HPI: 28-year-old male who presents to the Emergency department with right lower quadrant abdominal pain for 4 days. Pain is associated with vomiting and subjective fevers. No urinary complaints. WBC: 18.

Brief exam: Tenderness to palpation to the right lower quadrant. 

Imaging: Bedside ultrasound of the right lower quadrant

  What structures do you see?

What is abnormal about this ultrasound?

Appendix is outlined in Red

Diagnosis: Acute appendicitis

Management: Surgical Consultation and Antibiotics

Ultrasound Education:

The use of bedside ultrasound to evaluate a patient with abdominal pain is a common practice in the emergency department. Frequently ultrasound is used in the evaluation of a patient with possible appendicitis. Overall sensitivity of ultrasound in appendicitis is 86 to 92%. This exam can be quickly performed in the emergency department and avoids the significant radiation associated with Computed Tomography (CT).

Probe selection: Linear high frequency probe is ideal. The lower frequency curvilinear transducer maybe used in larger patients.

Approaches to locate the appendix:

1.     Ask the patient to point to the area of maximal pain. Small movements of the ultrasound probe in that location may reveal the appendix.

2.     Follow ascending colon down to the cecum. The Appendix will be noted coming off the cecum.

3.     Find the iliac artery. Adjacent to the vessel will be the appendix. 

Sonographic findings for appendicitis:

1.     Blind ended finger like structure with lack of peristalsis

2.     Non-compressible under pressure

3.     Diameter> 7mm

4.     Appendicolith maybe visualized

5.     Periappendiceal fluid is suggestive of inflammation

Limitations of Ultrasound:

1.     Patient size

2.     Operator Experience

Additional resources:

1.     Brief review on the use of ultrasound for appendicitis: Appendicitis Ultrasound Podcast

2.     Mallin M, Craven P, Ockerse P, Steenblik J Forbes B, Boehm K, Youngquist S. Diagnosis of Appendicitis by bedside Ultrasound. Am J Emerg Med. 2015 Mar;33 (3):430-2

3.     Elikashvili I, Tay ET, Tsung JW. The effect of point-of-care ultrasonography on emergency department length of stay and computed tomography utilization in children with suspected appendicitis. Acad Emerg Med. 2014;21(2):163-70.