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  • Title: Anatomic Reasons for Failure to Visualize the Appendix With Graded Compression Sonography: Insights From Contemporaneous CT.
    Author: Lin W, Jeffrey RB, Trinh A, Olcott EW.
    Journal: AJR Am J Roentgenol; 2017 Sep; 209(3):W128-W138. PubMed ID: 28829172.
    Abstract:
    OBJECTIVE: The purpose of this study is to identify the anatomic locations of appendixes on CT when graded compression sonography fails to visualize the appendix. MATERIALS AND METHODS: The study included 197 patients with suspected appendicitis whose appendixes were not visualized on graded compression sonography performed with typically used transducers of at least 10 MHz, who underwent CT within 48 hours following graded compression sonography, and who had available either pathologic examination following surgery or 6-week follow-up if surgery was not performed. Appendixes were retrospectively localized using four transverse quadrants (including the posteromedial quadrant) centered on the ileocecal valve and projected vertically, the craniocaudal level relative to the iliac crests, and the depth of the appendix as measured from the surface of the skin. Data were assessed using the Fisher exact test, t test, multinomial test, binomial distribution, ANOVA, and linear regression. RESULTS: Appendixes were most frequently located in the posteromedial quadrant (123 of 197 patients [62.4%]; 95% CI, 55.3-69.2%) at a statistically significantly greater frequency than that expected by chance (p < 0.00001). Appendixes were located above the iliac crests in 19.8% of patients (39/197; 95% CI, 14.5-26.1%) and at depths exceeding the penetration of typical transducers of at least 10 MHz in 19.3% of patients (38/197; 95% CI, 14.0-25.5%). All appendixes (95% CI, 98.1-100.0%) were located within the range of 6-MHz transducers. CONCLUSION: Appendixes that are not visualized on graded compression sonography are most frequently located in the posteromedial quadrant and are often located above the iliac crests or at depths too great for visualization with typically used transducers of at least 10 MHz. Accordingly, when the appendix is not visualized on graded compression sonography, targeted scanning of the posteromedial quadrant and the region above the iliac crests, and scanning with 6-MHz transducers, may enable visualization of the appendix and are recommended additions to scanning protocols.
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