上行結腸（Ac），盲腸（Ce）と骨盤腔内の小腸の液状内容物は麻痺性イレウスを示唆する（画像は省略したが上行結腸から肛門側に閉塞病変はない）ので，下腹部痛と麻痺性イレウスの原因となる病変を検索する．回腸末端（Ti）は図１０で分岐する．図１２の糞石（↑）から始まり，図１１の1から図８の4が腫大した虫垂で，図７〜図９で周囲脂肪組織の濃度上昇（▲）もあり急性虫垂炎である．図１２の少量のガスを含む部分（白矢印）が虫垂根部．虫垂壁の造影効果はやや弱く，麻痺性イレウスと骨盤腔内の相当量の腹水（図１５と図１６：※）を考慮すれば壊死性虫垂炎を疑うべきである．翌日手術となったが，壊死性虫垂炎が穿孔を起こしていた．左側に圧痛と反跳痛を認めた理由は不明であるが，極めてまれに遭遇する症例である．

文献考察：tip appendicitis 7例．
Am J Surg. 2009 Feb;197(2):211-5.
Tip appendicitis: clinical implications and management.
Mazeh H, Epelboym I, Reinherz J, Greenstein AJ, Divino CM.
Department of General Surgery, Hadassash-Hebrew University Medical Center, Jerusalem, Israel.
Abstract
BACKGROUND: Tip appendicitis describes a rare condition involving inflammatory changes of the distal appendix. We discuss the significance and management of this entity when it is identified on computed tomography (CT) imaging. METHODS: CT scans performed at our institution between 2003 and 2007 were reviewed to identify cases of tip appendicitis. Patients were divided into 2 groups（positive appendicitis：negative appendicitis）, determined by the confirmation of appendicitis on histopathology. Radiological findings and the clinical courses of both groups were documented and compared using univariate analysis. RESULTS: Of 18 patients with the CT finding of tip appendicitis, appendicitis was ultimately confirmed in 39%. Patients in this group had a higher rate of right lower quadrant (RLQ) tenderness (100% vs 55%, P = .04), leukocytosis (14.2 vs 10.5, P = .03), and clinical suspicion for acute appendicitis (43% vs 0%, P = .02). There were no complications or re-admissions. CONCLUSIONS: The CT finding of tip appendicitis can be managed conservatively in a subset of patients with low clinical suspicion for acute appendicitis.PMID: 18789423