European Journal of Cardiovascular Medicine

Acute appendicitis is one of the most frequently encountered surgical emergencies globally, with a lifetime risk estimated at 7–8% in the general population [1]. Timely diagnosis and surgical intervention are crucial to prevent complications such as gangrene, perforation, and generalized peritonitis. However, the clinical presentation can be highly variable and often overlaps with other causes of acute abdomen, particularly in pediatric and geriatric populations, posing a diagnostic challenge [2].

In this setting, imaging plays a pivotal role in improving diagnostic accuracy. Among the available modalities, ultrasonography (USG) is widely favored as the first-line investigation due to its non-invasive nature, absence of ionizing radiation, cost-effectiveness, and real-time bedside applicability [3]. Sonographic features such as an appendiceal diameter >6 mm, wall thickening, loss of compressibility, peri-appendiceal fat stranding, appendicoliths, and pericecal fluid collections have been incorporated into various imaging-based grading systems to assess the severity of appendicitis [4].

Several studies have proposed structured USG grading models to stratify disease severity and guide clinical decision-making. Notably, Gomes et al. introduced a comprehensive grading system integrating clinical, imaging, and laparoscopic findings to improve diagnostic precision and treatment outcomes [2]. However, limited prospective studies have systematically evaluated the correlation between these ultrasonographic grades and actual intraoperative findings.

Establishing a strong correlation between preoperative USG grading and intraoperative pathology is essential to validate its prognostic utility and surgical relevance[5].

This study was thus undertaken to evaluate the correlation between ultrasonographic grading of appendicitis and intraoperative findings in patients undergoing appendicectomy. Such correlation, if proven robust, could reinforce the clinical relevance of USG in preoperative decision-making and reduce diagnostic uncertainty in acute appendicitis.

This prospective observational study was conducted in the Department of General Surgery at RVM Institute of Medical Sciences, Telangana, India, over a period of 12 months from January 2024 to December 2024. The study aimed to assess the correlation between ultrasonographic grading and intraoperative findings in patients undergoing appendicectomy for suspected acute appendicitis.

Study Population

A total of 100 patients of all genders, aged ≥10 years, who presented with clinical features suggestive of acute appendicitis and underwent appendicectomy were enrolled after obtaining written informed consent.

Inclusion Criteria

• Patients with clinical suspicion of acute appendicitis.
• Age ≥10 years.
• Patients who underwent preoperative abdominal ultrasonography.
• Patients consenting for participation.

Exclusion Criteria

• Patients with negative appendectomy (histopathologically normal appendix).
• Patients with chronic appendicitis or appendicular mass managed conservatively.
• Pregnant women and hemodynamically unstable patients.
• Procedure

All patients underwent detailed clinical evaluation followed by abdominal ultrasonography, which was performed by an experienced radiologist using a high-frequency linear probe. The appendix was graded into four USG grades based on standard sonographic criteria:

Grade I: Mild wall thickening, compressible appendix.

Grade II: Non-compressible appendix >6 mm with peri-appendiceal fat stranding.

Grade III: Appendicolith, phlegmon, or localized fluid collection.

Grade IV: Features suggestive of perforation (fluid/pus collection, wall discontinuity).

Subsequently, all patients underwent open or laparoscopic appendicectomy as per surgeon discretion. Intraoperative findings were recorded in detail, including the condition of the appendix (catarrhal, suppurative, gangrenous, perforated) and presence of complications.

Statistical Analysis

Data were entered in Microsoft Excel and analyzed using SPSS version 26.0. Descriptive statistics were expressed as frequencies and percentages. The correlation between ultrasonographic grading and intraoperative findings was evaluated using Spearman’s rank correlation coefficient, with a p-value < 0.05 considered statistically significant.a

A total of 100 patients who underwent appendicectomy for suspected acute appendicitis were included in the study. The mean age of the cohort was 29.8 ± 9.6 years, with the majority (41%) aged between 21–30 years. There was a male predominance (62%), yielding a male-to-female ratio of 1.63:1. The most common presenting symptom was right lower quadrant abdominal pain, reported universally in all cases, followed by fever (68%), nausea/vomiting (55%), and anorexia (48%) (Table 1).

Table 1: Baseline Demographic and Clinical Characteristics (n = 100)

On ultrasonographic evaluation, Grade II appendicitis—characterized by a non-compressible, thickened appendix with peri-appendiceal fat stranding—was the most frequently observed (44%). Grade III features such as appendicolith and pericecal collection were noted in 26% of cases, while Grade I and Grade IV were seen in 18% and 12% of patients, respectively (Table 2).

Table 2: Ultrasonographic Grading of Appendicitis (n = 100)

Intraoperative assessment revealed suppurative appendicitis in 38% of patients, followed by gangrenous (25%), catarrhal (20%), and perforated appendicitis (17%). These findings are summarized in Table 3.

Table 3: Intraoperative Findings of Appendicitis (n = 100)

A strong correlation was observed between the ultrasonographic grading and the severity of intraoperative findings. Grade I was concordant with catarrhal appendicitis in 83.3% of cases, Grade II with suppurative appendicitis in 79.5%, Grade III with gangrenous pathology in 73.1%, and Grade IV with perforation in 91.7% of cases (Table 4).

Table 4: Correlation Between USG Grading and Intraoperative Findings

Statistical analysis demonstrated a significant positive correlation between ultrasonographic grade and intraoperative diagnosis with a Spearman’s correlation coefficient (ρ) of 0.812 (p < 0.001), indicating excellent diagnostic concordance and reliability of preoperative sonographic grading in predicting operative severity.

This prospective observational study, conducted at RVM Institute of Medical Sciences, assessed the correlation between ultrasonographic grading and intraoperative findings in patients with acute appendicitis. Our findings affirm the diagnostic and prognostic value of ultrasonography (USG) in acute appendicitis, particularly in stratifying disease severity prior to surgery.

The mean age of the cohort was 29.8 years, with a clear male predominance—demographics that align with global trends, as highlighted in similar studies from both high- and low-resource settings [9]. Universally, right iliac fossa pain was the presenting symptom, reaffirming its role as a cornerstone in the clinical diagnosis.

Grade II appendicitis, characterized sonographically by a non-compressible, thickened appendix with peri-appendiceal fat stranding, was the most frequently observed in our study (44%). This pattern is consistent with prior reports indicating that uncomplicated inflammatory appendicitis often represents the initial stage of disease progression [7,10]. Furthermore, we observed strong concordance between USG grades and intraoperative findings: 83.3% of Grade I patients had catarrhal changes, while 91.7% of Grade IV patients demonstrated perforation. Similar diagnostic accuracy has been reported in recent literature, reinforcing USG’s reliability in predicting operative severity [8,11].

Our correlation analysis yielded a Spearman’s coefficient of 0.812 (p < 0.001), indicating excellent agreement. This substantiates the role of sonographic grading not only as a diagnostic adjunct but also as a triaging tool, where higher USG grades may prompt earlier operative intervention, and lower grades might allow conservative approaches in selected cases [12,13].

Nonetheless, ultrasonography has inherent limitations. It is operator-dependent and less reliable in obese individuals or those with atypical anatomical presentations [6]. Despite these constraints, in resource-limited environments where access to CT imaging may be restricted, USG remains indispensable. Moreover, evolving techniques and better-trained personnel continue to enhance its diagnostic yield across age groups, including in neonatal and geriatric populations [6,9].

In addition, while USG proved highly predictive, intraoperative judgement remains essential, particularly in borderline or complicated cases. Recent insights suggest that incorporating intraoperative findings with USG and clinical scores such as the Alvarado or AIR score may offer a more comprehensive diagnostic framework [13].

This prospective observational study demonstrates a strong and statistically significant correlation between ultrasonographic grading and intraoperative findings in patients with acute appendicitis. Ultrasonography proved highly reliable in predicting the severity of appendicular inflammation, with excellent agreement across all grades. The findings support the use of USG not only as a diagnostic tool but also as a prognostic guide in surgical decision-making. Its non-invasive nature, affordability, and real-time availability make it particularly valuable in resource-limited settings. Incorporating USG grading into routine clinical protocols can enhance diagnostic accuracy, enable early intervention, and potentially reduce the risk of complications associated with delayed or unnecessary surgery.

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