Rule Out Appendicitis: “To Be or Not to Be”

(A) A 41-year-old man with epiploic appendagitis from redundant transverse colon. Axial contrast-enhanced computed tomography (CECT), demonstrating a fat attenuation mass with adjacent inflammation, hyperdense rim (black arrow), and central hyperdensity (white arrow). (B) A 36-year-old man with acute right lower quadrant pain and diarrhoea. Axial CECT revealed inflamed epiploic appendages of the sigmoid colon, with central hyperdensity (arrow). The sigmoid colon is the most common site for epiploic appendagitis, and the patient may present with left lower quadrant pain.

A 22-year-old woman with right lower quadrant (RLQ) pain of 48 hours' duration. Axial contrast-enhanced computed tomography, revealing a fat-attenuation lesion in the RLQ, with pericecal inflammation (white arrow) and thickening of the parietal peritoneum (black arrow). The patient was managed conservatively and recovered uneventfully.

A 23-year-old man with right lower quadrant (RLQ) pain. Axial computed tomography, showing slightly enlarged lymph nodes in the RLQ mesentery (arrow), with adjacent mild inflammation (arrowhead). The appendix was normal.

(A) A 55-year-old man with right lower quadrant for 3 days, with vomiting and an elevated leukocyte count. Axial contrast-enhanced computed tomography (CECT), demonstrating solitary cecal diverticulum (white arrow), with cecal-wall thickening (arrowhead) and adjacent inflammatory changes (black arrow). (B) Cecal diverticulitis in a 32-year-old Asian woman who presented with diffuse right lower abdominal pain for 2 days. Axial CECT, revealing inflamed cecal diverticulum with fecolith (arrowhead) surrounded by fat stranding (black arrow) and thickening of parietal peritoneum (white arrow).

Meckel diverticulitis in a 23-year-old man presenting with right lower quadrant (RLQ) pain and vomiting. (A, B) Axial contrast-enhanced computed tomography (CECT), revealing a blind ending tubular structure (white arrow) attached to the antimesenteric border of the ileum and showing inflammation surrounding its tip (black arrow. Intraoperative findings confirmed Meckel diverticulitis. (C, D) Meckel diverticulitis in a 40-year-old man presenting with RLQ pain and fever. There was a history of appendectomy. Coronal CECT, demonstrating a tubular structure arising from the distal ileum (white arrow), with an enterolith within the diverticulum (black arrow) and adjacent inflammation. Meckel diverticulum may contain fluid, an air-fluid level, and, occasionally, enterolith.

(A) A 35-year-old man with acute right lower quadrant (RLQ) pain, fever, and leucocytosis. Axial contrast-enhanced computed tomography (CECT), demonstrating long-segment thickening and abnormal enhancement of the distal ileum (white arrow). An abscess (black arrow) is seen adjacent to these bowel loops. Patients with local complications of Crohn disease often present with RLQ pain. (B, C) Crohn disease that involves the appendix in a 45-year-old man with acute RLQ pain, fever, and diarrhoea. Axial CECT, demonstrating appendicitis (black arrow), with multiple segmental areas of smooth circumferential wall thickening that involved the distal ileum (white arrows), giving a target appearance to these bowel loops. The vasa recta are prominent (arrowhead).

A 47-year-old man with typhilitis. The patient, with acute myelogenous leukaemia on chemotherapy, presented with right lower quadrant pain and fever. Axial contrast-enhanced computed tomography, showing marked low-density circumferential thickening of the cecum and right colon (arrows). The patient responded to broad-spectrum antibiotics.

A 40-year-man with right lower quadrant pain and fever. Axial contrast-enhanced computed tomography, revealing thickened inflamed appendix (white arrow) with mural thickening of the terminal ileum (black arrow). The patient had surgery, and, on a subsequent histopathology, was found to have Yersinia involvement of the ileum and appendix.

A 25-year-old woman with ileocecal tuberculosis presented with right lower quadrant pain, weight loss, and fever. A barium meal follow-through examination, showing deformed and a fixed cecal pole (arrowhead), with narrowed and ulcerated terminal ileum (arrow). The ileocecal angle is lost, resulting in “goose-neck” deformity.

Extensive small-bowel ascariasis in a 14-year-old Asian immigrant who presented with right lower quadrant pain and failure to gain weight. (A) Axial and (B) coronal contrast-enhanced computed tomography, showing multiple nodular and linear filling defects in the jejunum and ileum, characteristic of worm infestation. (C) A magnified view of the same ingested contrast within a few of these worms as hyperdense dots within their lumen (arrows).

(A) A 50-year-old man with a history of melanoma presented with right lower quadrant (RLQ) symptoms and bowel obstruction. Coronal contrast-enhanced computed tomography (CECT), demonstrating a bowel-within-bowel appearance (characteristic of ileocecal intussusception), with bowel obstruction. An enhancing nodule is seen as the lead point (arrow). A pathology-proven metastatic deposit from melanoma. (B, C) A 25-year-old woman with Puertz-Zegher syndrome presented with acute RLQ pain and blood in stools. Axial CECT, showing multiple polyps in the small and large bowel (arrows). A bowel-within-bowel appearance, with varying densities, is seen in the RLQ, characteristic of ileocolic intussusception. The patient had surgery; a polyp was the lead point.

(A) A 57-year-old man with acute on chronic right lower quadrant (RLQ) pain and weight loss. Axial contrast-enhanced computed tomography (CECT), revealing a soft-tissue mass in the cecum (arrow) and causing luminal obstruction and distention of the appendix (arrowhead). The patient underwent right hemicolectomy, which confirmed invasive adenocarcinoma. (B) Perforated colon cancer in a 65-year-old man who presented with fever and RLQ pain. Axial CECT, showing an inflamed cecum (arrow), with posterior perforation that led to abscess formation (arrowhead). Colonoscopy confirmed perforated cecal carcinoma.

A 20-year-old man with cecal volvulus presented with right lower quadrant pain. (A) Axial and (B) coronal contrast-enhanced computed tomography (CECT), showing dilated cecum in the left upper quadrant (arrow). A “whirl” caused by twisted mesentery is seen. Surgery confirmed cecal volvulus with viable bowel and was treated with right hemicolectomy.

(A) A 40-year-old man with a giant mucocele. Axial contrast-enhanced computed tomography (CECT), revealing a large cystic lesion with peripheral calcification (arrow) in close contact with the cecal pole (arrowhead). Surgery is performed for mucoceles >1.5 cm because of a high risk of underlying malignancy. (B, C) A 42-year-old woman with a giant mucocele. (A) Coronal contrast-enhanced T1W and (B) T2W images show a soft-tissue nodule (arrow) within the mucocele. Pathology results proved malignant mucinous tumour.

Primary appendicular adenocarcinoma in a 55-year-old man with acute right lower quadrant pain and leucocytosis. Coronal images show a subtle infiltrative expansile soft-tissue density appendiceal mass (arrow), with secondary appendicitis. This can easily be mistaken for primary appendicitis.

A 21-year-old man with right lower quadrant (RLQ) pain. (A) Axial and (B) oblique coronal contrast-enhanced computed tomography (CECT), demonstrating enhancing mass (arrow) at the base of the appendix, which caused secondary appendiceal distension (arrowhead). This patient underwent right hemicolectomy and subsequent histopathology confirmed primary appendicular carcinoid.

A 35-year-old man with acute right lower quadrant pain. Coronal contrast-enhanced computed tomography, revealing homogenous soft-tissue mass in the proximal appendix (arrowhead), which caused enlargement of the appendix (arrow) but typically maintained its vermiform appearance. Histopathology confirmed non-Hodgkin's involvement of the appendix.

A 45-year-old woman with right groin and lower abdominal pain. (A, B) Coronal contrast-enhanced computed tomography (CECT), revealing a femoral hernia with a distended inflamed appendix (arrow) within it. The cecum (arrowhead) was low lying in the pelvis. During surgery, an incarcerated appendix was seen within the femoral hernia.

A 26-year-old man with recurrent right lower quadrant pain 4 months after appendectomy. (A) Axial contrast-enhanced computed tomography (CECT) at the time of initial presentation, revealing uncomplicated appendicitis (arrow). The patient underwent laparoscopic appendectomy. (B) Axial CECT performed 4 months later, when the patient presented with recurrent pain, showing an impacted fecolith in the appendicular stump (arrow), with adjacent inflammation, consistent with the diagnosis of stump appendicitis.

(A, B) A 21-year-old woman with acute right lower quadrant (RLQ) pain. (A) Doppler ultrasonography, showing enlarged right ovary with hypoechoic follicles (arrow). No arterial or venous flow is seen within it. (B) Axial contrast-enhanced computed tomography (CECT), showing an enlarged midline ovarian mass with multiple peripheral low-attenuation follicles (arrowheads). (C, D) A 28-year-old woman with torsion of right ovarian dermoid. (C) Axial in-phase and (D) out-of phase T1W magnetic resonance imaging (MRI), demonstrating a complex mass in the left hemi pelvis, with twisted vascular pedicle (arrowhead). T1 bright fluid (black arrow) is seen in this lesion, which does not suppress on out-of-phase images, consistent with hemorrhagic fluid. T1 isointense nodule (white arrow) is seen, which shows signal drop on the out-of-phase images, consistent with fat within the lesion.

(A) Pyosalpinx in a 27-year-old woman with fever and lower abdominal pain. Axial T2W images, demonstrating a tubular structure in the right hemi pelvis (arrowheads) and showing a fluid debris level (black arrow) consistent with pyosalpinx. An incomplete projection (white arrow) is seen within the lesion, characteristic of hydrosalpinx. (B) Another patient with pelvic inflammatory disease who presented with right lower quadrant pain and fever. Axial contrast-enhanced computed tomography, demonstrating an abscess (white arrow), with dilated and enhancing right fallopian tube (black arrow). There is adjacent fluid and stranding.

Right hemorrhagic cyst in a 25-year-old woman who presented with right pelvic pain. (A) ultrasonogram (USG) showing complex septated cyst with debris. (B) Coronal T1W magnetic resonance imaging (MRI) shows fluid-fluid level, with hyperintense superior component (arrow).

Right ovarian endometrioma in a 30-year-old woman with right lower quadrant pain. (A) Axial fat-suppressed T1W magnetic resonance imaging (MRI), demonstrating a hyperintense mass (arrow). (B) Axial T2W1 MRI, showing a mildly hyperintense signal, with areas of signal loss because of hemosiderin (arrow).+O

Ovarian vein thrombosis in a 25-year-old, postpartum, patient with right lower quadrant (RLQ) pain and fever. Coronal contrast-enhanced computed tomography, demonstrating a tubular structure (arrows) that extended from the right hemi pelvis to the infrarenal inferior vena cava (IVC) (black arrow). It shows enhancing walls and low attenuation thrombus within it.

A 35-year-old woman who presented with pain and vaginal bleeding. A pregnancy test was positive. (A) Transvaginal scan of the uterus, showing hypertrophied endometrium (arrow), with the absence of a gestational sac. (B) Transvaginal scan of the right adnexa, demonstrating an adnexal mass with thick hyperechoic walls (arrow). This figure is available in colour online at http://carjonline.org/.

Right ureteric vesical junction (UVJ) calculus in this patient who presented with acute right lower quadrant pain. (A) Supine and (B) prone noncontrast axial computed tomography, showing a calculus (arrow) impacted at the right UVJ.

Focal right pyelonephritis in a 54-year-old woman who presented with right lower quadrant pain and fever. Axial contrast-enhanced computed tomography, showing differential area of low density along the posterior cortex (arrow), with adjacent inflammation characteristic of focal pyelonephritis.

A 28-year-old man experienced sudden right lower quadrant pain while performing sit-ups, with the subsequent appearance of a palpable mass. (A, B) Axial contrast-enhanced computed tomography, showing a large hematoma in the right rectus sheath (arrowheads), with perisheath hematoma in the right lower quadrant (black arrow). The inferior epigastric artery is seen (white arrow) and was injured in this case.

A 38-year-old woman with right lower quadrant (RLQ) pain. (A) Ultrasound, showing a linear sharp object (arrowheads) in the RLQ, with adjacent fluid collection (arrow). (B) Axial contrast-enhanced computed tomography confirmed a linear object in the terminal ileum (arrowheads), which caused localized perforation with adjacent inflammation (arrow). The patient subsequently did confirm a history of swallowing a toothpick and subsequently had surgery. The toothpick was not visualized on a plain film, because most wood pieces are not opaque.

Right lower quadrant gossypiboma in this 54-year-old female with a history of hysterectomy, presented with acute right lower quadrant pain. Axial contrast-enhanced computed tomography, showing a hypodense mass (black arrow) with thick peripheral rind (arrowhead) and the metallic marker (white arrow). The characteristic spongiform pattern with gas bubbles was not seen in this case.