In children the appendix is not seen on a substantial minority of ultrasound examinations — bowel gas, body habitus, a retrocaecal position, or a distressed child who will not tolerate graded compression. Reporting that as 'appendix not visualised' and stopping there is read by the referring team as reassurance, and it is one of the commonest routes to a delayed diagnosis.
So report the secondary signs deliberately, whether or not you found the appendix: free fluid in the right iliac fossa, echogenic inflamed periappendiceal fat, mural thickening of adjacent bowel, a localised ileus, an appendicolith, and focal tenderness under the transducer. Their presence in a non-visualised study raises the probability substantially; their complete absence in a well-performed study lowers it, and that is worth saying explicitly too.
Then state what the study can and cannot exclude, and what should happen next — repeat ultrasound after an interval, or cross-sectional imaging, or surgical review on clinical grounds. A report that ends without a recommendation leaves the least experienced person in the chain to decide what it meant.
- Never let 'appendix not visualised' stand alone as the conclusion.
- Report secondary signs explicitly, present or absent: free fluid, inflamed fat, mural thickening, appendicolith.
- Record sonographic tenderness at the point of maximum pain — it is part of the examination.
- State plainly that a non-visualised appendix does not exclude appendicitis.
- Recommend the next step: interval repeat, cross-sectional imaging, or surgical review.
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