Invest Clin 65(1): 27 - 36, 2024 https://doi.org/10.54817/IC.v65n1a03
Corresponding author: Ning Lin: Department of Ultrasound, Fujian Provincial Hospital, Fuzhou 350001, Fujian
Province, China. E-mail: hengpo22445803885@163.com
Diagnostic value of abdominal ultrasound in
patients with acute appendicitis and analysis
of the expression of related inflammatory
factors.
Siyuan Yang1, Mingyan Wang2, Linxin Yang1 and Ning Lin1
1Department of Ultrasound, Fujian Provincial Hospital, China.
2Department of Ultrasound, Fujian Provincial Hospital (South Branch), China.
Keywords: acute appendicitis; abdominal ultrasound; inflammatory factors; fuzzy
appendiceal border; ultrasound signs.
Abstract. Appendicitis is an inflammation of the appendix that, if left un-
treated, can be life-threatening. Abdominal ultrasound helps diagnose it and
differentiate it from other causes of abdominal pain. This study aimed to evalu-
ate the diagnostic value of abdominal ultrasound in acute appendicitis (AA)
and assess inflammatory factor levels in different types of appendicitis. One
hundred patients with AA were selected as the observation group, and 30 pa-
tients with simple abdominal pain as the control group. Among the 100 AA
patients, 37 (37%) cases had blurred appendiceal boundaries, 24 (24%) cases
had fecal calculus in the appendix cavity, 13 (13%) cases had enhanced echo
intensity of surrounding fat, 15 (15%) cases presented enlarged outer diameter
of the appendix (> 6mm), one (1%) case had peripheral lymphadenopathy, and
one (1%) case had peripheral effusion. None of the cases (0%) presented a pe-
ripheral mass. The levels of white blood cells (WBC) and inflammatory factors:
C-reactive protein (CRP), interleukin-6 (IL-6), and tumor necrosis factor α
(TNF-α)) patients with uncomplicated appendicitis were lower than those with
suppurative appendicitis, gangrenous appendicitis, or peri-appendiceal abscess
(p <0.05). The blurred boundary of the appendix, fecal stones in the appendix
cavity, an enlarged outer diameter of the appendix (> 6mm), and an enhanced
echogenicity of the surrounding fat are the most common ultrasonic signs of
AA. Abdominal ultrasound has an excellent diagnostic value on pathological
types of AA. The increase in the level of inflammatory factors can indicate the
severity of the disease to a certain extent.
28 Yang et al.
Investigación Clínica 65(1): 2024
Valor diagnóstico de la ecografía abdominal en pacientes
con apendicitis aguda y análisis de la expresión de factores
inflamatorios relacionados.
Invest Clin 2024; 65 (1): 27 – 36
Palabras clave: apendicitis aguda; ultrasonido abdominal; factores inflamatorios;
limites apendiculares borrosos; signos de ultrasonido.
Resumen. La apendicitis es la inflamación del apéndice, que si no es trata-
da puede poner en peligro la vida. La ecografía abdominal ayuda a diagnosticar-
la y diferenciarla de otras causas de dolor abdominal. Este estudio tuvo como
objetivo evaluar el valor diagnóstico de la ecografía abdominal en la apendicitis
aguda (AA) y evaluar los niveles de factores inflamatorios en diferentes tipos de
apendicitis. Se seleccionaron 100 pacientes con AA como grupo de observación
y 30 pacientes con dolor abdominal simple como grupo control. Entre los 100
pacientes con AA, 37 (37%) casos tenían límites apendiculares borrosos, 24
(24%) casos tenían cálculos fecales en la cavidad del apéndice, 13 (13%) casos
tenían aumento de la ecogenicidad de la grasa circundante, 15 (15%) casos
presentaron agrandamiento del diámetro exterior del apéndice (> 6 mm), 1
(1%) caso tenía adenopatías periféricas y 1 (1%) caso tenía derrame periférico.
Ninguno de los casos (0%) presentó una masa periférica. Los niveles de glóbu-
los blancos (WBC) y factores inflamatorios como proteína C reactiva (CRP),
interleucina-6 (IL-6) y factor de necrosis tumoral α (TNF-α)) en pacientes con
apendicitis no complicada, fueron más bajos en comparación con pacientes
con apendicitis supurativa, apendicitis gangrenosa o absceso peri apendicular
(p <0,05). El límite borroso del apéndice, los cálculos fecales en la cavidad del
apéndice, un diámetro externo agrandado del apéndice (> 6 mm) y un aumen-
to de la ecogenicidad de la grasa circundante son los signos ultrasónicos más
comunes de AA. La ecografía abdominal tiene un buen valor diagnóstico en los
tipos patológicos de AA. El aumento en el nivel de factores inflamatorios puede
indicar la gravedad de la enfermedad hasta cierto punto.
Received: 18-06-2023 Accepted: 10-10-2023
INTRODUCTION
Appendicitis is usually caused by a bac-
terial infection in the lumen of the appen-
dix, especially when the appendix is blocked;
bacteria can multiply inside the appendix,
causing inflammation and infection 1-4. If
left untreated, the inflammation may spread
to tissues and organs around the appendix,
leading to peritonitis and other infections 5.
In addition, infection in the appendix may
accumulate pus, forming an appendiceal
abscess. The exact etiology of appendicitis
is not fully understood, but it is generally
thought to result from obstruction and in-
fection 6,7. Obstruction in the lumen of the
appendix is one of the most common causes,
and solid feces, tumors, lymphoid tissue hy-
pertrophy, foreign bodies, or parasites may
cause this obstruction 8. Appendicitis can
Diagnostic value of abdominal ultrasound in patients with acute appendicitis 29
Vol. 65(1): 27 - 36, 2024
affect people of any age, and there is no sig-
nificant difference in the incidence between
men and women. Therefore, AA should be
diagnosed and treated as early as possible,
and once suspected symptoms appear (such
as right lower abdominal pain, fever, nau-
sea, vomiting, and loss of appetite), people
should seek medical attention to avoid po-
tential complications and harm 9,10.
There are many methods for the clini-
cal diagnosis of appendicitis, including
symptom assessment and physical examina-
tion (including light palpation, tenderness,
and rebound pain; in the early stages of ap-
pendicitis, where the tender point is in the
right lower quadrant of the abdomen, mus-
cle tension and tender reactions may occur).
The medical history and symptoms help the
doctor initially to judge the possibility of ap-
pendicitis 11–14. Blood cell count (WBC) is
usually elevated, and the C-reactive protein
(CRP) levels, an abdominal CT scan can be
performed in complex or ambiguous cases
with suspected appendicitis, and imaging
examination 15, 16.
Abdominal ultrasound is a non-inva-
sive and non-radiation medical examination
method used to evaluate the structure and
function of internal organs in the abdomen,
which has the advantages of safety and non-
invasive nature 17. In the diagnosis of appen-
dicitis, abdominal ultrasound is often used
to check the status of the appendix, which
can help identify other possible causes of
abdominal pain and check the location and
size of the appendix.
This research highlights the ultrasonic
indicators and inflammatory markers linked
to appendicitis. Therefore, it was necessary
to conduct this study to investigate the ul-
trasonic signs and inflammatory markers re-
lated to acute appendicitis.
MATERIALS AND METHODS
Study subjects
One hundred AA patients who under-
went surgical treatment in the Fujian Pro-
vincial Hospital from September 1, 2019, to
February 28, 2023, were enrolled, including
47 males and 53 females, aged 3-73 years
old, and were set as the observation group.
Thirty patients with simple abdominal pain
admitted during the same period were en-
rolled as the control group.
All subjects agreed to sign an informed
consent form with the approval of their fam-
ily members. Authorization for the trial’s
conduct was obtained from the Hospital Eth-
ics Society.
Inclusion criteria: (1) clinical diagno-
sis of AA; (2) patients with different degrees
of abdominal pain; (3) under indication of
appendicitis surgery; (4) patients had com-
plete clinical data.
Exclusion criteria consisted of patients
with (1) acute parenchymal organ rupture,
(2) mental diseases, (3) severe coagulopa-
thy, (4) acquired immunodeficiency syn-
drome, (5) pregnant or lactating women,
and (6) patients who did not cooperate with
the trial.
Abdominal ultrasound examination
methods
Abdominal ultrasound examinations
were performed using a Philips iU22 ultra-
sound system with a 5-2 MHz curved array
transducer. With the patient in the supine
position, an ultrasound scanner using a con-
vex array probe was used to scan from the as-
cending colon to the cecum, focusing on the
site of pain. The direct and indirect signs of
appendicitis were recorded. The gallbladder,
bile duct, right kidney, and right ureter were
routinely examined before exploring the ap-
pendix. The right pelvic cavity was examined
in women.
Direct ultrasound signs included a hy-
poechoic mass with a finger shape, a target
ring sign, dilatation and effusion of the ap-
pendiceal lumen, hyperechoic with acous-
tic shadow in the lumen, and irregular hy-
poechoic mass. Indirect ultrasonographic
signs mainly included effusion around the
appendix.
30 Yang et al.
Investigación Clínica 65(1): 2024
Blood collection and examination
Peripheral venous blood (5mL) was col-
lected from all patients within three hours of
admission. A routine blood examination was
performed using a Siemens ADVIA® 2120i
hematology analyzer. CRP was measured by
rate nephelometry. WBC with blood routine
examination The serum levels of interleukin-6
(IL-6) and tumor necrosis factor (TNF-α)
were detected by enzyme-linked immunosor-
bent assays.
Observation indicators
The examination results calculated the
incidence of symptoms, positive signs, and
ultrasound signs in patients with appendi-
citis. The occurrence rates of blurred ap-
pendiceal boundaries, fecal calculus in the
appendiceal cavity, enhanced peripheral
omentum echo, peripheral mass formation,
peripheral lymph node enlargement, and
peripheral effusion in ultrasound signs were
counted. The types of appendicitis were re-
corded as uncomplicated, suppurative, gan-
grenous, peri-appendiceal abscess.
Statistical methods
The IBM® SPSS19.0 statistical soft-
ware was employed for data analysis. Mea-
surement data were expressed as means ±
standard deviations (±SD), and count data
were expressed as percentages (%). Repeated
measurement analysis of variance was adopt-
ed for inter-group comparison, and two-way
analysis of variance was adopted for intra-
group comparison. p <0.05 was considered
statistically significant for two-sided tests.
RESULTS
Comparison of patient’s primary data
As illustrated in Fig. 1, there were 47
males and 53 females with a mean age of
32.52±17.5 years in the observation group and
18 males and 12 females with a mean age of
35.64±11.33 years in the control group. There
was no significant difference in the number of
males and females and the mean age between
the two groups (p >0.05).
Ultrasound signs
As displayed in Fig. 2, among the 100 AA
patients, ultrasound images showed 37 (37%)
cases with blurred appendiceal boundaries,
24 (24%) cases with fecal stones in the appen-
diceal cavity, 15 (15%) cases with enlarged
outer diameter of the appendix (> 6mm),
13 (13%) cases with an enhanced echo of
surrounding fat, 1 (1%) case with peripheral
lymphadenopathy, 1 (1%) case with periph-
eral effusion and 9 (9%) cases with no signs.
Fig. 3 shows the ultrasound data of a
female patient in the right lower abdomi-
nal cavity (appendix area). A cord-like hy-
poechoic wall was detected in the right low-
er abdominal cavity; the widest diameter was
about 7.9 mm, the boundary was still clear,
the shape was tortuous, and the transverse
section was a “target ring sign”.
Fig. 1. Comparison of patients’ primary data.
(A: number of males and females; B: age).
Diagnostic value of abdominal ultrasound in patients with acute appendicitis 31
Vol. 65(1): 27 - 36, 2024
There was a hypoechoic wall in the pe-
riphery, with poor sound transmission in the
liquid dark area inside, and no evident hy-
perechoic area was found in the cavity. On
one side of the cavity, there was a blind end,
and the other side seemed to extend with the
cecum. No obvious peristalsis was observed
for several minutes, and the shape and size
did not change significantly. After the probe
was pressurized, the tenderness was appar-
ent. The Color Doppler flow imaging showed
small punctate blood flow signals on the pe-
ripheral hypoechoic wall.
Fig. 4 indicates the ultrasound data
of a female patient’s right lower abdomi-
nal cavity (appendix region); the abdominal
wall was thick, and abdominal muscles were
tense in the patient. A strip of the hypoecho-
ic image extending inward and downward,
about 13mm in width, and high echo (about
9mm × 6mm in size) could be observed in
the right lower abdominal ileocecal region.
The end wall of the strip was not clearly
displayed, and a heterogeneous, irregu-
lar hypoechoic mass with an area of about
72mm×35mm was observed downward, with
a little blood flow signal around it. A slightly
hyperechoic wrapping (omental echo) was
observed around it. A dark fluid area in the
pelvic cavity, about 39mm deep, with accept-
able sound transmission was present.
Fig. 5 presents the ultrasound data of
a male patient in the right lower abdomi-
nal cavity (appendix area). A cord-like hy-
poechoic area was detected in the right low-
er abdominal cavity, with the broadest inner
diameter of about 8mm, a clear boundary,
a tortuous shape, and a “target ring sign”
Fig. 2. Ultrasound of AA patients. N1-N6: blurred
appendiceal boundaries (N1), fecal stone in
the appendiceal cavity (N2), enlarged outer
diameter of the appendix (N3), enhanced
echo of surrounding fat (N4), peripheral
lymphadenopathy (N5), peripheral effusion
(N6), no signs (N7).
Fig. 3. Ultrasound data of the right lower abdominal cavity (appendiceal region) in a 35 years old female pa-
tient. Cord-like hypoechoic wall was (A, B), hypoechoic wall in the periphery (C), side of the cavity (D).
Note: A-C is 2D ultrasound; D is color Doppler flow imaging.
n
32 Yang et al.
Investigación Clínica 65(1): 2024
in the transverse section. A liquid dark area
with poor sound transmission surrounded
the hypoechoic wall. One side was the blind
end, and the other seemed to continue with
the cecum. No obvious peristalsis was ob-
served for several minutes, and the shape
and size did not change significantly. After
the probe was pressurized, tenderness was
evident. Color Doppler flow imaging showed
small blood flow signals on the peripheral
hypoechoic wall.
Ultrasound diagnosis results
As displayed in Fig. 6, among the 100
AA patients, there were 31 cases of uncom-
plicated appendicitis, 40 cases of suppura-
tive appendicitis, 21 cases of gangrenous
appendicitis, and eight cases of peri-appen-
diceal abscess.
Comparison of inflammatory factor levels
in different types of patients
Fig. 7 indicates the levels of WBC, CRP,
IL-6, and TNF-α in patients with uncompli-
cated appendicitis were lower when com-
pared to those of patients with suppurative
appendicitis, gangrenous appendicitis, or
peri-appendiceal abscess (p <0.05). The lev-
els of WBC, CRP, IL-6, and TNF-α in patients
with peri-appendiceal abscess were higher
against patients with suppurative appendici-
tis, gangrenous appendicitis, or peri-appen-
diceal abscess (p <0.05).
Fig. 4. Ultrasound data of a nine-year-old female patient’s right lower abdominal cavity (appendiceal region).
Hypoechoic image inward and downward (A), irregular hypoechoic mass (B), wrapping (omental
echo) (C), pelvic cavity (D).
Note: A-C is 2D ultrasound; D is color Doppler flow imaging.
Fig. 5. Ultrasound data of the right lower abdominal cavity (appendiceal region) of a 31-year-old male patient.
Cord-like hypoechoic (A, B), target ring sign (C, D).
Note: A-C is 2D ultrasound; D is a color Doppler flow imaging.
Diagnostic value of abdominal ultrasound in patients with acute appendicitis 33
Vol. 65(1): 27 - 36, 2024
Comparison of inflammatory factor levels
in patients
The inflammatory factor levels in pa-
tients are presented in Table 1. The levels of
WBC, CRP, IL-6, and TNF-α in the observa-
tion group were higher compared to the con-
trol group (p <0.05).
DISCUSSION
AA is a common disease in surgery,
ranking first in all kinds of acute abdomen
causes. AA can occur at any age but is more
common in adolescents. Uncomplicated ap-
pendicitis often presents with paroxysmal or
S1
S2
S3
S4
0 5 10 15 20 25 30 35 40
n
Fig. 6. Ultrasound diagnosis results.
S1: uncomplicated appendicitis, S2: suppurative
appendicitis, S3: gangrenous appendicitis,
S4: peri-appendiceal abscess.
Fig. 7. Comparison of inflammatory factors levels. (S1-S4: uncomplicated appendicitis, suppurative appendi-
citis, gangrenous appendicitis, peri-appendiceal abscess).
* indicates p <0.05 compared to patients with simple appendicitis; # indicates p <0.05 when compared to
patients with periappendiceal abscess.
34 Yang et al.
Investigación Clínica 65(1): 2024
persistent dull pain; persistent severe pain
often suggests suppurative or gangrenous
appendicitis 18–20. Persistent severe pain in-
volving the middle and lower abdomen or
both sides of the lower abdomen is often a
sign of gangrenous perforation of the ap-
pendix. Sometimes, the abdominal pain di-
minishes, but this phenomenon of pain re-
lief is temporary, and other accompanying
symptoms and signs do not improve or even
worsen 21. Therefore, the early diagnosis of
AA is of great clinical significance.
One hundred patients who would under-
go elective laparoscopic surgery in the Fujian
Provincial Hospital from September 1, 2019,
to February 28, 2023, as the observation
group, and 30 patients with simple abdomi-
nal pain who were admitted during the same
period were considered as the control group.
First, the primary data of the two groups
were compared, and the number of males
and females and the average age of the ob-
servation group were not statistically signifi-
cant relative to the control group (p>0.05).
According to ultrasound signs, among 100
AA patients, there were 37 cases (37%) with
blurred appendiceal boundaries, 24 cases
(24%) with fecal stones in the appendiceal
cavity, 15 cases (15%) with enlarged outer
diameter of the appendix (> 6mm), 13 cases
(13%) with an enhanced echo of surround-
ing fat, 1 case (1%) with peripheral lymph-
adenopathy, 1 case (1%) with peripheral
effusion, and 0 cases (0%) with peripheral
mass formation. This suggests that most
AA patients present direct ultrasound signs,
and the most common ultrasound signs are
blurred appendiceal boundaries, fecal stones
in the appendiceal cavity, and peripheral
omental echo enhancement. The results of
the ultrasound diagnosis were further ana-
lyzed. Among 100 AA patients, there were
31 cases of uncomplicated appendicitis, 40
cases of suppurative appendicitis, 21 cases
of gangrenous appendicitis, and eight cases
of an appendiceal abscess. These results are
similar to those reported by Ravichandran
et al. 22, indicating that ultrasound repre-
sents a particularly useful diagnostic tool for
AA pathological types and has an excellent
clinical application value 23,24. In the present
article, we also collected the peripheral ve-
nous blood of the patients for the detection
of inflammatory factors and found that the
levels of WBC, CRP, IL-6, and TNF-α in the
observation group were higher than those of
the control group (p <0.05). Inflammatory
factors are molecular signaling substances
involved in the inflammatory response 25.
These results suggest that the increased
levels of inflammatory factors are related to
the occurrence of AA. We further compared
the levels of inflammatory factors in patients
with different types of AA and found that the
levels of WBC, CRP, IL-6, and TNF-α in pa-
tients with uncomplicated appendicitis were
lower in contrast to patients with suppura-
tive appendicitis, gangrenous appendicitis,
or peri-appendiceal abscess (p <0.05).
One hundred AA patients were enrolled,
and 30 patients presenting simple abdominal
pain were considered as the control group.
The results revealed that the most common
ultrasonic signs were the blurred boundary
of the appendix, fecal stones in the appendix
cavity, an enlarged outer diameter of the ap-
pendix (>6mm), and enhanced echogenicity
of surrounding fat. The ultrasonic diagnosis
of AA pathological types was good and had an
excellent clinical application value. With the
aggravation of AA, the levels of inflammatory
factors also increase, therefore, they can indi-
cate the severity of the patient’s condition to
a certain extent. However, the sample size of
patients included in the present work is rela-
Table 1
Inflammatory factor levels in patients.
Factor Observation
Group
Control
Group
p*
WBC (×109L) 16.81±3.22** 10.57±1.25 <0.05
CRP (mg/L) 30.14±4.55 10.96±3.08 <0.05
IL-6 (pg/mL) 24.71±6.02 5.24±0.92 <0.05
TNF-α (ng/mL) 57.43±5.81 30.71±4.21<0.05
* t-test, ** (mean ± SD).
Diagnostic value of abdominal ultrasound in patients with acute appendicitis 35
Vol. 65(1): 27 - 36, 2024
tively small, and all of the patients came from
the same source, which may have had some
influence on the results. In the process of the
ultrasound examination, because the appendix
is a blind tube-like structure and the position is
not fixed, the congestion and swelling of acute
uncomplicated appendicitis are mild, and the
typical structure changes may not be apparent.
Therefore, in future studies, more AA cases will
be selected to explore further the diagnostic
value of the ultrasound imaging technology in
AA. In conclusion, this result provides a refer-
ence for the assessment of AA.
ACKNOWLEDGMENTS
We would like to express our heartfelt
gratitude to all those who have contributed
to the successful completion of this research
project.
Conflict of competence
The authors declare no conflict of in-
terest.
Funding
None.
ORCID Numbers
• Siyuan Yang (SY):
0000-0001-6218-0156
• Mingyan Wang (MW):
0000-0002-4640-9376
• Linxin Yang (LY):
0009-0006-9738-6932
• Ning Lin (NL):
0000-0003-4457-0593
Contributions of authors
SY played a key role in data collection
and analysis, MW contributed significantly
to the literature review and research design,
LY provided expertise in statistical analysis
and data interpretation, and NL made subs-
tantial contributions to the manuscript’s
drafting and critical revisions. All authors ac-
tively collaborated throughout the research
process and reviewed the final manuscript to
ensure its accuracy and quality.
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