Fig. 1.58. The illustration represents US axial slides of the appendix. The hyperechoic layers (RINGS) correspond to the mucosal surface (MS), submucosa (SB) and serosa layers (SE). When inflammation progresses, these rings gradually disappear from inner to outer. Normal appendix: AP diameter < than 6 mm, mucosal predominance. Three rings pattern: AP diameter > than 6 mm, collapsed lumen and submucosal prominence. Thin rings pattern: AP diameter > than 6 mm, dilated lumen and thinned wall: Patent SB and SE with subtle mucosal surface. Two rings pattern: non-visible central spot or inner ring (MS). The appendiceal center may represent either the inflamed mucosa or hypoechoic content. Both the submucosa and serosa are preserved. One ring pattern: Appendix homogeneously hypoechoic. Only serosal layer is preserved. Non-visible mucosa and submucosa. When inflammation progresses, outside the appendix prominence of periappendicular fat, appendicular contour irregularity and, finally, the presence of loculated collections or echogenic ascites are observed. As in a count-down, the progressive loss of those rings leads to perforation (3 - 2 - 1 - perforation) [From del Pozo (1994)]
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