0:01

So a lot of patients do present with right

0:02

lower quadrant pain, and it's not always the

0:04

appendix that's the problem, but it's always

0:07

something you're going to be looking for.

0:08

So in this case, as we're following that

0:11

colon down, you already see your inflammation.

0:13

You see some peritoneal

0:15

wall thickening right here, some

0:16

fascial thickening, inflammation.

0:19

You have your fatty terminal ileal valve right

0:21

there, and the terminal ileum coming out.

0:23

Your cecum here. And then we have the

0:25

appendix, or at least part of it, right here.

0:28

Here, it's exiting from the cecum,

0:29

and blind-ending tubular structure.

0:31

So the question here is, do you

0:32

have acute appendicitis, and they

0:34

need to go to the operating room?

0:36

Or is this something else?

0:38

So the way to tell what this is, and whether

0:40

it's something else, or whether it's the

0:42

appendix that's the problem, is to look

0:44

at where the inflammation is centered.

0:46

And I would argue in this

0:47

case, the appendix is abnormal.

0:48

It is thickened.

0:49

It is enhancing.

0:50

It has an abnormal morphology,

0:52

but the inflammation is not really

0:54

centered around the appendix itself.

0:56

It's really centered more around the

0:57

cecum and perhaps the terminal ileum over

1:00

here, which doesn't look normal either.

1:03

And if you're not sure, sometimes

1:05

it's hard to tell for sure.

1:07

Use your sagittal or your

1:08

coronal reconstructions.

1:09

So here's a sagittal image right here.

1:11

And you can see, you can see the nice

1:12

hepatic flexure coming all the way down here.

1:14

Here's your valve right here for the TI.

1:16

Here's that thickened abnormal cecum.

1:19

Looks completely different than

1:20

the rest of the colon here.

1:21

And here's your appendix coming off posteriorly.

1:24

And this is a beautiful image

1:25

because even though that appendix is

1:27

wildly abnormal, the fat above it is

1:30

completely or nearly completely clean.

1:32

There's no inflammation over here.

1:33

And if the appendix is the problem and

1:35

you have an appendicitis, that "itis" or

1:38

inflammation should be surrounding the appendix.

1:40

And it is not; it is only on this side of it.

1:43

So as you're seeing right here, there's

1:44

this abnormal loop of bowel right here,

1:46

which is thickened wall enhancement,

1:49

lots of edema in the walls itself.

1:52

This is more likely going to be a terminal

1:54

iliitis that's causing reactive thickening

1:56

and inflammation of the appendix.

1:57

So this person does not necessarily

1:59

need a surgeon, at least not acutely.

2:02

Um, they can manage this depending on

2:03

the etiology, whether it's infectious or

2:05

whether it's an inflammatory bowel disease.

2:07

But the first thing is non-operative.

2:09

They're not calling the surgeon first.

2:11

They're calling somebody else to help take care of this.

2:12

The appendix is not the issue here.