2:52

to transducer palpation when the patient

2:54

was being evaluated by the sonographer.

2:56

And if we measure this appendix, it

2:58

only measures about six millimeters,

3:01

but because the patient was symptomatic,

3:03

and because the appendix had this distended

3:05

non-compressible appearance, we were able

3:07

to make a diagnosis of acute appendicitis.