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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

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and transvaginal pelvic ultrasound, which

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demonstrated a viable first-trimester

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pregnancy without acute pathology.

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Because the pelvic ultrasound was normal,

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but the patient was having persistent

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pain, the referring clinicians also

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ordered a limited right lower quadrant

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ultrasound to evaluate for appendicitis.

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We can see that some of the first images

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obtained by the sonographer are not of the right

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lower quadrant, but of the right upper quadrant.

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In patients who are presenting with acute

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abdominal pelvic pathology, particularly

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in the context of early pregnancy, it's

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important to examine the upper abdominal

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quadrants to make sure that there's not a

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large volume of free fluid within the abdomen.

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These are transabdominal ultrasound

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images of the right lower quadrant.

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And we can see that the sonographer is panning

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back and forth and is showing us an elongated,

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thickened, hypoechoic tubular structure.

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It has a gut signature about it

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when we turn on this structure and

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can view it in the axial plane.

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And so what I'm focusing on in these

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images is this ring-like, concentric,

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hypoechoic, and hyperechoic structure

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in the right lower quadrant.

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If we pan through these images, we can see

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that this structure disappears and is blind

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ending. We can also trace it back to the

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cecum, which is on this side of the screen.

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And so this was identified

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as the patient's appendix.

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This was extremely tender

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to transducer palpation.

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We can see a small amount of free fluid

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adjacent to the appendix, and the sonographers,

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when they identify the appendix, will

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attempt something called graded compression,

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which is where they'll apply pressure to the

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appendix with the abdominal ultrasound probe

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along the length of the appendix to attempt

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to elicit pain and also try to collapse the

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appendix to show that it is not obstructed.

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So in patients who have acute appendicitis,

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often there is some obstructing lesion

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or stone near the appendiceal orifice, and

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the appendix will not compress and will be

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extremely tender on transducer palpation.

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These are additional transabdominal

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ultrasound images of the right lower quadrant.

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We can see in better detail the

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stool and fluid-filled cecum here

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on the left side of the screen.

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And we can see this tubular structure

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that is arising from the cecum.

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We can see a gut signature here, that

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kind of three-layered appearance.

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And this appendix is distended and filled

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with fluid and debris and was extremely tender

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to transducer palpation when the patient

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was being evaluated by the sonographer.

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And if we measure this appendix, it

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only measures about six millimeters,

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but because the patient was symptomatic,

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and because the appendix had this distended

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non-compressible appearance, we were able

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to make a diagnosis of acute appendicitis.

Report

Faculty

Erin Gomez, MD

Assistant Professor of Radiology

Johns Hopkins Hospital

Tags

Women's Health

Ultrasound

Non-infectious Inflammatory

Gynecologic (GYN)

Genitourinary (GU)

Gastrointestinal (GI)

Body

Appendix

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