Appendicolith: a stone in the appendix
Here’s the answer to the weekend’s image quiz 2. This gentleman presented with right lower quarter abdominal pain on lying flat, relieved by lifting his right leg up. Examination revealed localised tenderness (pain on pressure) at the right lower quadrant, which is a sign of some irritant in the abdominal cavity, usually due to appendicitis. This X-ray showed an opacity (something which blocks the transmission of X-rays) in the area of tenderness. Plus, urine examination showed blood in the urine.
In fact, the most common cause of an opacity in that region is a lower ureteric stone, that is, a stone in the urine tract between the kidney and the bladder. A CT scan was performed since there was a doubt regarding the location of the stone. The CT revealed: a stone in the appendix and a collection pus around it. So, the answer to the quiz is an appendicolith or faecolith in the appendix. It is made up of hardened faecal material which has collected over years and become stone-like. The presence of a faecolith in the appendix increases the risk of developing appendicitis. In this case, the appendix had become inflammed and progressed into an abscess (pus collected).
The X-ray again: a yellow circle shows the stone. The blue line marks the usual site of the ureter, although it can be variable and can appear just like this X-ray. So, “ureteric stone” scores half a mark.
CT scan: appendix abscess. Marked by the crossing measurement lines.
CT scan: appendix abscess. Yellow circles mark the right and left ureters.
Laparoscopic appendicectomy and wash-out of the abscess cavity was performed. The appendix was removed piecemeal from the abscess cavity. Fortunately, the stump of the appendix was found and securely tied.
The appendix was in 3 parts sitting in the abscess. It had been broken into pieces by the inflammatory process. Can you see the stone?
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scroll down (not a surprise)
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scroll a bit more… just to give you a chance to spot the stone before I show it.
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The stone is the white bit with an arrow pointing to it.
