Answer to the question page 508.

Prawidłowa odpowiedź: C.

Correct answer: C.

This is my 32nd patient with serologically confirmed yersiniosis(. Compylobacteriosis and, more rarely, salmonellosis, shigellosis and Clostridium difficile may cause similar changes. In the last three disease entities, mesenteric adenomegaly is usually not present or not clearly visible and the wall edema affects the region of the cecum and ascending colon. The most common localization of lesions in Crohn's disease (in about 50%) and in tuberculosis (in about 90%) is the ileum. Tuberculosis is currently the rarest conditions out of these mentioned above. In such cases, the diagnosis is usually established on the basis of the specimens obtained during colonoscopy with the evaluation of the terminal ileum. In acute cases, however, the ability to distinguish between appendicitis and infectious terminal ileitis is crucial since these two diseases require different kinds of treatment. US examinations provide such a possibility. I can remember three patients treated surgically because of the suspicion of appendicitis, who were finally diagnosed with inflammation of the mesenteric lymph nodes. Fig. 1 B presents a color Doppler examination of both hyperemic terminal ileum and unchanged appendix (arrows). The visualization of this anatomic element allows for the differentiation between these two conditions. In about 20% of patients with appendicitis acuta, we observe slightly enlarged lymph nodes. Sometimes, reactive cecal wall thickening is also present. Due to these changes, the ability to conduct the US examination of the appendix, whose proper condition is observed in about 50% of the European population, is very important(. The proper assessment of the appendix in patients with Crohn's disease constitutes another problem. It is quite frequently evaluated – in 20–36% of the cases (fig. 2). Sarrazin and Wilson(, in 1996, claimed that such a coincidence was demonstrated by enlarged appendix, but without any features of wall hyperemia in color Doppler examination. Ten years later, upon the publication of Ripollés et al. research, the situation complicated(. The appendixes, which they considered affected by the granulation process in the course of Crohn's disease, demonstrated the features of hyperemia in 72% of cases (the cause may have been a more sensitive Doppler). After using a multivariate logistic data analysis, the authors concluded that ileum thickening above 5 mm with the features of hyperemia as well as simultaneous thickening and hyperemia of the appendix wall indicates the lack of appendicitis acuta. However, the same presentation of the appendix but with ileal edema not greater than 5 mm and without hyperemia suggests appendicitis acuta. Cecal thickening occurs with various frequency in both clinical situations but in appendicitis acuta, it is not accompanied by thickening and hyperemia of the ileum.

Fig. 2