Ultrasonography-triggered diagnosis of putrid, ulcero-phlegmonous, hemorrhagic appendicitis and periappendicitis with an atypical symptom pattern: a case report

Abstract

Background: Asymptomatic and oligosymptomatic appendicitis are rare and challenging diagnoses that should not be missed.

Case presentation: A young female patient presented with mild to moderate pain in the middle and lower abdomen, and the results of physical examination, including digital rectal examination, were otherwise non-contributory. Ultrasonography demonstrated a marked increase of the outer appendiceal diameter up to 12 mm and a trace of free liquid around the terminal ileum. Subsequent surgical exploration and histological examination allowed for a final diagnosis of putrid, ulcero-phlegmonous, hemorrhagic appendicitis and periappendicitis.

Conclusions: Ultrasonography is increasingly used for the diagnosis of appendiceal inflammation, particularly in military medical settings. Increases in the outer appendiceal diameter up to >6 mm under compression have recently been demonstrated to be indicative of acute appendicitis. At a minimum, in cases with doubtful physical examination results, ultrasonography should be considered as an element in the diagnosis of acute appendicitis.

Keywords: Acute appendicitis; Oligosymptomatic; Surgery; Ultrasound.

Fig. 1

Ultrasonography of the abdomen. An ultrasound-triggered suspicion of acute appendicitis was based on the free liquid around the terminal ileum, the intestinal cockade sign and the increase of the wall thickness of the proximal appendix to 3 mm. D1 (2.7 mm) ist equal to the increased wall thickness with weak echo signal intensity. D2 (6.8 mm) is equal to the diameter of the inflamed appendix in its proximal part

Fig. 2

Intraoperative situs with an inflamed phlegmonous appendix. The suboptimal shooting angle and range make the observation of the anatomical relations difficult, which reflects the real-life surgical situation