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The complexity of the entity known as the acute abdomen as such that a careful, methodic diagnostic approach is necessary in order to arrive at a correct diagnosis. Sometimes information from the history, physical examination, laboratory data and radiographic studies are not conclusive. Acute appendicitis (Heper Fitz et al 1886) is the most common abdominal surgical emergency. The diagnosis may be easy but may also be very difficult. The clinical diagnosis of appendicitis is as wrongly made as it is initially overâ€‘looked, leading to unnecessary surgery or to illâ€‘advised delay. Other appendicitis mimicking conditions are mesenteric lymphadenitis, gynaecological diseases such as persistent or haemorrhagic ovarian cysts, ectopic pregnancy, adnexal torsion and tuboâ€‘ovarian abscess, caecal and sigmoid diverticulitis, Chloecystitis, perforated peptic ulcer, Crohn's disease, urological conditions, small bowel obstruction, omental infarction, intussusception, rectus sheath haematoma, ruptured aortic aneurysm, pancreatitis and Meckel's diverticulitis (Willsen et al 1987).
Introduction of USG in medical field in 1940 change the era of diagnosis of appendicitis. Since then there are various changes in USG occurred.
In this study, attempt is made to evaluate the role of ultrasonography for correct of appendicitis.
Material and Methods
The present study was carried out on 80 patients of provisionally diagnosed as acute appendicitis admitted in the wards of Surgical Unit A of M.B.G. Hospital, Udaipur during the year 2009-10.
80 patients with suspected acute appendicitis were evaluated by ultrasound image 3.5 - 7.5 MHz with graded compression technique.
Graded compression USG was done using 3.5 - 7.5 MHz linear - array transducers according to the situation. The following accepted criteria were considered for the diagnosis of an inflamed appendix.
Visualization of non-compressible appendix as a blind ending tubular aperistatlic structure
Target appearance of 6mm (6 millimeters) in the total diameter on cross section maximal mural wall thickness 2mm.
Diffuse hypoechogenesity (associated with a higher incidence of perforation).
Lumen may be distended with anechoic / hyper echoic material.
Loss of wall layers.
Visualization of appendicolith
Localized peri-appendiceal fluid collection.
Prominent hyper echoic mesoappendix /pericaecal fat.
Free pelvic fluid.
All patients were routinely asked the site of maximal pain in right lower quadrant (RLQ) with single finger, scanning of this area was often helpful in identification of aberrantly located appendixes.
The inflamed appendix was most often visualized at the base of caecal tip during maximal graded compression.
Most of the patients of appendicitis were in 21-30 age group (36.25%), 65% were male, presenting symptoms (Table 1).
Clinical findings included tenderness in right iliac fossa is 100%, rigidity in right iliac fossa is 56.25% and lump in right iliac fossa is 12.50% cases. TLC more than 12000/mm3 was present in only 25% cases. The USG findings of appendicitis (Table 2).
Increase in tenderness was found in 82.5% cases, while decreased in 5% cases and non-change in 12.5% of cases. Position of appendix detected during USG were Retrocecal, Pelvic, and Paracecal 75.68%, 18.92%, 5.41% respectively while operatively, they were 75%, 20% and 5% respectively.
Among the 80 cases, in 37 cases (46.25%) the diameter of appendix could be detected. In maximum number of cases i.e. 13 (35.13%) had diameter of 8-10 mm, followed by 6-8 mm 11 (29.22%), 4-6 mm 8 (21.62%) cases. In our study only one patient had less than 6 mm diameter (5.8).
The operative findings in these cases are shown in (table 3). Histopathological examinations show 85% as acute appendicitis and 15% chronic appendicitis.
Among the 10 cases of normal study on histopathological examination 6 (60%) cases proved to be chronic appendicitis and 4 (40%) cases were diagnosed as acute appendicitis.
Ultrasonography has been used mainly in the diagnosis and complications of this disease and to exclude other diagnosis (Krishan JN, 1986, Parulekar, 1983).
High resolution ultrasonography is fairly accurate in showing the inflamed appendix in patients with uncomplicated acute appendicitis (Puylaert JBCM, 1986, Deutsh, 1981) while others have shown that it is only accurate in diagnosis of phlegmonous and gangrenous appendix (Tskado, 1886).
Policy of ultrasonography in the present series was of urgent ultrasonography of suspected acute appendicitis based on the symptomatology and physical sign of right lower quadrant pain, tenderness and found out zero negative appendicectomy rate, as shown in subsequent histopathological examination.
Ultrasonographic technique, described by Puyleart JBCM, et al. (1986) made it possible to directly visualize the inflamed appendix with its characteristic target appearance. In this, a high resolution linear array transducer and graded compression are used in the evaluation of appendix, while Takado (1986) has shown that it is only accurate in diagnosis of phlegmonous and gangrenous appendix.
Graded compression USG was done using 3.5 - 7.5 MHz linear - array transducers according to the situation.
In 63.75% of cases of our study were diagnosed as appendicitis on ultrasonography, whereas in the series of 60 patients of pain right iliac fossa was studied by JBCM (1986) and ultrasound performed in which 41.6% of patients reveled the features of acute appendicitis.
R. Brooke Jeffrey (1987) performed ultrasound on 90 patients of pain right iliac fossa out of these only 44.09% of patients were diagnosed as acute appendicitis on ultrasonography. In 1992 P.C. Kala et al studied 100 patients of pain RIF, out of these only 57% were diagnosed as acute appendicitis.
In the present study of 80 cases of appendicitis, during ultrasonographic evaluation, various associated pathology were found; in 6.25% cases, there were gynecological lesions e.g. pregnancy in 2 cases, ovarian cyst with pelvic inflammatory disease in 3 cases and uterine fibroid in 1 case. 3 (3.75%) cases had enlarged spleen, another 3 cases had renal calculus and one had enlarged prostate.
In our study, all of ultrasonographic positive cases had evidence of appendicitis on exploration and in histopathological examination.
In this study of 80 patients, there was change in intensity of tenderness in 70 cases by applying pressure during performing ultrasonography. In 66 cases the pain and tenderness increased in intensity by increasing pressure. In 4 cases, decrease in intensity of pain and tenderness by applying pressure was found and these cases on ultrasonographically were diagnosed as perforated appendix and later on by surgical exploration all were found to be perforated appendix. In 10 cases, change in intensity of pain and tenderness during performing ultrasonography was not found.
Jeffery (1987) advised to explore the case of acute appendicitis in adult patient presenting with persistent right lower quadrant pain and visualization of appendix on ultrasonography with more than 6 mm of diameter. In this series, diameter of appendix varied from 6-14 mm under ultrasonography and mean 8.19 mm diameter of appendix and all these were the proved to be cases of acute appendicitis.
Ultrasonographic characteristic pattern of gastrointestinal tract commonly referred to as the bull's eye or Target appearance. This echo complex consist of Hyperechoic core surrounded by anechoic halo, the central core arise from the mucous lining of the bowel lumen and anechoic halo from the bowel lumen and bowel wall itself (Blutt EL 1979, Fleisher AC 1980, Morgan CL).
Tauro et al (2009) did a study of 100 patients. The specificity of ultrasonography was 88.09% and sensitivity was 91.37% in the diagnosis of acute appendicitis. "Four cases of right iliac fossa pain were not included in our study because on investigation these were found to be cases of right ureteric calculus.
The present study was carried out in 80 patients of suspected appendicitis admitted in the wards of surgical unit A of M.B. Govt. Hospital Udaipur during the year 2009-10.
The maximum number of cases were found in age group 21-30 (38.25%) years.
Males (52) were affected nearly twice than females (28).
Pain in right iliac fossa was present in all (100%) patients, which was followed by symptoms of gastric upset in 60% of cases.
Tenderness in right iliac fossa was present in all (100%) cases and it was followed by rigidity/guarding in 56.25% cases.
75% of cases had less than 12,000 TLC counts and in only 25% it was more than 12000/mm3.
Probe tenderness was present in 87.50% cases in ultrasonographic evaluation.
Appendix could be visualized in 37 (46.25%) cases by U.S.G.
Maximum number of patients had retrocaecal appendix i.e. in 28 cases (75.68%) as detected by USG.
By USG, when appendix was visualized, the commonest characteristic findings were blind ended tubular structure, non compressible and target lesion.
Probe tenderness alone was found to be an important finding during USG and it was found in 37 cases out of which 33 later proved to cases of appendicitis and 4 cases had right ureteric calculus.
66 (82.50%) cases had increase in probe tenderness during USG examination and decrease in probe tenderness was detected in 4 cases (5%) and all these 4 cases later proved to be of perforated appendix.
In maximum number of cases i.e. 13 (35.13%) the diameter of appendix was 8-10 mm as detected by USG.
During operation, maximum number of cases (75%) were found to have retrocaecal appendix.
Histopathologically, 68 (85%) cases were diagnosed as acute appendicitis and 12 (15%) cases as chronic appendicitis.
10 cases of normal study on USG showed, 6 (60%) as chronic appendicitis and 4 (40%) as acute appendicitis on histopathological examination.