title: Ultrasonography-triggered diagnosis of putrid, ulcero-phlegmonous, hemorrhagic appendicitis and periappendicitis with an atypical symptom pattern: a case report.
abstract: BACKGROUND
  Asymptomatic and oligosymptomatic appendicitis are rare and challenging diagnoses that should not be missed.
  
  
  METHODS
  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.
authors.affiliation: Department of Tropical Medicine at the Bernhard Nocht Institute, German Armed Forces Hospital of Hamburg, Hamburg, Germany ; Institute for Microbiology, Virology and Hygiene, University Medicine Rostock, Rostock, Germany.
authors.forename: Hagen
authors.initials: H
authors.lastname: Frickmann
authors.affiliation: Practice Dr. Jungblut, Frankfurt/Main, Germany.
authors.forename: Sven A
authors.initials: SA
authors.lastname: Jungblut
keywords: Acute appendicitis; Oligosymptomatic; Surgery; Ultrasound