Rechter fossa syndroom

Rechter fossa syndroom5/12/2013

Terugkomdag Heelkunde

Casus 1 – Nils Veressen– Man, 22 jaar

• Huidig probleem– Gisteren op werk abdominale last en algemene

malaise. Vandaag voelde hij zich beter, maar ging toch naar de huisarts. Deze stuurde hem door naar echografie, omwille van heel lichte gevoeligheid in het rechter hypogastrium.

– Deze echo toonde het beeld van een beginnende acute appendicitis, waarna de patiënt naar spoed verwezen werd

• Anamnese– Welke ?...

HistoryCommon Complaints:

Abdominal painChange in appetiteDysphagia/

OdynophagiaNausea/VomitingJaundice

Change in bowel habitsMelena/

HematocheziaHemorrhoids


• Anamnese– Er is geen nausea of braken. Er is ook geen

ziektegevoel. De patiënt heeft vandaag ook geen abdominale last meer gehad.

– Normale eetlust en normale stoelgang zijn aanwezig.

– De patiënt heeft 4 pakjaren (sporadisch gebruik van cannabis) en een lichte allergie voor huisstofmijt. De patiënt heeft geen vervoerspijn.

• Verdere anamnese, welke ?...


• Medicatie– Xyzall

• Voorgeschiedenis– IBS

• Familiale voorgeschiedenis– “moeder heeft slechte bloedvaten”

• Klinisch onderzoek– Welke ?...

Anatomy Regions (Anatomical) Quadrants (Clinical)

Surface Anatomy

Exam OrderInspectionAuscultation

Percussion or palpation can alter bowel sound frequency

PercussionPalpation

Abdominal Physical ExamPalpation

Start farthest from pain and move towards it

4 abdominal quadrantsLight palpationDeep palpation

Peritoneal inflammationPain with coughing, gentle palpationInvoluntary rigidityRebound tenderness

Abdominal Physical ExamPalpation - Right Lower

QuadrantCecumVermiform appendix

McBurney’s pointRovsing’s signPsoas signObturator sign

Most of ileumAscending colon: inferior partRight ovaryRight uterine tubeRight spermatic cordUterus (if enlarged)Urinary bladder (if full)

Abdominal Physical ExamPalpation - Right Lower

Quadrant


• Klinisch onderzoek


• Klinisch onderzoek– Geen koorts (36,4°C)– Hartritme: 80; Bloeddruk: 11,7, normale

capillaire refill– Comfortabele patiënt– Soepel abdomen, geen diepe drukpijn.– Geen loslaatpijn, geen percussiepijn– Rovsing, Mc Burney negatief– Geen nierslagpijn

• Labo– Welke ?...


• Labo• Extern uitgevoerd, nog niet alle waarden werden

bepaald:– Leukocyten, leukocytenformule, MCH, MCHC,

thrombocyten waren normaal– Nog niet bepaald: CRP, ijzer, ferritine, B12,

glucose, creatinine, GFR, SGOT, SGPT, gamma-GT, alk. fosf., LDH, VIT D-25

• Differentieel diagnose ?...

More common in adults More common in the elderly

Adult females Genitourinary Medical

Appendicitis, Appendix abscess

Inflammatorybowel disease

Caecal tumour Ruptured ectopicpregnancy

Ureteric calculus Pneumonia

Gastroenteritis Epiploic appendagitis

Caecal perforation Adnexal torsion Urinary tractinfection

Diabetic ketoacidosis

Intestinal obstruction

Acute cholecystitis/ascending cholangitis

Acute diverticulitis Ruptured/torsionovarian cyst

Pyelonephritis Nerve rootentrapment

Pancreatitis, Peptic ulcer perforation

Inguinal or femoralhernia

Caecal or sigmoidvolvulus

Pelvic inflammatorydisease

Testicular torsion Herpes zoster

Carcinoid Ischaemic bowel Abdominal aorticaneurysm

Endometriosis Acute porphyria

Lymphoma Constipation Ruptured ovarianfollicle

Acute appendicitis Most common cause of acute RIF pain Clinical diagnosis on patient history and

physical examination– Any age, but most common 10-20 years– Abdominal pain

• Colicky, central abdominal pain• Followed by vomiting and migration of pain to RIF

(50%)– Loss of appetite, constipation, nausea – Pyrexia, tachycardia and localized

tenderness– Accuracy for clinical diagnosis

• Men : 80-90% Women : 60-80%

Conventional surgical wisdom is based on the belief that an inverse relationship exists between the negative appendectomy rate (NAR), i.e. removal of a non-inflamed appendix, and the perforation rate

Thus, a false-negative appendectomy rate of 15–23% is regarded as an index of appropriate management and the failure to maintain such a surgical threshold is an indication of insufficient surgical aggression, with an attendant risk of an excessive rate of perforation

Acute appendicitis

Crohn’s disease Although inflammatory bowel disease is

usually a chronic condition, flare-ups may present acutely

Peak age of onset 15-30 years Many cases of Crohn’s diagnosed during

work-up of acute LRQP since ileocecal region is most commonly affected– Apposed to ulcerative colitis which dominates the left colon

CT best imaging modality– Two most common imaging findings

• Eccentric wall thickening• Mucosal hyperenhancement

Crohn’s disease CT imaging

– Presence of intramural fat indicates chronic changes

– Segmental involvement with skipped (normal) regions

• vs ulcerative colitis – involves bowel in more continuous fashion

– Comb sign• Engorgement of the vasa recta penetrating the bowel

wall• Advanced, extensive and active Chron’s disease

– Creeping fat sign • Fibrofatty proliferation along the mesenteric border of

the affected bowel - almost pathagnomonic– Complications

• Small bowel strictures causing obstruction• Fistulas and abscesses

Crohn’s disease : Thickened terminal ileum ; diagnosis confirmed at histology

Thickened terminal ileum ; strictures ; mucosal hyperenhancement ; proliferation of mesenteric fat (black arrow)

Y shaped fistula : Cecum (arrowhead) ; terminal ileum (white arrow) ; psoas abscess (*)

Infectious enterocolitis Infectious enterocolitis have symptoms

similar to viral gastroenteritis Most cases require no imaging

– In cases of severe or persistent imaging is helpful for differentiation from alternative diagnosis

Most common organisms– Yersinia enterocolitica– Campylobacter jejeni– Salmonella enteritidis

Non-specific CT findings– Circumferencial mural thickening

of terminal ileum and cecum– Homogenous mural enhancement– Adjacent lymphadenopathy

Neutropenic colitis (Typhlitis) Neutropenic patient undergoing

chemotherapy RLQP, fever, diarrhoea, ± peritonitis CT is study of choice if suspected

– Risk of bowel perforation with contrast enema or colonoscopy

Typhlitis usually involves the right colon, but terminal ileum and transverse colon may be involved

CT findings– Cecal distension– Circumferential wall thickening with areas of

low attenuation due to edema or necrosis– Inflammatory stranding of adjacent

mesenteric fat, ± lymphadenopathy

Neutropenic colitis (Typhlitis) : cecal mural thickening (white arrow) ; normal left colon wall (black arrow) ; pericecal lymphadenopathy (arrowhead)

Diverticulitis One of the most common causes of

acute abdominal pain in the elderly Left and sigmoid colon predominantly

affected Less commonly right colon and cecum

may be affected – mimicking appendicitis

CT investigation of choice– Asymmetric or circumferential colonic wall

thickening– Associated focal pericolic fat stranding– Inflammed diverticulum often visible at

level of maximal fat stranding– Normal appendix is important in

differentiating from appendicitis– Pericolic lymphnodes suggests malignancy

rather than diverticulitis

Diverticulitis Rare causes

– Aquired small bowel diverticula• Mucosal herniation of bowel at sites of

vscular entry• Mesenteric border of terminal ileum < 7,5

cm from ileocecal valve– Meckel diverticulum

• Most common congenital abnormality of the GI tract

• Omphalomesenteric duct does not obliterate during development

• Anti-mesenteric border of ileum, ± 100 cm from ileocecal valve

• May contain ectopic gastric mucosa– Mucosal ulceration and GIT bleeding

Diverticulitis : Multiple right colonic diverticula ; adjacent fat stranding (arrow) ; sigmoid diverticula with no fat stranding (arrowheads)

Diverticulitis : Multiple sigmoid diverticula (straight white arrows) ; thick walled sigmoid colon (curved white arrow) ; mesenteric fat stranding (black arrow)

Epiploic appendagitis Round fat containing peritoneal

pouches arising from serosal surface of the colon – 0,5 – 5 cm in lentgh– More common in left and sigmoid

colon Uncommon and self limiting

condition Mostly middle aged men Caused by torsion or

venous thrombosis of the epiploic appendages

CT findings– Pericolic, round tot oval lesion

of fat attenuation with a hyperattenuating rim

Mesenteric adenitis Primary mesenteric adenitis

defined as– Clustered (>3) right sided

lymphnodes in small bowel mesentery or anterior to psoas muscle

– Larger than 5mm– No identifiable acute inflammatory

condition More common in children

– Acute RLQP, fever, leukocytosis Diagnosis of exclusion

Malignancies LRQP may be the intial presentation of

malignancy involving the ileocecal region Especially in event of complications

like perforation or abscess Adenocarcinoma

– >95% of all malignant cecal masses– Focal concentric mass with overhanging

shoulders– Associated enlarged pericolic nodes

Lymphoma– 80% of lymphoma of ileum and colon occur in

ileocecal region• Peyer patches (lymphoid tissue) develop in terminal

ileum– Older patients 50-70 yrs

Malignancies Lymphoma

– Non-specific symptoms (weight loss and abd pain), so often presents late

– Four forms of ileocecal lymphoma• Circumferential or constrictive

– Most common and may mimic adenocarcinoma

– Usually longer segment affected more gradual transition fromtumor to normal bowel

– Lack of bowel obstruction in presence of a large massshould raise suspicion of lymphoma

• Polypoid• Ulcerative• Aneurysmal

Intussusception Rare in adults (<5%)

– Mostly idiopathic in children ; <2yrs (40% 3-6mnths)

– Adults secondary to lead point – benign or malignant neoplasm

Target shaped bowel-within-bowel appearance is the classic appearance on axial scans and is pathognomonic

Cecal volvulus Rare condition in patients with abnormally

mobile cecum– Due to congenital or acquired abnormal fixation

to the posterior parietal peritoneum Predisposing or triggering factors

– Previous laparotomy, distal obstruction, neoplasm, constipation and pregnancy

Presents with acute constant or cramping RLQP

Three types– type I : Axial torsion type

• the cecum twists in the axial plane, rotating along its long axis

– type II : Loop type• the distended cecum twists and inverts

– type III : Cecal bascule• the distended cecum folds anteriorly without any

torsion

Cecal volvulus Diagnosis on plain radiography <

50% of cases MDCT can recognize subtypes and

complications (ischemia and obstruction)– combination of a distended ectopic

cecum and the swirl of the mesenteric vessels is seen in type I and II

– type II volvulus (the loop type), the cecum usually occupies the left upper quadrant

– in the bascule type, the swirl of the vessels is not present


• Beleid– Omwille van deze zeer weinige klinische last,

en normaal bloedbeeld (huidig moment een alvaradoscore van 0) werd door de assistent heelkunde beslist om de echografie opnieuw uit te voeren.

– Echo: Deze toonde opnieuw een beeld van een acute beginnende appendicitis. (verdikte eerste 2 cm aan de basis van appendix met een transversale dikte van 7,4mm met verdikte wand en hyperreflectief mucosareliëf)


• Diagnose– Acute beginnende appendicitis (van echo)– Opname voor laparoscopische appendectomie

• APO– Beperkte eosinofilie

• Bedenkingen ?...


• Vragen casus–Wat is de waarde van de

Alvaradoscore? – Is het aangewezen een echo opnieuw

uit te voeren, indien deze extern gebeurd is door een onbekende arts, indien de Alvaradoscore 0 is

• The Alvarado score for predicting acute appendicitis: a systematic review, Ohle et al. BMC Medicine 9:139 (2011)

Casus 2 – Anke Van Hauwaert– Vrouw, 36 jaar

• Anamnese–Sinds gisteren stekende pijn t.h.v

rechter fossa, nu eerder een continu zeurend karakter.

–Geen nausea, geen braken, normale eetlust

–Normaal stoelgangspatroon, normale mictie

–Koorts, koude rillingen–Tijdens laatste pilvrije periode geen

bloeding gehad, laatste bloeding 5weken geleden

–Regelmatige cyclus onder Yaz, geen intermenstrueel bloedverlies

–Geen postcoïtaal bloedverlies, geen abnormaal vaginaal verlies, laatst gegeten om 16u00


• Medische voorgeschiedenis–Borstingreep–Endometriose–Hypothyroïdie

• Medicatie–Anticonceptie –L-thyroxine


• Klinisch onderzoek–Abdomen:

Uitlokbare drukpijn over punt van Mc Burney

Geen loslaatpijn Geen spierverzet Geen percussiepijn Rovsing: negatief Psoasteken: negatief


• Klinisch onderzoek–Gynaecologisch:

Inspectie vulva/vagina: normaal

In speculo: gave cervix, wisser werd afgenomen

Bimanueel vaginaal onderzoek: uterus in AVF, adnexen palpatoir negatief

–Urologisch: NSP rechts (niet zeer duidelijk)


• Labo–CRP: 6.2 mg/dl–HCG: negatief–Creatinine: 0.95mg/dl–Leukocytose: 11 x 10^3/microliter

–LDH: 213U/L–Bilirubine totaal: 0.27mg/dl–Na+, K+, Cl-, HCO3-: ok


• Labo• Microbiologie cervicale wisser:

–aerobe cultuur: normale vaginale flora

• Urinestaal midstream:–WBC: +++–RBC/Hb/myoglobuline: ++

• Microscopie:–RBC: 76/microliter–WBC: 20/microliter

• Aerobe cultuur: enterococcus species


• Technische onderzoeken:–Transvaginale echografie

Uterus in AVF, normaal aspect Endometrium goed aflijnbaar en dun (3mm)

Linker ovarium: normaal aspect Rechter ovarium: normaal aspect

Geen vrij vocht, geen evidentie voor massa, niet-pijnlijk onderzoek


• Technische onderzoeken:–Echografie abdomen

Normaal volume en reflectiepatroon van de lever. Cholecystolithiasis.

Normaal kaliber galwegen. Normaal voorkomen pancreas, milt en nieren.

Geen vrij vocht. Geen pathologische darmwandverdikking.

De appendix is niet visualiseerbaar, Geen indirecte argumenten voor appendicitis.


• Alvarado-score 6• Differentieel diagnose ?...• Diagnose en beleid ?...

More common in adults More common in the elderly

Adult females Genitourinary Medical

Appendicitis, Appendix abscess

Inflammatorybowel disease

Caecal tumour Ruptured ectopicpregnancy

Ureteric calculus Pneumonia

Gastroenteritis Epiploic appendagitis

Caecal perforation Adnexal torsion Urinary tractinfection

Diabetic ketoacidosis

Intestinal obstruction

Acute cholecystitis/ascending cholangitis

Acute diverticulitis Ruptured/torsionovarian cyst

Pyelonephritis Nerve rootentrapment

Pancreatitis, Peptic ulcer perforation

Inguinal or femoralhernia

Caecal or sigmoidvolvulus

Pelvic inflammatorydisease

Testicular torsion Herpes zoster

Carcinoid Ischaemic bowel Abdominal aorticaneurysm

Endometriosis Acute porphyria

Lymphoma Constipation Ruptured ovarianfollicle

Adult (reproductive age) females

Ruptured ectopic pregnancy– Ultrasound usually used to confirm intra-

uterine pregnancy and exclude ectopic pregnancy

– Identification of extrauterine gestational sac is uncommon

– Ultrasound findings• Empty uterus,(+ β-hCG), adnexal mass• Complex fluid in the Pouch of Douglas is the only

positive finding in up to ¼ of patients

Ectopic pregnancy : Complicated adnexal mass (arrow) in a 25-yearold woman with a positive pregnancy test ; adjacent uterus (curved arrowhead) did not contain a gestational sac


Adnexal torsion– Complete or partial rotation of

the adnexa along the vascular pedicle

• Predisposing factors in half of pt– Ipsilateral functional cyst or

neoplasm– Ultrasound findings

• Incomplete torsion– Massive ovarian edema– Enlarged ovary with multiple

peripheral fluid filled spaces

• Complete torsion– Similar picture, but complex cystic

regions due to ischemic necrosis

– Fluid in the Pouch of Douglas


Ovarian cysts– May cause pain by

• Predisposing to ovarian torsion• Intra cystic hemorrhage• Rupture

Pelvic inflammatory disease – Ascending spread of infection from the

female genital tract- Chlamydia trachomatis, Neisseria gonorrhoeae

– Inflammatory change of the fallopian tube is the hallmark of PID

• Normally fallopian tubes are not seen on U/S• If infection spread to ovary a tubo-ovarian

complex forms

Pelvic Inflammatory Disease : Occluded tube (thick

arrow) ; purulent peritoneal fluid (thin arrow)


Endometriosis– Most common cause of chronic pelvic pain

• May occasionally present acutely– Endometrial tissue present outside the uterus

• Pouch of Douglas, ovaries, pelvic peritoneum• GIT

– Rectosigmoid colon– Ileum, jejunum and cecum– Appendix <1%

– Transvaginal U/S of value in acute setting if suspected

– MRI of pelvis in more elective situation• Endometriomas high signal on T1 and

heterogenous high T2• Fat-Sat increases sensitivity• Lesions > 1cm routinely seen


Ruptured ovarian follicle– During mid cycle rupture may realease

small amount of blood– Resultant peritoneal irritation may cause

transient pain – mittelschmertz

Food for thought Diagnostic laparoscopy in the evaluation of right lower abdominal pain: a one-year audit. Authors : Lim GH, Shabbir A, So JB Institution Department of Surgery, National University

Hospital,Singapore. Source : Singapore Med J 2008 Jun; 49(6) :451-3.Abstract

INTRODUCTIONAcute appendicitis is the commonest cause for right lower abdominal pain. Clinical features, laboratory and imaging investigations are either not very sensitive or specific, and neither is therapeutic. We aimed to define the role of diagnostic laparoscopy in patients with right lower abdominal pain.METHODSData was collected retrospectively from January 1, 2005 to December 31, 2005. Patients admitted to the Emergency Department and subsequently transferred to the Department of Surgery, National University Hospital, Singapore, with right lower abdominal pain and who eventually underwent diagnostic laparoscopy were evaluated.RESULTS691 patients with right lower abdominal pain were admitted with suspected diagnosis of appendicitis. Diagnostic laparoscopy was undertaken in 103 patients aged 17-71 years old. Of the 83 females, 78 (94 percent) were premenopausal . Histology-proven acute appendicitis was diagnosed in 78 (75.7 percent) patients. Interestingly, within this group, 25.6 percent had other concomitant pathologies found on laparoscopy. 25 patients had a normal appendix; gynaecological causes accounted for pain in 15 of these 25 (60 percent) cases. In four (3.9 percent) patients, no pathology was found. Complication rate was 1.9 percent, which included ileus in two patients. In 32 (31.1 percent) patients, diagnostic laparoscopy altered the management plan, requiring either intervention or care by a subspecialty.CONCLUSIONDiagnostic laparoscopy is useful in evaluating patients with right lower abdominal pain, especially in those with equivocal signs of acute appendicitis. It also has the additional benefit of being therapeutic. Premenopausal women benefit the most from this procedure.

Food for thought Right iliac fossa pain in women. Conventional diagnostic

approach versus primary laparoscopy. A controlled study (65 cases)Authors Champault G, Rizk N, Lauroy J, et al.

Institution Service de Chirurgie Générale et Digestive, Hôpital Jean-Verdier, Bondy.Source Ann Chir 1993; 47(4) :316-9. Abstract

In a series of 187 patients with acute abdominal pain syndrome, 65 young women reported non specific pain in right iliac or pelvic area. A controlled study compared 33 patients with immediate laparoscopy and 32 explored with a laboratory contrast or imaging approach. In the laparoscopic group, an exact diagnosis was made in 97% of the patients, allowing in 2/3 of cases the endoscopic treatment. Only 28% in the second group had an exact diagnosis. Hospital stay was shorter in the laparoscopic group (4.18 vs 6.16 days; p = 0.01) decreasing the hospital cost. The authors suggest that immediate laparoscopy should be performed in young women presenting with non-specific abdominal pain.

Casus 3 – Carolien Dreeskens– Man, 41 jaar

• Medische voorgeschiedenis–In 1999: PCI/stent, in stent trombose, CABG, redo PCI

• Anamnese–Uw patiënt bood zich aan via de dienst spoedgevallen omwille van buikpijn. De pijn was die nacht rond 1.30u opgekomen. Hij werd er wakker van.

–De pijn was stekend van aard en lokaliseerde zich epigastrisch.


• Anamnese–Momenteel lokaliseert de pijn zich eerder thv de rechter fossa. Flatus is nog aanwezig. Geen ontlasting gehad. Rond 3u heeft hij een Dafalgan Codeïne genomen.

–Gisteren was zijn ontlasting normaal.

–Geen mictiedrang.


• Klinisch onderzoek– Algemeen: ziet er niet ziek uit– Parameters: 139/86, 74 bpm, 36.8°C, 100 % sat– Cor: S1S2, regelmatig ritme, geen souffle– Longen: normaal bilateraal vesiculair ademgeruis,

geen bijgeluiden– Abdomen: bewaarde peristaltiek, weerstand thv de

onderbuik > globus ? > appendiculair plastron ?, geen loslaatpijn, percussie niet gedempt sondage 150 cc geconcentreerde urine

– Geen nierslagpijn, bij slaan op rechter nierloge pijn in de buik


• Labo–Parameters infectie / inflammatie:

CRP + 85.0 mg/L–Celtelling: Witte

bloedcellen + 21.0 x10*3/µL–Celdifferentiatie: –Neutrofielen segmentkernig + 81.1 %–Lymfocyten - 8.7 % 20.0 – 45.0–Stolling: Normaal

• Biochemie: –Licht afwijkend natrium - 135.8 mmol/L –Bilirubine

direct/geconjugeerd + 0.3 mg/dL


• CT abdomen–Beeld van acute appendicitis met wat

peri-appendiculaire inflammatie.–Pathologische opzetting van de

appendix–Verdikte aankleurende wand–Vergrijzing van het peri-appendiculair

vetweefsel–Geen perforatie, want er is geen vrije

lucht te weerhouden. Geen abcesvorming.

• D/ acute retrocaecale appendicitis => lap appendectomie


• Bedenkingen– Is een echo een nuttig onderzoek in de

diagnose van appendicitis? Want ik merkte in de praktijk dat dit onderzoek vaak vals negatief is. Ten slotte kost dit onderzoek ook geld.

–De Alvarado-score, biochemie en een CT zijn in de praktijk betere manieren om een appendicitis met grote waarschijnlijkheid vast te stellen

– Imaging rechter fossa syndroom

Selection of the most appropriate imaging modality

Depends on– 1) Patient age and body habitus

• < 20 years– Ultrasound initially, regardless of suspected

pathology– Then CT or MRI if additional information is required

• > 20 years– Ultrasound initially in young, slim adults

» Particularly women of reproductive age• Older or obese patients

– CT

Depends on – 2) Suspected pathology, based on

clinical and laboratory findings• Appendicitis• Renal colic• Gynaecological• Hernia• Bowel related• Vascular

Selection of the most appropriate imaging

modality

XRA– Feacal sign caecum– Otherwise unhelpful (caecal volculus)

Acute appendicitis

Ultrasound– Advantages

• Widely available and inexpensive• Avoidance of ionizing radiation

– Especially women of reproductive age and children– Gynecological disease gives further reason for U/S

evaluation• Useful in identifying an alternative diagnosis

– Disadvantages • Operator dependant

– Technique• Graded compression with high frequency linear

probe– gradual and constant increase in the compression by

the US probe in the right iliac fossa – displaces normal, air-filled bowel, or compresses it

against the posterior abdominal wall – abnormal, non-compressible appendix is thus

revealed

Acute appendicitis

Acute appendicitis

Transverse U/S : Inflammed appendix (between calipers) ; adjacent inflamed fat (arrow) ; terminal ileum with air (curved arrow)

Longitudinal U/S : inflammed appendix with proximal appendicolith

Acute appendicitis CT

– Technique• Variety of techniques in an attempt to

– Reduce radiation dose– Maximize diagnostic yield – Minimize preparation time for the scan

• Variation in – Amount of abdomen imaged– Use of IV, oral and rectal contrast

• All share same basic concept– Acquiring thin collimation images (5mm or less) in a

single breath hold

• Unenhanced CT abdomen (No IVI, oral or rectal contrast) – Reduces delay for patient preparation and reduces per

patient cost– Relies on intra-abdominal fat to provide contrast

» Difficult to obtain good results in thin patients» More difficult to interpret initially, but just as

accurate when experienced (reasonably high sensitivity and specificity for clinical decision-making 93% and 96% respectively)

Acute appendicitis CT

– Appearance on CT• Filling of appendix with oral contrast is an important

negative feature• Normal appendix wall 1-2mm in thickness• Periappendiceal fat should appear homogenous

– CT diagnosis of acute appendicitis can be made if• Abnormal appendix identified

– Appendix diameter > 6mm– With homogenously enhancing wall – Mural edema may produce a target sign– Periappendiceal inflammation in 98%

» Fat stranding• Calcified appendicolith with pericecal inflammation

– Perforated appendicitis • Accompanied by pericecal phlegmon or abscess• Associated findings

– Extraluminal air– Ileocecal thickening– Localized lymphadenopathy– Peritoneal enhancement– Small bowel obstruction

Inflamed appendix with a target sign : enhancing serosa and mucosa seperated by oedematous fluid in wall

Appendix abscess : Ring enhancing collection with adjacent appendicolith

Appendicitis : dilated appendix ; appendicoliths ; adjacent fat stranding

Acute appendicitis MRI

– Currently limited to patients with right iliac fossa pain during pregnancy

• Avoiding ionizing radiation is of prime importance

– Limited information available• small number of studies with little

patient numbers– Imaging techniques used

• no IV contrast• axial, coronal and sagittal noncontiguous T2-weighted

single-shot fast spin-echo (SE) sequences • axial fat-suppressed T2-weighted fast SE sequences• axial T1-weighted gradient-recalled-echo sequences• axial and coronal inversion-recovery sequences

performed through the lower abdomen and pelvis– Illustrates normal and abnormal appendix

• May be useful in diagnosing adnexal pathology

Appendicitis : dilated appendix (black

arrowhead) ; appendicolith (black arrow) ; adjacent fat stranding (white arrowheads)

Conclusies– Rechter fossa syndroom

• Uitgebreide differentieel diagnose

• Combinatie anamnese / klinisch onderzoek / biochemie en beeldvorming noodzakelijk !

• Vrouwen gynaecologische pathologie• Multidisciplinair overleg pediater – internist

– chirurg – gynaecoloog – radioloog

Vragen ?

Rechter fossa syndroom

Health & Medicine

Transcript of Rechter fossa syndroom