Compared to children, the hunt for acute appendicitis in the adult using ultrasound can be a discouraging affair. With the larger abdominal torso (and adipose tissue), searching for a tiny blind ending tubular structure that is 6mm in diameter is a challenge to say the least. Excessive bowel gas and abdominal guarding (i.e. inability to relax) often complicate matters.
According to a meta-analysis by Doria, the sensitivity of picking up acute appendicitis is only 83% (95% CI: 78-87%).
There are 3 standard methods described to locate the appendix:
Vessel route - Scrutinize the right iliac vessels, as the appendix frequently drapes over them
Bowel route- Descend on the ascending colon until you reach the “caecum”, where the appendix should make its exit.
McBurney’s route - Start where the appendix is likely to be located according to the textbooks, and hope for the best.
But there is an easier way. Simply get the best sonographer for acute appendicitis, who is available 24/7, to do it for you.
A female in her early thirties presented to our department with periumbilical abdominal discomfort for a day. She felt uncomfortable and “distended”, especially on her lower belly when she moved.
Vitals: T 36.2, BP 113/57mmHg, RR 12, PR 96. There was tenderness in the RIF. Alvarado score was 5. That’s an “intermediate” range, where some form of imaging would be beneficial. Suspecting acute appendicitis, we got the best sonographer to hunt for an inflamed appendix for us. With the probe in her hands, she masterfully showed us this still image, within 5 seconds of handling the probe.
Who is this mysterious master of appendix sonography?