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Rechter fossa syndroom5/12/2013
Terugkomdag Heelkunde
Casus 1 – Nils Veressen– Man, 22 jaar
• Huidig probleem– Gisteren op werk abdominale last en algemene
malaise. Vandaag voelde hij zich beter, maar ging toch naar de huisarts. Deze stuurde hem door naar echografie, omwille van heel lichte gevoeligheid in het rechter hypogastrium.
– Deze echo toonde het beeld van een beginnende acute appendicitis, waarna de patiënt naar spoed verwezen werd
• Anamnese– Welke ?...
HistoryCommon Complaints:
Abdominal painChange in appetiteDysphagia/
OdynophagiaNausea/VomitingJaundice
Change in bowel habitsMelena/
HematocheziaHemorrhoids
Casus 1 – Nils Veressen– Man, 22 jaar
• Anamnese– Er is geen nausea of braken. Er is ook geen
ziektegevoel. De patiënt heeft vandaag ook geen abdominale last meer gehad.
– Normale eetlust en normale stoelgang zijn aanwezig.
– De patiënt heeft 4 pakjaren (sporadisch gebruik van cannabis) en een lichte allergie voor huisstofmijt. De patiënt heeft geen vervoerspijn.
• Verdere anamnese, welke ?...
Casus 1 – Nils Veressen– Man, 22 jaar
• Medicatie– Xyzall
• Voorgeschiedenis– IBS
• Familiale voorgeschiedenis– “moeder heeft slechte bloedvaten”
• Klinisch onderzoek– Welke ?...
Anatomy Regions (Anatomical) Quadrants (Clinical)
Surface Anatomy
Exam OrderInspectionAuscultation
Percussion or palpation can alter bowel sound frequency
PercussionPalpation
Abdominal Physical ExamPalpation
Start farthest from pain and move towards it
4 abdominal quadrantsLight palpationDeep palpation
Peritoneal inflammationPain with coughing, gentle palpationInvoluntary rigidityRebound tenderness
Abdominal Physical ExamPalpation - Right Lower
QuadrantCecumVermiform appendix
McBurney’s pointRovsing’s signPsoas signObturator sign
Most of ileumAscending colon: inferior partRight ovaryRight uterine tubeRight spermatic cordUterus (if enlarged)Urinary bladder (if full)
Abdominal Physical ExamPalpation - Right Lower
QuadrantCecumVermiform appendix
McBurney’s pointRovsing’s signPsoas signObturator sign
Most of ileumAscending colon: inferior partRight ovaryRight uterine tubeRight spermatic cordUterus (if enlarged)Urinary bladder (if full)
Abdominal Physical ExamPalpation - Right Lower
Quadrant
Casus 1 – Nils Veressen– Man, 22 jaar
• Klinisch onderzoek
Casus 1 – Nils Veressen– Man, 22 jaar
• Klinisch onderzoek– Geen koorts (36,4°C)– Hartritme: 80; Bloeddruk: 11,7, normale
capillaire refill– Comfortabele patiënt– Soepel abdomen, geen diepe drukpijn.– Geen loslaatpijn, geen percussiepijn– Rovsing, Mc Burney negatief– Geen nierslagpijn
• Labo– Welke ?...
Casus 1 – Nils Veressen– Man, 22 jaar
• Labo• Extern uitgevoerd, nog niet alle waarden werden
bepaald:– Leukocyten, leukocytenformule, MCH, MCHC,
thrombocyten waren normaal– Nog niet bepaald: CRP, ijzer, ferritine, B12,
glucose, creatinine, GFR, SGOT, SGPT, gamma-GT, alk. fosf., LDH, VIT D-25
• Differentieel diagnose ?...
More common in adults More common in the elderly
Adult females Genitourinary Medical
Appendicitis, Appendix abscess
Inflammatorybowel disease
Caecal tumour Ruptured ectopicpregnancy
Ureteric calculus Pneumonia
Gastroenteritis Epiploic appendagitis
Caecal perforation Adnexal torsion Urinary tractinfection
Diabetic ketoacidosis
Intestinal obstruction
Acute cholecystitis/ascending cholangitis
Acute diverticulitis Ruptured/torsionovarian cyst
Pyelonephritis Nerve rootentrapment
Pancreatitis, Peptic ulcer perforation
Inguinal or femoralhernia
Caecal or sigmoidvolvulus
Pelvic inflammatorydisease
Testicular torsion Herpes zoster
Carcinoid Ischaemic bowel Abdominal aorticaneurysm
Endometriosis Acute porphyria
Lymphoma Constipation Ruptured ovarianfollicle
Acute appendicitis Most common cause of acute RIF pain Clinical diagnosis on patient history and
physical examination– Any age, but most common 10-20 years– Abdominal pain
• Colicky, central abdominal pain• Followed by vomiting and migration of pain to RIF
(50%)– Loss of appetite, constipation, nausea – Pyrexia, tachycardia and localized
tenderness– Accuracy for clinical diagnosis
• Men : 80-90% Women : 60-80%
Conventional surgical wisdom is based on the belief that an inverse relationship exists between the negative appendectomy rate (NAR), i.e. removal of a non-inflamed appendix, and the perforation rate
Thus, a false-negative appendectomy rate of 15–23% is regarded as an index of appropriate management and the failure to maintain such a surgical threshold is an indication of insufficient surgical aggression, with an attendant risk of an excessive rate of perforation
Acute appendicitis
Crohn’s disease Although inflammatory bowel disease is
usually a chronic condition, flare-ups may present acutely
Peak age of onset 15-30 years Many cases of Crohn’s diagnosed during
work-up of acute LRQP since ileocecal region is most commonly affected– Apposed to ulcerative colitis which dominates the left colon
CT best imaging modality– Two most common imaging findings
• Eccentric wall thickening• Mucosal hyperenhancement
Crohn’s disease CT imaging
– Presence of intramural fat indicates chronic changes
– Segmental involvement with skipped (normal) regions
• vs ulcerative colitis – involves bowel in more continuous fashion
– Comb sign• Engorgement of the vasa recta penetrating the bowel
wall• Advanced, extensive and active Chron’s disease
– Creeping fat sign • Fibrofatty proliferation along the mesenteric border of
the affected bowel - almost pathagnomonic– Complications
• Small bowel strictures causing obstruction• Fistulas and abscesses
Crohn’s disease : Thickened terminal ileum ; diagnosis confirmed at histology
Thickened terminal ileum ; strictures ; mucosal hyperenhancement ; proliferation of mesenteric fat (black arrow)
Y shaped fistula : Cecum (arrowhead) ; terminal ileum (white arrow) ; psoas abscess (*)
Infectious enterocolitis Infectious enterocolitis have symptoms
similar to viral gastroenteritis Most cases require no imaging
– In cases of severe or persistent imaging is helpful for differentiation from alternative diagnosis
Most common organisms– Yersinia enterocolitica– Campylobacter jejeni– Salmonella enteritidis
Non-specific CT findings– Circumferencial mural thickening
of terminal ileum and cecum– Homogenous mural enhancement– Adjacent lymphadenopathy
Neutropenic colitis (Typhlitis) Neutropenic patient undergoing
chemotherapy RLQP, fever, diarrhoea, ± peritonitis CT is study of choice if suspected
– Risk of bowel perforation with contrast enema or colonoscopy
Typhlitis usually involves the right colon, but terminal ileum and transverse colon may be involved
CT findings– Cecal distension– Circumferential wall thickening with areas of
low attenuation due to edema or necrosis– Inflammatory stranding of adjacent
mesenteric fat, ± lymphadenopathy
Neutropenic colitis (Typhlitis) : cecal mural thickening (white arrow) ; normal left colon wall (black arrow) ; pericecal lymphadenopathy (arrowhead)
Diverticulitis One of the most common causes of
acute abdominal pain in the elderly Left and sigmoid colon predominantly
affected Less commonly right colon and cecum
may be affected – mimicking appendicitis
CT investigation of choice– Asymmetric or circumferential colonic wall
thickening– Associated focal pericolic fat stranding– Inflammed diverticulum often visible at
level of maximal fat stranding– Normal appendix is important in
differentiating from appendicitis– Pericolic lymphnodes suggests malignancy
rather than diverticulitis
Diverticulitis Rare causes
– Aquired small bowel diverticula• Mucosal herniation of bowel at sites of
vscular entry• Mesenteric border of terminal ileum < 7,5
cm from ileocecal valve– Meckel diverticulum
• Most common congenital abnormality of the GI tract
• Omphalomesenteric duct does not obliterate during development
• Anti-mesenteric border of ileum, ± 100 cm from ileocecal valve
• May contain ectopic gastric mucosa– Mucosal ulceration and GIT bleeding
Diverticulitis : Multiple right colonic diverticula ; adjacent fat stranding (arrow) ; sigmoid diverticula with no fat stranding (arrowheads)
Diverticulitis : Multiple sigmoid diverticula (straight white arrows) ; thick walled sigmoid colon (curved white arrow) ; mesenteric fat stranding (black arrow)
Epiploic appendagitis Round fat containing peritoneal
pouches arising from serosal surface of the colon – 0,5 – 5 cm in lentgh– More common in left and sigmoid
colon Uncommon and self limiting
condition Mostly middle aged men Caused by torsion or
venous thrombosis of the epiploic appendages
CT findings– Pericolic, round tot oval lesion
of fat attenuation with a hyperattenuating rim
Mesenteric adenitis Primary mesenteric adenitis
defined as– Clustered (>3) right sided
lymphnodes in small bowel mesentery or anterior to psoas muscle
– Larger than 5mm– No identifiable acute inflammatory
condition More common in children
– Acute RLQP, fever, leukocytosis Diagnosis of exclusion
Malignancies LRQP may be the intial presentation of
malignancy involving the ileocecal region Especially in event of complications
like perforation or abscess Adenocarcinoma
– >95% of all malignant cecal masses– Focal concentric mass with overhanging
shoulders– Associated enlarged pericolic nodes
Lymphoma– 80% of lymphoma of ileum and colon occur in
ileocecal region• Peyer patches (lymphoid tissue) develop in terminal
ileum– Older patients 50-70 yrs
Malignancies Lymphoma
– Non-specific symptoms (weight loss and abd pain), so often presents late
– Four forms of ileocecal lymphoma• Circumferential or constrictive
– Most common and may mimic adenocarcinoma
– Usually longer segment affected more gradual transition fromtumor to normal bowel
– Lack of bowel obstruction in presence of a large massshould raise suspicion of lymphoma
• Polypoid• Ulcerative• Aneurysmal
Intussusception Rare in adults (<5%)
– Mostly idiopathic in children ; <2yrs (40% 3-6mnths)
– Adults secondary to lead point – benign or malignant neoplasm
Target shaped bowel-within-bowel appearance is the classic appearance on axial scans and is pathognomonic
Cecal volvulus Rare condition in patients with abnormally
mobile cecum– Due to congenital or acquired abnormal fixation
to the posterior parietal peritoneum Predisposing or triggering factors
– Previous laparotomy, distal obstruction, neoplasm, constipation and pregnancy
Presents with acute constant or cramping RLQP
Three types– type I : Axial torsion type
• the cecum twists in the axial plane, rotating along its long axis
– type II : Loop type• the distended cecum twists and inverts
– type III : Cecal bascule• the distended cecum folds anteriorly without any
torsion
Cecal volvulus Diagnosis on plain radiography <
50% of cases MDCT can recognize subtypes and
complications (ischemia and obstruction)– combination of a distended ectopic
cecum and the swirl of the mesenteric vessels is seen in type I and II
– type II volvulus (the loop type), the cecum usually occupies the left upper quadrant
– in the bascule type, the swirl of the vessels is not present
Casus 1 – Nils Veressen– Man, 22 jaar
• Beleid– Omwille van deze zeer weinige klinische last,
en normaal bloedbeeld (huidig moment een alvaradoscore van 0) werd door de assistent heelkunde beslist om de echografie opnieuw uit te voeren.
– Echo: Deze toonde opnieuw een beeld van een acute beginnende appendicitis. (verdikte eerste 2 cm aan de basis van appendix met een transversale dikte van 7,4mm met verdikte wand en hyperreflectief mucosareliëf)
Casus 1 – Nils Veressen– Man, 22 jaar
• Diagnose– Acute beginnende appendicitis (van echo)– Opname voor laparoscopische appendectomie
• APO– Beperkte eosinofilie
• Bedenkingen ?...
Casus 1 – Nils Veressen– Man, 22 jaar
• Vragen casus–Wat is de waarde van de
Alvaradoscore? – Is het aangewezen een echo opnieuw
uit te voeren, indien deze extern gebeurd is door een onbekende arts, indien de Alvaradoscore 0 is
• The Alvarado score for predicting acute appendicitis: a systematic review, Ohle et al. BMC Medicine 9:139 (2011)
Casus 1 – Nils Veressen– Man, 22 jaar
Casus 1 – Nils Veressen– Man, 22 jaar
Casus 2 – Anke Van Hauwaert– Vrouw, 36 jaar
• Anamnese–Sinds gisteren stekende pijn t.h.v
rechter fossa, nu eerder een continu zeurend karakter.
–Geen nausea, geen braken, normale eetlust
–Normaal stoelgangspatroon, normale mictie
–Koorts, koude rillingen–Tijdens laatste pilvrije periode geen
bloeding gehad, laatste bloeding 5weken geleden
–Regelmatige cyclus onder Yaz, geen intermenstrueel bloedverlies
–Geen postcoïtaal bloedverlies, geen abnormaal vaginaal verlies, laatst gegeten om 16u00
Casus 2 – Anke Van Hauwaert– Vrouw, 36 jaar
• Medische voorgeschiedenis–Borstingreep–Endometriose–Hypothyroïdie
• Medicatie–Anticonceptie –L-thyroxine
Casus 2 – Anke Van Hauwaert– Vrouw, 36 jaar
• Klinisch onderzoek–Abdomen:
Uitlokbare drukpijn over punt van Mc Burney
Geen loslaatpijn Geen spierverzet Geen percussiepijn Rovsing: negatief Psoasteken: negatief
Casus 2 – Anke Van Hauwaert– Vrouw, 36 jaar
• Klinisch onderzoek–Gynaecologisch:
Inspectie vulva/vagina: normaal
In speculo: gave cervix, wisser werd afgenomen
Bimanueel vaginaal onderzoek: uterus in AVF, adnexen palpatoir negatief
–Urologisch: NSP rechts (niet zeer duidelijk)
Casus 2 – Anke Van Hauwaert– Vrouw, 36 jaar
• Labo–CRP: 6.2 mg/dl–HCG: negatief–Creatinine: 0.95mg/dl–Leukocytose: 11 x 10^3/microliter
–LDH: 213U/L–Bilirubine totaal: 0.27mg/dl–Na+, K+, Cl-, HCO3-: ok
Casus 2 – Anke Van Hauwaert– Vrouw, 36 jaar
• Labo• Microbiologie cervicale wisser:
–aerobe cultuur: normale vaginale flora
• Urinestaal midstream:–WBC: +++–RBC/Hb/myoglobuline: ++
• Microscopie:–RBC: 76/microliter–WBC: 20/microliter
• Aerobe cultuur: enterococcus species
Casus 2 – Anke Van Hauwaert– Vrouw, 36 jaar
• Technische onderzoeken:–Transvaginale echografie
Uterus in AVF, normaal aspect Endometrium goed aflijnbaar en dun (3mm)
Linker ovarium: normaal aspect Rechter ovarium: normaal aspect
Geen vrij vocht, geen evidentie voor massa, niet-pijnlijk onderzoek
Casus 2 – Anke Van Hauwaert– Vrouw, 36 jaar
• Technische onderzoeken:–Echografie abdomen
Normaal volume en reflectiepatroon van de lever. Cholecystolithiasis.
Normaal kaliber galwegen. Normaal voorkomen pancreas, milt en nieren.
Geen vrij vocht. Geen pathologische darmwandverdikking.
De appendix is niet visualiseerbaar, Geen indirecte argumenten voor appendicitis.
Casus 2 – Anke Van Hauwaert– Vrouw, 36 jaar
• Alvarado-score 6• Differentieel diagnose ?...• Diagnose en beleid ?...
More common in adults More common in the elderly
Adult females Genitourinary Medical
Appendicitis, Appendix abscess
Inflammatorybowel disease
Caecal tumour Ruptured ectopicpregnancy
Ureteric calculus Pneumonia
Gastroenteritis Epiploic appendagitis
Caecal perforation Adnexal torsion Urinary tractinfection
Diabetic ketoacidosis
Intestinal obstruction
Acute cholecystitis/ascending cholangitis
Acute diverticulitis Ruptured/torsionovarian cyst
Pyelonephritis Nerve rootentrapment
Pancreatitis, Peptic ulcer perforation
Inguinal or femoralhernia
Caecal or sigmoidvolvulus
Pelvic inflammatorydisease
Testicular torsion Herpes zoster
Carcinoid Ischaemic bowel Abdominal aorticaneurysm
Endometriosis Acute porphyria
Lymphoma Constipation Ruptured ovarianfollicle
More common in adults More common in the elderly
Adult females Genitourinary Medical
Appendicitis, Appendix abscess
Inflammatorybowel disease
Caecal tumour Ruptured ectopicpregnancy
Ureteric calculus Pneumonia
Gastroenteritis Epiploic appendagitis
Caecal perforation Adnexal torsion Urinary tractinfection
Diabetic ketoacidosis
Intestinal obstruction
Acute cholecystitis/ascending cholangitis
Acute diverticulitis Ruptured/torsionovarian cyst
Pyelonephritis Nerve rootentrapment
Pancreatitis, Peptic ulcer perforation
Inguinal or femoralhernia
Caecal or sigmoidvolvulus
Pelvic inflammatorydisease
Testicular torsion Herpes zoster
Carcinoid Ischaemic bowel Abdominal aorticaneurysm
Endometriosis Acute porphyria
Lymphoma Constipation Ruptured ovarianfollicle
Adult (reproductive age) females
Ruptured ectopic pregnancy– Ultrasound usually used to confirm intra-
uterine pregnancy and exclude ectopic pregnancy
– Identification of extrauterine gestational sac is uncommon
– Ultrasound findings• Empty uterus,(+ β-hCG), adnexal mass• Complex fluid in the Pouch of Douglas is the only
positive finding in up to ¼ of patients
Ectopic pregnancy : Complicated adnexal mass (arrow) in a 25-yearold woman with a positive pregnancy test ; adjacent uterus (curved arrowhead) did not contain a gestational sac
Adult (reproductive age) females
Adnexal torsion– Complete or partial rotation of
the adnexa along the vascular pedicle
• Predisposing factors in half of pt– Ipsilateral functional cyst or
neoplasm– Ultrasound findings
• Incomplete torsion– Massive ovarian edema– Enlarged ovary with multiple
peripheral fluid filled spaces
• Complete torsion– Similar picture, but complex cystic
regions due to ischemic necrosis
– Fluid in the Pouch of Douglas
Adult (reproductive age) females
Ovarian cysts– May cause pain by
• Predisposing to ovarian torsion• Intra cystic hemorrhage• Rupture
Pelvic inflammatory disease – Ascending spread of infection from the
female genital tract- Chlamydia trachomatis, Neisseria gonorrhoeae
– Inflammatory change of the fallopian tube is the hallmark of PID
• Normally fallopian tubes are not seen on U/S• If infection spread to ovary a tubo-ovarian
complex forms
Pelvic Inflammatory Disease : Occluded tube (thick
arrow) ; purulent peritoneal fluid (thin arrow)
Adult (reproductive age) females
Endometriosis– Most common cause of chronic pelvic pain
• May occasionally present acutely– Endometrial tissue present outside the uterus
• Pouch of Douglas, ovaries, pelvic peritoneum• GIT
– Rectosigmoid colon– Ileum, jejunum and cecum– Appendix <1%
– Transvaginal U/S of value in acute setting if suspected
– MRI of pelvis in more elective situation• Endometriomas high signal on T1 and
heterogenous high T2• Fat-Sat increases sensitivity• Lesions > 1cm routinely seen
Adult (reproductive age) females
Ruptured ovarian follicle– During mid cycle rupture may realease
small amount of blood– Resultant peritoneal irritation may cause
transient pain – mittelschmertz
Food for thought Diagnostic laparoscopy in the evaluation of right lower abdominal pain: a one-year audit. Authors : Lim GH, Shabbir A, So JB Institution Department of Surgery, National University
Hospital,Singapore. Source : Singapore Med J 2008 Jun; 49(6) :451-3.Abstract
INTRODUCTIONAcute appendicitis is the commonest cause for right lower abdominal pain. Clinical features, laboratory and imaging investigations are either not very sensitive or specific, and neither is therapeutic. We aimed to define the role of diagnostic laparoscopy in patients with right lower abdominal pain.METHODSData was collected retrospectively from January 1, 2005 to December 31, 2005. Patients admitted to the Emergency Department and subsequently transferred to the Department of Surgery, National University Hospital, Singapore, with right lower abdominal pain and who eventually underwent diagnostic laparoscopy were evaluated.RESULTS691 patients with right lower abdominal pain were admitted with suspected diagnosis of appendicitis. Diagnostic laparoscopy was undertaken in 103 patients aged 17-71 years old. Of the 83 females, 78 (94 percent) were premenopausal . Histology-proven acute appendicitis was diagnosed in 78 (75.7 percent) patients. Interestingly, within this group, 25.6 percent had other concomitant pathologies found on laparoscopy. 25 patients had a normal appendix; gynaecological causes accounted for pain in 15 of these 25 (60 percent) cases. In four (3.9 percent) patients, no pathology was found. Complication rate was 1.9 percent, which included ileus in two patients. In 32 (31.1 percent) patients, diagnostic laparoscopy altered the management plan, requiring either intervention or care by a subspecialty.CONCLUSIONDiagnostic laparoscopy is useful in evaluating patients with right lower abdominal pain, especially in those with equivocal signs of acute appendicitis. It also has the additional benefit of being therapeutic. Premenopausal women benefit the most from this procedure.
Food for thought Right iliac fossa pain in women. Conventional diagnostic
approach versus primary laparoscopy. A controlled study (65 cases)Authors Champault G, Rizk N, Lauroy J, et al.
Institution Service de Chirurgie Générale et Digestive, Hôpital Jean-Verdier, Bondy.Source Ann Chir 1993; 47(4) :316-9. Abstract
In a series of 187 patients with acute abdominal pain syndrome, 65 young women reported non specific pain in right iliac or pelvic area. A controlled study compared 33 patients with immediate laparoscopy and 32 explored with a laboratory contrast or imaging approach. In the laparoscopic group, an exact diagnosis was made in 97% of the patients, allowing in 2/3 of cases the endoscopic treatment. Only 28% in the second group had an exact diagnosis. Hospital stay was shorter in the laparoscopic group (4.18 vs 6.16 days; p = 0.01) decreasing the hospital cost. The authors suggest that immediate laparoscopy should be performed in young women presenting with non-specific abdominal pain.
Casus 3 – Carolien Dreeskens– Man, 41 jaar
• Medische voorgeschiedenis–In 1999: PCI/stent, in stent trombose, CABG, redo PCI
• Anamnese–Uw patiënt bood zich aan via de dienst spoedgevallen omwille van buikpijn. De pijn was die nacht rond 1.30u opgekomen. Hij werd er wakker van.
–De pijn was stekend van aard en lokaliseerde zich epigastrisch.
Casus 3 – Carolien Dreeskens– Man, 41 jaar
• Anamnese–Momenteel lokaliseert de pijn zich eerder thv de rechter fossa. Flatus is nog aanwezig. Geen ontlasting gehad. Rond 3u heeft hij een Dafalgan Codeïne genomen.
–Gisteren was zijn ontlasting normaal.
–Geen mictiedrang.
Casus 3 – Carolien Dreeskens– Man, 41 jaar
• Klinisch onderzoek– Algemeen: ziet er niet ziek uit– Parameters: 139/86, 74 bpm, 36.8°C, 100 % sat– Cor: S1S2, regelmatig ritme, geen souffle– Longen: normaal bilateraal vesiculair ademgeruis,
geen bijgeluiden– Abdomen: bewaarde peristaltiek, weerstand thv de
onderbuik > globus ? > appendiculair plastron ?, geen loslaatpijn, percussie niet gedempt sondage 150 cc geconcentreerde urine
– Geen nierslagpijn, bij slaan op rechter nierloge pijn in de buik
Casus 3 – Carolien Dreeskens– Man, 41 jaar
• Labo–Parameters infectie / inflammatie:
CRP + 85.0 mg/L–Celtelling: Witte
bloedcellen + 21.0 x10*3/µL–Celdifferentiatie: –Neutrofielen segmentkernig + 81.1 %–Lymfocyten - 8.7 % 20.0 – 45.0–Stolling: Normaal
• Biochemie: –Licht afwijkend natrium - 135.8 mmol/L –Bilirubine
direct/geconjugeerd + 0.3 mg/dL
Casus 3 – Carolien Dreeskens– Man, 41 jaar
• CT abdomen–Beeld van acute appendicitis met wat
peri-appendiculaire inflammatie.–Pathologische opzetting van de
appendix–Verdikte aankleurende wand–Vergrijzing van het peri-appendiculair
vetweefsel–Geen perforatie, want er is geen vrije
lucht te weerhouden. Geen abcesvorming.
• D/ acute retrocaecale appendicitis => lap appendectomie
Casus 3 – Carolien Dreeskens– Man, 41 jaar
• Bedenkingen– Is een echo een nuttig onderzoek in de
diagnose van appendicitis? Want ik merkte in de praktijk dat dit onderzoek vaak vals negatief is. Ten slotte kost dit onderzoek ook geld.
–De Alvarado-score, biochemie en een CT zijn in de praktijk betere manieren om een appendicitis met grote waarschijnlijkheid vast te stellen
– Imaging rechter fossa syndroom
Selection of the most appropriate imaging modality
Depends on– 1) Patient age and body habitus
• < 20 years– Ultrasound initially, regardless of suspected
pathology– Then CT or MRI if additional information is required
• > 20 years– Ultrasound initially in young, slim adults
» Particularly women of reproductive age• Older or obese patients
– CT
Depends on – 2) Suspected pathology, based on
clinical and laboratory findings• Appendicitis• Renal colic• Gynaecological• Hernia• Bowel related• Vascular
Selection of the most appropriate imaging
modality
XRA– Feacal sign caecum– Otherwise unhelpful (caecal volculus)
Acute appendicitis
Ultrasound– Advantages
• Widely available and inexpensive• Avoidance of ionizing radiation
– Especially women of reproductive age and children– Gynecological disease gives further reason for U/S
evaluation• Useful in identifying an alternative diagnosis
– Disadvantages • Operator dependant
– Technique• Graded compression with high frequency linear
probe– gradual and constant increase in the compression by
the US probe in the right iliac fossa – displaces normal, air-filled bowel, or compresses it
against the posterior abdominal wall – abnormal, non-compressible appendix is thus
revealed
Acute appendicitis
Acute appendicitis
Transverse U/S : Inflammed appendix (between calipers) ; adjacent inflamed fat (arrow) ; terminal ileum with air (curved arrow)
Longitudinal U/S : inflammed appendix with proximal appendicolith
Acute appendicitis CT
– Technique• Variety of techniques in an attempt to
– Reduce radiation dose– Maximize diagnostic yield – Minimize preparation time for the scan
• Variation in – Amount of abdomen imaged– Use of IV, oral and rectal contrast
• All share same basic concept– Acquiring thin collimation images (5mm or less) in a
single breath hold
• Unenhanced CT abdomen (No IVI, oral or rectal contrast) – Reduces delay for patient preparation and reduces per
patient cost– Relies on intra-abdominal fat to provide contrast
» Difficult to obtain good results in thin patients» More difficult to interpret initially, but just as
accurate when experienced (reasonably high sensitivity and specificity for clinical decision-making 93% and 96% respectively)
Acute appendicitis CT
– Appearance on CT• Filling of appendix with oral contrast is an important
negative feature• Normal appendix wall 1-2mm in thickness• Periappendiceal fat should appear homogenous
– CT diagnosis of acute appendicitis can be made if• Abnormal appendix identified
– Appendix diameter > 6mm– With homogenously enhancing wall – Mural edema may produce a target sign– Periappendiceal inflammation in 98%
» Fat stranding• Calcified appendicolith with pericecal inflammation
– Perforated appendicitis • Accompanied by pericecal phlegmon or abscess• Associated findings
– Extraluminal air– Ileocecal thickening– Localized lymphadenopathy– Peritoneal enhancement– Small bowel obstruction
Inflamed appendix with a target sign : enhancing serosa and mucosa seperated by oedematous fluid in wall
Appendix abscess : Ring enhancing collection with adjacent appendicolith
Appendicitis : dilated appendix ; appendicoliths ; adjacent fat stranding
Acute appendicitis MRI
– Currently limited to patients with right iliac fossa pain during pregnancy
• Avoiding ionizing radiation is of prime importance
– Limited information available• small number of studies with little
patient numbers– Imaging techniques used
• no IV contrast• axial, coronal and sagittal noncontiguous T2-weighted
single-shot fast spin-echo (SE) sequences • axial fat-suppressed T2-weighted fast SE sequences• axial T1-weighted gradient-recalled-echo sequences• axial and coronal inversion-recovery sequences
performed through the lower abdomen and pelvis– Illustrates normal and abnormal appendix
• May be useful in diagnosing adnexal pathology
Appendicitis : dilated appendix (black
arrowhead) ; appendicolith (black arrow) ; adjacent fat stranding (white arrowheads)
Conclusies– Rechter fossa syndroom
• Uitgebreide differentieel diagnose
• Combinatie anamnese / klinisch onderzoek / biochemie en beeldvorming noodzakelijk !
• Vrouwen gynaecologische pathologie• Multidisciplinair overleg pediater – internist
– chirurg – gynaecoloog – radioloog
Vragen ?