Right lower quadrant pain, nausea, elevated CRP and leukocytosis. Abdominal ultrasound demonstrated increased echogenicity of the fatty tissue in the ileocaecal region, and pelvic free fluid, but could not visualise the appendix. Negative pregnancy test.
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The appendix is thickened (see key image), and its wall shows contrast enhancement especially in the distal part. The appendix is arching down deep into the pelvis, explaining why visualization with ultrasound was likely unsuccessful. Surrounding fat stranding an low density periappendicular and pelvic free fluid (key image 2) is observed. A relative increase of the size of the mesenteric lymph nodes is visible in the right lower quadrant. Altogether the findings are in line with the diagnosis of acute appendicitis. The inflamed appendix was successfuly removed laparoscopically.
A fairly common case of appendicitis, where despite a seemingly ideal patient anatomy CT was needed to visualize the appendix due to its position.