Ultrasonography-triggered diagnosis of putrid, ulcero-phlegmonous, hemorrhagic appendicitis and periappendicitis with an atypical symptom pattern: a case report

BACKGROUND: Asymptomatic and oligosymptomatic appendicitis are rare and challenging diagnoses that should not be missed. CASE PRESENTATION: A young female patient presented with mild to moderate pain in the middle and lower abdomen, and the results of physical examination, including digital rectal examination, were otherwise non-contributory. Ultrasonography demonstrated a marked increase of the outer appendiceal diameter up to 12 mm and a trace of free liquid around the terminal ileum. Subsequent surgical exploration and histological examination allowed for a final diagnosis of putrid, ulcero-phlegmonous, hemorrhagic appendicitis and periappendicitis. CONCLUSIONS: Ultrasonography is increasingly used for the diagnosis of appendiceal inflammation, particularly in military medical settings. Increases in the outer appendiceal diameter up to >6 mm under compression have recently been demonstrated to be indicative of acute appendicitis. At a minimum, in cases with doubtful physical examination results, ultrasonography should be considered as an element in the diagnosis of acute appendicitis.