The diagnostic value of point-of-care ultrasound in suspected appendicitis
Dr Himanshu Gul Mirani
Case Presentation:
A patient presented with a three-day history of progressively worsening periumbilical pain, which later localised to the right iliac fossa. On arrival to the emergency department, the patient reported persistent vomiting and escalating abdominal pain, appearing acutely distressed.
Clinical assessment demonstrated tachycardia and marked tenderness in the right lower quadrant, with features concerning for an acute intra-abdominal process.
Management and Outcome:
During the initial assessment, while blood investigations were being obtained, point-of-care ultrasound (POCUS) was performed to expedite diagnostic evaluation. This identified a non-compressible tubular structure measuring greater than 1 cm in diameter, with associated periappendiceal fluid. These findings were highly suggestive of severe appendicitis, with possible perforation.
Given the concerning ultrasound features and clinical deterioration, the patient underwent urgent CT imaging, which confirmed complicated appendicitis. Surgical referral was made promptly for definitive management.
Key Learnings and Points:
Point-of-care ultrasound findings in appendicitis:
POCUS is a valuable adjunct in the early assessment of suspected appendicitis, particularly when clinical findings are equivocal. Key sonographic features include:
A non-compressible, blind-ended tubular structure arising from the caecum
Diameter greater than 6 mm (values exceeding 10 mm raise concern for complicated disease)
Wall thickening and loss of normal wall stratification
Presence of periappendiceal fluid or abscess formation
Echogenic periappendiceal fat, indicating local inflammation
An appendicolith, which may appear as a hyperechoic focus with posterior shadowing
Features suggestive of perforation include:
Disruption of the appendiceal wall
Complex fluid collections
Phlegmon or abscess formation
While ultrasound is operator dependent, its use at the bedside can significantly shorten time to diagnosis and guide the need for urgent cross-sectional imaging or surgical intervention.