A big stone causing RIF pain


This patient presented with gradual onset RIF pain, which was maximal in the right lower paracolic gutter, just above the iliac crest.


  • This is a case of acute appendicitis where an appendicolith obstructs the lumen of the appendix causing distention and inflammation of the distal appendix.
  • The appendix is typically described as a non-peristalsing, blind ending tube with bowel wall signature, originating from the caecum.
  • It usually measures less than 6mm across but in this case where it is distended it measures 14mm across.
  • It maintains the normal sonographically differentiable layers indicating no frank necrosis or perforation.
  • An echogenic shadow casting faecolith obstructs the proximal appendix
  • The base can also bee seen and has a more typical appearance of an inflamed appendix as it enters the caecum.
  • There is no associated free fluid, nor particularly echogenic mesenteric fat.

  • The appendix lies in highly variable locations.
  • Ensure you explore throughout the right side of the abdomen in your search for the appendix, but particularly at the site of maximal pain.
  • An appendicolith is often but not invariably seen in appendicitis.
  • Steps in diagnosis are:
    • Find the appendix – a grid search of the abdomen using a high frequency linear transducer
    • Confirm it is the appendix
    • Assess for features of appendicitis – distended to >6mm across, tender, appendicolith, surrounding free fluid, surrounding echogenic mesenteric fat, hyperaemia
    • Assess for complications – perforation, abscess formation
    • Assess for alternate causes of the pain

About James Rippey

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

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