Ultrasound is the initial imaging study of choice for evaluation of patients with right upper quandrant pain. Using the liver as an acoustic window, ultrasound can detect cholelithiasis, cholecystitis, choledocholithiasis, biliary duct dilation, and pancreatic masses, both solid and cystic. Ultrasound is also the modality of choice for evaluating patients with pelvic pain. Transvaginal scanning has supplemented the transabdominal approach because of better visualization with higher-frequency endovaginal probe transducers (see Chap 109, "Pelvic Imaging"). Ultrasonography of the genitourinary system is discussed in ChapteL9Z, "Renal Imaging."

Graded-compression ultrasound imaging for acute appendicitis has been studied extensively. Sensitivities for appendicitis range from 68 to 93 percent and specificities between 73 and 100 percent, with accuracy in the 95 percent range.15 Negative laparotomy result rates were reduced significantly using graded-compression ultrasonography.16 The ultrasonographer is searching for a tubular structure off the cecum that is compressible without pain and is no more than 6 mm in diameter. An infected, inflamed appendix is tender, larger than 6 mm in diameter, fluid filled, and noncompressible. The appendix is difficult to visualize, and the examination is best left to experienced ultrasonographers. Negative ultrasound results in the face of a strong clinical suspicion should never delay surgical intervention. The false-negative rate for graded-compression ultrasonography is from 6 to 14 percent. Other disease processes that can confuse the clinical picture are cecal diverticulitis, inflammatory bowel disease involving the terminal ileum, and periappendiceal phlegmon. Graded-compression ultrasonography is most helpful in the evaluation of patients with atypical right lower quadrant pain and a suspicion of appendicitis.

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