An unusual cause of pelvic pain

History

This young woman presented with right sided pelvic pain, with associated urinary frequency and dysuria.

Answer

  • In this case the appendix can be seen arising from the caecum in the right iliac fossa, and traversing medially across the psoas muscle and iliac vessels, to lie within the pelvis.
  • Its tip lies between the bladder and uterus, and there is a little free fluid seen in the Pouch of Douglas.
  • The appendix is distended to 12 mm, is surrounded by echogenic mesentry and was the site of maximal tenderness.

  • Ultrasound examination of the patient presenting with pelvic pain should include a search of the right iliac fossa for appendicitis.
  • The appendix comes in many shapes and sizes and lies in highly varied positions.
  • Correspondingly the presentations and complications of appendicitis are very diverse.
  • The appendix
    • Is a blind ending tube with bowel wall signature, originating from the caecum
    • In the non-inflamed state it is less than 6mm across, is compressible with the probe but non-peristalsing, and is non tender.
  • In acute appendicitis the appendix typically develops the following characteristics:
    • Distended to more than 6mm in diameter
    • Non compressible
    • Tender to probe palpation
    • Echogenic mesentry surrounding it
    • Small amount of free fluid
    • Hyperaemia
    • An appendicolith may be present
    • Complications such as perforation and abscess formation may be present

About James Rippey

Emergency physician with a passion for ultrasound and educating the masses @theSonoCave + James Rippey

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