 A warm welcome to all of you, myself, Dr. Prathimesh Vizha Kothorekar, I'm a second year grader, I guess this resident. I'm Dr. Iwai Patil, hospital, Kolhapur. Today my topic for paper presentation is impact of CT in ultrasound negative patients for diagnosing appendicitis. Now the most typical reasons why people are admitted to emergency department with abdominal pain is appendicitis. Now it can be also be accompanied by view omitting fever and diarrhea. And the many causes of abdominal discomfort range from benign to seriously dangerous conditions. It is easy to diagnose appendicitis in young male patients, whereas in case of premenopausal woman, they have comparable clinical symptoms and history. So it is difficult sometimes. Due to the serious complications such as perforation, acute appendicitis it requires from diagnosis and treatment. And even if there is no clear signs, clinical signs or proper diagnosis of appendicitis, few surgeons they support for an ugly laprotomy to reduce the risk of appendix perforation. Now we will see the surface anatomy. The base of appendix it lies two centimeter below the point of intersection of trans-tropical pain, plane and mid-clerical pain. And the position of appendix in that retrocholic position is the most common 65.28 percent followed by the pelvic position 31 percent, which is followed by paracolic, mid-invinal, pre-illel and post-illel positions. The appendix is supplied by the appendicular artery, which is in turn a branch of inferior division of heliopolyc artery, which is in turn a branch of superior dysentery artery. And histologically appendix it consists of four layers, mucosa, submucosa, muscularis and cirrhosa. Also we can see meso-appendix. Now the diagnostic imaging acute appendicitis. Appendicitis are mostly evaluated by clinical science and clinical source. However, when only clinical findings of patients are correlated and favorable appendicitomy rates, it is dramatically enhanced. In patients with equivocal or atypical clinical symptoms, imaging model it is the air surgeon in reaching a diagnosis rather than keeping the patient under observation. In this case, CT and UHG have played an important role in identifying acute appendicitis in the early stage. UHG is the primary modality as it is low cost and it lacks any radiation. However, the drawbacks are that it is heavily operated dependent and it is based on radiologist expertise and experience. Also sometimes the appendix position is such that it is difficult to visualize appendix. So in this cases, we need to switch to CT and CT is more specific than UHG and appendicitis can be quickly ruled out. Many research and literatures have discussed the optimum technique for detecting acute appendicitis. Fortunately, the majority of them have produced the same conclusions. Both these imaging technologies have dramatically lowered the rate of negative appendixctomy in the recent years. Now what is the role of X-ray? X-ray is useful in diagnosing the presence of appendicolitis. It is confirmed by X-ray itself in 80 to 100% of the cases. Now along with these certain radiological features we can see in abdominal X-ray are air fluid labor localized to cecum or the terminal earm. They are indicative of localized inflammation in the right ilium posa. There is gas in cecum, terminal ilium, ascending colon and localized aerodynamic alias. Soft tissue density is increased in the right lower cordon. Right flank stripe gets blurred. There is appendicolitis in the right lower cordon. There is blurring and alteration of the swaths outline at its distal third. A rare but valuable sign is the gas-filled appendix. There is free gas or external mineral gas in the retroperitoneal or other peritoneal space. There is deformity of cecum or there is blurring of swath shadow in the right seam. On UHG, UHG basically we use graded compression technique. It has advantage of displacing the gas filled bar lobe between the abdominal wall and thus helps in better visualization of the appendix freely from the intestinal loops. Hence higher rates of detection are also found in lean patients. On UHG we can see that the inflamed appendix it is seen as a non- compressible peristaltic blind lobe and the diameter is greater than 6 millimeters. Now these are the images which show appendix in longitudinal axis. We can see the appendix measures of greater than 6 millimeter diameter. Whereas in transverse view, we can see a target like appearance. In case of CT, we have primary diagnostic criteria of thickened and distended appendix with width greater than 6 millimeter. Neural thickening and enhancement wall thickening of appendix is greater than 2 millimeter or peri appendix is trending. In secondly diagnostic criteria it includes appendiculate, peri appendixel abscess, small bowel obstruction, pericycle inflammation, then target appearance which is concentric inflammatory thickening of appendix and the presence of bearing either extra luminal or intraluminal. Another aim is an objective of this study. It is to assess the accuracy of CT in cases where an ultrasound has failed to identify appendicitis. Secondly, to evaluate CT's effectiveness as detecting appendicitis complications. Thirdly, to determine whether there is differential diagnosis for right lower cotton pain that mimics appendicitis. And lastly is to assess the average CT thickness of normal appendix in the Indian population by evaluating the appendix diameter in CTM from it for other cases. Now this study design, it is a hospital based observational study. The patients had right lower cotton pain with negative edgy findings was the study population and the sample size was 200. The duration of the study was from May 2022 to April 2023. That is 12 months duration and it was carried out in department of radiology in collaboration with surgical surgery in Dr. Yovar Patil Hospital, Kullapur. Now the patients, all patients who were suspected to have appendicitis and showed negative edgy findings in ultrasound they were included in the study whereas the exclusion criteria patients who showed typical findings of appendicitis in ultrasound itself or the patients who were medically unped to undergo contrast study like real-failure patients or patients with hypersensitivity reactions or the pregnant patients were excluded from the study. Or also the patients with age between 11 to 55 years they were considered for this study. Now the UHG protocol of our UHG we used, I used geologic effect machine for abdomen and pelvis examinations with 3 to 5 megahertz convex transducer to carry out this study. Then the normal appendix was visualized as it is seen as a blind-ended loop with no vormiculation. The graded compression technique was also used for better visualization of the appendix and the appendix it showed a tubular blind-ended structure in the anterior, seen anterior to the elect vessel and it is non-compressible with diameter of greater than 6 millimeter. Sometimes the increased follicular vascularity was seen in the wall of appendix on Doppler study due to mural inflammation. And the UHG findings were reported at positive or negative for acute appendicitis and any other finding or diagnosis which if achieved was reported. On CT, for CT performing CT a 16 slice MD CT, semen somatom sensation was used. And CT of abdomen and pelvis were taken from zephyte process to pubic, symphysis area was covered. And a non-ionic contrast material I exhaled 350 ohm, that is only part 350 was used for carrying the contrast study. And axial reconstructions with 3 millimeter thickness slices were also used for examination. And the CT reports were positive, negative or inclusive. The criteria for appendicitis it is more similar to that of UHG. Alternative diagnosis or other findings if any when achieved were reported. Now the different, we will see a few cases that we had studied. So this is the first case wherein there is a 50 per year old male where abdomen pain for three days with fever was still she count to leucocytone was 13,800 increased. Sure right lower quadrant probe tenderness with other findings on UHG whereas CT showed appendix of 7 to 8 millimeter. That is 7.551 millimeter average with a peri appendicell fat stranding and is retro sickling position as we can see in this image. Now the case two is an anterior of female with vague abdomen pain for four days with no evidence of fever vomiting. UHG showed no evidence of abdominal findings. However the CT showed diameter of appendix 7.3 millimeter with peri appendicell fat stranding and see in the image. Third case was of 35 year male right lower quadrant pain and on and off pain for the past two months TLC count was 4700. UHG was not significant CT showed thickened appendix of diameter 10.2 millimeter with no evidence of fat stranding, no evidence of bald enhancement that is thickened appendix. The case four was a 13 year male severe abdominal pain and distinction for five days. TLC count was 13,700 which was increased. Fluid filled bowel like structure with no peristalsis with no evidence of peristalsis in the adjacent bowel loops was seen on UHG. On CT we could find appendiculitis with appendiculitis and appendicular access. It was seen in the right left side. Fifth case was of 18 year female lower abdominal pain for four days with history of fever for three days, vomiting and loose tools for three days. I trust one of you should play with collection in the right lower quadrant pain with adjacent bowel loop showed mild irritation and showed mild peristalsis. Appendix was not separately visualized. CT showed appendix perforation in the tip and appendiculitis in the image with peri appendicitis fluid collection was noted. Appendix is pelvic in position and see the appendiculitis in this image. Now we will see the statistical analysis. Now the age, the age group of 20 to 24 years had higher incidence whereas males that is out of 232 males were showed right lower quadrant pain. They presented with type 4 quadrant pain that is higher incidence was seen in male population. Now the various presenting complaints which of which abdominal pain was found in all of them however it was followed by fever being the next major symptom 49% followed by vomiting in 13% of the patients and painful mituration in 14.5% of the patients. On ultrasonography it was normal in 112 patients whereas frequent was seen in 37 patients and misentrical it was observed in 51 patients. On CT the most common position of appendix was retrocicle followed by pelvic, then prelial, posterior followed by the rest others. That is retrocicle is the commonest position. Now the diameter of appendix, now the diameter of appendix less than 6 mm appendix was observed in 112 patients that is 56% of the patients and 25% of the patients had diameter of 7 to 8 mm, 25% of the patients. Now the appendicitis on CT on CT, 77 cases had found to have appendicitis present which was diagnosed on CT. Now the other findings which mimic appendicitis were misentrical infarctitis, distal urethric calculei, illusical thickening, uphoritis, pantheritis, soire subsets, Crohn's or colitis and Crohn's or colitis. Of this mimicking symptoms the misentrical infarctis was the most common followed by distal urethra urethric calculus. Now the management in majority of cases the management was conservatively done, however the rest of the patients, 27% of the patients underwent surgical management. Now the results, the statistical evaluation of the study leads to the following conclusion that is based on CT findings, 77% patients of 200 cases study participants with right lower cordon pain and negative ultrasonic findings had appendicitis. According to the study appendicitis was diagnosed in individuals with CT findings of appendicular diameter of greater than 6 millimeter that is 7 to 8 millimeter in particular. It was which was confirmed by additional collaborative findings, intraoperative findings and histological correlation. This leads us to conclusion that CT has more considerable sensitivity, specificity, positive and negative predictive value in diagnosis of appendicitis in patients with negative ultrasonic findings. Now the discussion for this study majority of 200 total patients majority of them that is 45.5% worried the age group of 20 to 24 years and of which males they showed more the incidence than females that is 132 males of 200 showed more more incidence and age and sex did not significantly correlate. Despite the fact that USG did not reveal an inflame appendix misintric, well, infant 90s were discovered in 51 patients and free fluid was seen in 31 patients on ultrasonography. The most frequent position of appendix on CT it was retrocecal, which was found to be 6% in our study. This may account for difficult detection of the appendix on USG. It is caused by the shadow created by the bubble gas above. Now according to Nuno Pintole IT et al. on September 2004 he proposed that the appendix diameter of less than 6 millimeter or if it is greater than 6 millimeter diameter with gas in the middle appendix or 6 to 10 millimeter diameter appendix without any other city science mentioned as possible appendicitis if it is 6 to 10 millimeter appendix with wall thickening and wall hyper enhancement with or without fat spending then it's probable appendicitis if it is diameter is greater than 10 millimeter or 6 to 10 millimeter diameter with wall thickening wall enhancement and fat spending it is definitive appendicitis now the complications like appendix perforation abscess they were found in 6 in the study population the patient in our study who had free fluid in the right left was on ultrasound were later discovered to have inflammatory appendix masks there here findings other than appendicitis among these 117 cases were detected in CT the most common mimicar of acute appendicitis was mesentric infantitis which was found to be 18 percent of patients therefore diagnosis made with use of CT decreases the incidence of unnecessary appendicitomy or surgery thereby reducing the negative appendicitomy rates in our study 112 patients who were diagnosed other than appendicitis like mesentric infantitis colitis, illusical thickening found to have normal appendix in CT thickness of appendix in the group excluding inflamed appendix was found to be 5.7 millimeter now the conclusion of the study according to the study findings CT is the next imaging model of choice in patients with right lower quadrant discomfort vomiting fever or backache and with ambiguous or negative ultrasound findings among the 200 participants in study 77 cases they were discovered in CT 50 patients or that 25 percent of cases had appendiceal diameter of 7 to 8 millimeter peri appendiceal fat stranding and appendiceal wall enhancement and they had been given diagnosis of appendicitis due to opacity and appendix retrocicle location which was obscured by gas shadows and negative USG results for appendicitis were obtained when the appendix is 7 to 8 millimeter in diameter the peri appendiceal fat is stranded CT is the best model for detecting appendicitis one of the results of significant percentage of individual diagnosed with appendicitis in the study who had negative ultrasound finding was 7 to 8 millimeter of appendix associated with surrounding CT alterations on CT image mimics of appendicitis including miscentric lymphenitis, right distal uretric calculus heliocital thickening and colitis were found the normal appendix diameter in the patient with right lower cordon pain who were diagnosed with disease other than appendicitis such as miscentric lymphenitis heliocital thickening was 5.7 millimeter on CT and finally as a result of the association between appendicular diameter, peri appendicular fat stranding and wall enhancement CT was determined to be predominant modality of choice in assisting clinicians in diagnosing appendicitis in patients with negative ultrasound findings thereby prompting early intervention treatment and reducing the unnecessary complications CT also aids in exclusion of appendicitis lowering the negative appendix of tomorrhoid these are certain references which I used for this study sharing of this study thank you all for patiently listening to me thank you all