Endgames Spot Diagnosis

A man with severe abdominal pain

BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2379 (Published 27 April 2016) Cite this as: BMJ 2016;353:i2379
  1. Joseph Dalby Sinnott, core surgical trainee1,
  2. David C Howlett, consultant radiologist2
  1. 1Department of Surgery, East Sussex Hospitals NHS Trust, Eastbourne, UK
  2. 2Department of Radiology, East Sussex Hospitals NHS Trust
  1. Correspondence to: J D Sinnott j.d.sinnott{at}gmail.com

A 38 year old man presented to the emergency department with a 12 hour history of central and right sided severe abdominal pain. The pain had been getting gradually worse, he had vomited, and he was finding it difficult to walk. On examination he looked unwell, his temperature was 38.7°C, and he had a rigid abdomen. What does the computed tomogram of the abdomen and pelvis show (fig 1)?


Acute appendicitis: a dilated, thick walled appendix, in continuation with the caecum, with inflammatory changes of the peri-appendicular mesenteric fat, and a calcified appendicolith within the neck of the appendix (fig 2).


Fig 2 Computed tomogram showing a dilated, thick walled appendix (A), in continuation with the caecum (C), with peri-appendicular mesenteric fat inflammatory changes, and a calcified appendicolith within the neck of the appendix (S)


There is no independent diagnostic sign for acute appendicitis but the combination of the findings described above is enough to make this diagnosis. An appendicolith alone would not be enough to make the diagnosis, although there is a strong correlation between these calcified deposits and appendicitis. It is also worth noting that an appendicolith is a relevant finding for the surgical team because of the small risk of it being dislodged during appendectomy.


  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: None.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

  • Patient consent obtained.

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