True or false: There is terminal ileitis.
False. The dilated structure in the right iliac fossa is the vermiform appendix.
True or false: There is pneumoperitoneum consistent with perforated hollow viscus.
False. There is no pneumoperitoneum. Besides, free air in the peritoneal cavity secondary to perforation of an acutely inflamed appendix is extremely rare.
What is the next step in patient management?
Emergent surgical consultation is warranted. Appendectomy is currently the gold-standard treatment for acute appendicitis.
What is your tentative diagnose for the tip of the appendix?
The ovoid fat-containing lesion off the tip of the appendix resembles a torquated epiploic appendage.
Why bother? Epiploic appendagitis is a common precursor of acute appendicitis.
That is not correct. To the author´s knowledge, synchronous acute appendicitis and epiploic appendagitis have not (yet!) been reported in the English literature. And why surrender yourself to satisfaction of search?
There is a contrast-enhancing fluid-filled dilated blind-ending tubular structure in the right lower quadrant with an outer diameter of 12 mm. In addition to the haziness of the mesoappendix, focal edematous thickening of the cecal pole and focal peritoneal thickening in the right iliac fossa, ovoid contrast-enhancing lymph nodes in the ileocecal station without lymphadenopathy after size criteria are also noted. While a small amount of free intraperitoneal fluid is seen in the pouch of Douglas, there are no organized fluid collections.
The antimesenteric site of the tip of the appendix houses a 2 cm ovoid sharply demarcated fat-containing lesion which is intervened by branching thin tubular hyperdensities.
Incidental note is made of a small hiatal hernia, sliding type, a splenule at the upper lateral pole of the spleen, colonic diverticulosis and a vesicourachal diverticulum without evidence of infection. Degenerative spine disease with a single-level posterior disc calcification (L5/S1) without herniation is also noted.
The remainder of the study is within normal limits.
Impression
CT findings are strongly suggestive of acute appendicitis.
Synchronous epiploic appendagitis of the appendix is likely.