Computed Tomography in the Diagnosis of Acute Appendicitis (A Clinical Case)

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Introduction. Acute appendicitis is considered to be one of the most common surgical diseases of the abdominal cavity[1]. Uncharacteristic variations in the course of acute appendicitis are recognized in about 20-30% of patients[2]. Consequently, the clinical diagnosis of a pathological appendix with its non-standard location still poses a real threat. The most important point in this case is the timely diagnosis of the disease and the early decision on the need for surgery. Later surgical treatment of acute appendicitis leads to the development of numerous complications in the peritoneum. [3, 4]. The results of an objective examination are important in the diagnosis of appendix inflammation. Many scientists note the need to check all known symptoms of this disease, but even in this case, the diagnosis of acute appendicitis can be confirmed in no more than 72-88% of cases[5, 6]. The use of laboratory methods helps to substantiate the diagnosis, taking into account the lack of their specificity. The available list of instrumental diagnostic methods for acute appendicitis includes ultrasound, computed tomography, MRI and laparoscopy. Ultrasound is the most preferred choice, but its results are not always reliable, which is the reason for using more imaging methods. Patients with suspected "erased" clinical picture of acute appendicitis are more often prescribed computed or magnetic resonance imaging of the abdominal organs to improve the accuracy and conduct differential diagnosis with other acute diseases of the abdominal cavity in case of uninformative ultrasound diagnostics.The aim of the work was to evaluate the informative value of computed tomography in the diagnosis of inflammation of the appendix with its atypical localization using the example of a clinical case.Materials and methods of research. Patient B., 20 years old, was admitted on the evening of 02/16/2026. 6 hours after the onset of the disease, complaining of intense pain in the lumbar region on the right with irradiation into the right hypogastrium. On the day of the onset of the disease, I did not notice nausea, vomiting, or fever. Urination is not disturbed, the stool is decorated without any special features. The disease was associated with intense physical activity the day before. Upon admission, the condition is closer to satisfactory. The skin is of normal color, clean. Breathing is vesicular, symmetrical throughout the pulmonary field, there is no wheezing. The heart tones are clear and rhythmic. Pulse is 76 beats per minute, blood pressure is 120/70 mmHg. The temperature in the armpit is 36.6 ° C. The tongue is moist. An objective examination of the patient revealed no convincing evidence for acute appendicitis, peritoneal symptoms were negative. Peristalsis was heard satisfactorily in all departments. A general blood test revealed leukocytosis (11.3×109/l). Ultrasound examination of the abdominal organs revealed no pathological changes. With the introduction of antispasmodics, the pain decreased. The patient refused to be hospitalized.The next day, 02/17/2026, the pain in the lumbar region increased, but did not decrease while taking analgesics. I went to the surgeon again.  Pathology from the respiratory and cardiovascular systems was not revealed. Pulse 78 beats per minute, blood pressure 125/80 mmHg, armpit temperature 36.8 ° C. The tongue is moist, covered with a gray coating. An objective examination of the patient lying on his back was performed after the appointment of antispasmodics. On palpation, the abdomen is soft, moderately painful in the hypogastric region on the right. There were no symptoms of acute appendicitis or irritation of the peritoneum. Peristalsis was heard – slightly increased in the right iliac region, satisfactory in the rest of the departments. Per rectum: the tone of the sphincters is normal, the walls of the rectum are smooth and painless. There is brown feces on the glove. The total blood count showed an increase in the number of leukocytes to 14.9×109/l, rod–shaped neutrophils – 11%, lymphocytes - 17%, C-reactive protein - 15.8 mg/l. Ultrasound examination of the abdominal organs revealed no pathology, and free fluid was not detected among the intestinal loops. Given the onset of the disease associated with intense physical exertion, severe pain in the lumbar region radiating to the right groin area, and the absence of pathology from the abdominal organs during ultrasound, additional examination of the patient is recommended. Within 2 hours, a multispiral computed tomography of the abdomen was performed on a 64-slice Toshiba Aquilion 64 device. Attention is drawn to the thickening of the fiber in the area of the cecum dome (Fig.1), an increase in the diameter of the appendix to 22-23 mm, and an uneven thickening of its wall (Fig. 2), an increase in regional lymph nodes (Fig. 4). No fluid or free gas was detected. The paranephral tissue is not compressed.The patient was given a preliminary diagnosis of acute appendicitis. Laparoscopic appendectomy was performed. Intraoperatively, a vermiform process was found, located mesoceliacally, parallel to one of the small intestinal loops in the right iliac region, tip-up, S-shaped curved, thickened to about 2.0 cm with loose fibrin deposits. The course of the postoperative period is smooth. The histological conclusion is phlegmonous appendicitis. He was discharged on the third day after the operation.The results of the study. The above observation demonstrates one of the diverse "masks" of acute appendicitis and the difficulties of clinical diagnosis of the disease with mesoceliac localization of the appendix. The "atypical" onset of the disease, which the patient associates with intense physical exertion, intense pain in the lumbar region radiating to the right iliac region, the absence of nausea, vomiting, fever, unusual for acute appendicitis, physical data: normal urination and the presence of unchanged stools - became insufficient grounds for a preliminary diagnosis. For this purpose, additional diagnostic methods were subsequently performed: ultrasound, multispiral computed tomography. As a result, a preliminary diagnosis was made – acute appendicitis, which was confirmed at the time of surgery – a video laparoscopic appendectomy (macroscopic picture) and the results of a histological examination. Conclusion. Despite the fact that diagnostic research methods have advanced in recent years, the accurate diagnosis of acute appendicitis with atypical localization of the appendicular process is still difficult due to various factors. In order to improve the accuracy of diagnosis and timely surgical treatment, patients with suspected inflammation of the appendix need a multidisciplinary and multimodal approach, taking into account the patient's age, gender and constitution. Using only clinical data and laboratory parameters to confirm acute appendicitis without imaging diagnostic methods is not always reliable and informative.

About the authors

Sofya Sergeevna Boldina

Burdenko Voronezh State Medical University

Email: kharina_79@inbox.ru
ORCID iD: 0009-0005-4187-9888
https://vk.ru/id151243645

Student

Russian Federation, 10 Studenchskaya Street, 394036, Voronezh, Russian Federation

Andrey Alexandrovich Gritsai

Burdenko Voronezh State Medical University

Email: x-ray73@mail.ru
ORCID iD: 0009-0004-8237-3907
SPIN-code: 4311-6986
Scopus Author ID: 1246982
https://vrngmu.ru/academy/personnel/35300/

Candidate of Medical Sciences, Associate Professor of the Department of Instrumental Diagnostics, Voronezh State Medical University named after N. N. Burdenko, Ministry of Health of the Russian Federation, Voronezh, Russian Federation

Russian Federation, 10 Studenchskaya Street, 394036, Voronezh, Russian Federation

Oleg Olegovich Izotov

Burdenko Voronezh State Medical University

Email: izotovol777@mail.ru
ORCID iD: 0009-0006-7366-4192
https://vk.com/izot.ol777

Student

Russian Federation, 10 Studenchskaya Street, 394036, Voronezh, Russian Federation

Olga Gennadievna Deryaeva

Burdenko Voronezh State Medical University

Author for correspondence.
Email: centaurea_cyanus@mail.ru
ORCID iD: 0000-0002-4562-6416
SPIN-code: 2786-0295
Scopus Author ID: 833518
https://vrngmu.ru/academy/personnel/7190/

Candidate of Medical Sciences, Associate Professor of the Department of Instrumental Diagnostics, Voronezh State Medical University named after N. N. Burdenko, Ministry of Health of the Russian Federation, Voronezh, Russian Federation

Russian Federation, 10 Studenchskaya Street, 394036, Voronezh, Russian Federation

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