MyPACS.net: Radiology Teaching Files > Case 7099454

Never visited 061031 RUPTURED APPENDICITIS WITH RIGHT HYDRONEPHROSIS
Contributed by: pedrad CSH, Radiologist, Chung Shan Medical University Hospital, Taiwan.
Patient: 11 year old male
History:

Persistent abdominal pain for about 5 days
(from epigastric region shifted to periumbilical area,
 follow by RLQ, then diffuse whole abdomen)
Ever treated as urinary tract infection in other hospital
(Urine RBC:20-35/HPF, WBC: 10-20/HPF)

Vomiting: 4-5 times/day; Watery diarrhea: 3-4 times/day;
Mild fever: 37.8C
WBC: 20260/mm3 (4000-11000)

Images:[small]larger

Fig. 1: KUB

Fig. 2: CT without IV or oral contrast

Fig. 3: CT with IV contrast

Fig. 4: CT with IV contrast

Fig. 5: CT with IV contrast

Fig. 6: CT with IV contrast

Fig. 7: CT with IV contrast

Fig. 8: CT with IV contrast
Findings:

KUB:
1. Much air retention in T-colon but relative decreased
   bowel gas in A-colon, "right-side colon cutoff sign"
   can be compatible. Suggest CT scan, please.

CT scan of abdomen with pre- and post- IV contrast:

1. Air-containment abscess over right lower abdomen with multiple
   calcifications and small lymph nodes, suggesting ruptured
   appendicitis with abscess and appendicolithes. Mild right
   hydronephrosis due to adjacent mesenteric strainding and
   encasement of right lower third ureter.

Diagnosis: Ruptured appendicitis with abscess and right mild hydronephrosis.
Discussion:

Roentgenographic signs of perforated appendicitis:
1. Right-side colon cutoff sign.
2. Functional small bowel obstruction with or without a paucity of gas in the right lower quadrant or pelvis.
3. Inflammatory mass or abscess in the right lower quadrant or pelvis.
4. Positive flank stripe sign.
5. Obliteration of the properitoneal fat line on the right.
6. Free intraperitoneal air.

References: Emergency Imaging of the Acutely Ill or Injured Child, Fourth Edition, Leonard E. Swischuk
Comments:

Q: How to confirm the "Right-side colon cutoff sign"?
A: 1. Decubitus film with right side up. 
         True colon cutoff sign present right-side ascending colon
         gas diminished is due to the spasm of colon not the full
         of fecal material. If there is doubt about this sign
         on supine view, a decubitus film can be employed.
     2. Abdominal CT is another good choice because easy detection
         abscess or air from ruptured appendicitis. CT also provides
         much other useful information in cases of acute abdominal pain.

By Dr. Tsao

--pedrad CSH, 2006-11-06
Additional Details:

Case Number: 7099454Last Updated: 02-19-2007
Anatomy: Gastrointestinal (GI)   Pathology: Non-Infectious Inflammatory Disease
Modality: CT, Conventional RadiographAccess Level: Readable by all users
Keywords: ruptured appendicitis hydronephrosis colon cut-offACR: 751.291

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