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Appendicitis Imaging

  • Author: Lutfi Incesu, MD; Chief Editor: Eugene C Lin, MD  more...
 
Updated: May 19, 2016
 

Overview

The appendix is a blind-ending tubular structure arising from the cecum. Appendicitis results from an acute inflammation of the appendix and creates the most common abdominal surgical emergency. A color Doppler ultrasonogram of appendicitis is shown below.

Suppurative appendicitis; transverse view, color D Suppurative appendicitis; transverse view, color Doppler ultrasound image. Circumferential colors are observed in the wall of the inflamed appendix (arrows), a strong indicator of acute appendicitis.

A diagnosis of acute appendicitis is usually made on the basis of a patient's clinical history in conjunction with physical examination and laboratory studies. Because the surgical aim is to operate early—before appendiceal rupture and peritonitis develop—patients who present with typical findings undergo immediate surgery without radiologic evaluation. However, such imaging is advisable in patients with atypical symptoms, which can occur in infants and small children, the elderly, and young women (see the image below).

Atypical presentation of appendicitis in a young w Atypical presentation of appendicitis in a young woman; computed tomography scan. The patient presented with an elevated white blood cell count and right upper quadrant pain. Left, there is pericholecystic fluid and free fluid in the right paracolic gutter, which is caused by retrocecal appendicitis. Right, the appendix, observed in axial section, has an increased diameter and an enhancing thickened wall.

See Appendicitis: Avoiding Pitfalls in Diagnosis, a Critical Images slideshow, to help make an accurate diagnosis.

Preferred examination

Controversy exists as to whether imaging is required in patients with the classic history and physical findings of acute appendicitis. Opinion varies as to whether these modalities should be performed in all patients with suggested appendicitis or if radiology should be reserved for select patients with atypical or confusing clinical presentations.

Appropriateness criteria have been published by the American College of Radiology (ACR) for right lower quadrant pain suggestive of appendicitis. In the appropriateness criteria, ratings of 7 to 9 are considered "usually appropriate." Computed tomography of the abdomen and pelvis with intravenous contrast is rated 8, and CT of the abdomen and pelvis without contrast is rated 7.[1]

Ratings of 4 to 6 indicate that studies "may be appropriate." Right lower quadrant ultrasound with graded compression is rated 6, and abdominal radiographs (for excluding free air or obstruction) are rated 5. Magnetic resonance imaging is rated 4. Ratings of 1 to 3 indicate that studies "are usually not appropriate." Barium enema and technetium-99m white cell scanning are rated 3.[1]

According to the ACR, computed tomography is the most accurate imaging study for evaluating suspected acute appendicitis and alternative etiologies of right lower quadrant pain. In children, ultrasound is the preferred initial examination, because it is nearly as accurate as CT for the diagnosis of acute appendicitis in this population without use of ionizing radiation. In pregnant women, ultrasound is preferred initially, with MRI as a second imaging examination in inconclusive cases.[2]

Multidetector computed tomography scanning and graded-compression Doppler ultrasonography are powerful imaging methods that substantially improve diagnostic accuracy in patients with clinically equivocal appendicitis.

Continuous improvements in imaging technology, technique, and interpretation that have been achieved over the past 15 years have substantially increased the accuracy of imaging methods. Since 1986, US and, after the 1990s, CT scanning have gained acceptance as the primary imaging techniques for acute appendicitis by virtue of their ability to directly image the appendix, adjacent fat, and gut.

Graded-compression US of the right lower quadrant (RLQ) has been shown to be a useful examination because of this technique’s safety and high accuracy (approximately 90%) in the diagnosis of acute appendicitis. Advantages of US include lack of radiation exposure, noninvasiveness, short acquisition time, and the potential for diagnosis of other causes of abdominal pain, particularly in the subset of patients who are women of childbearing age. Several authors suggest that US should be the first imaging method used in pregnant women and pediatric patients because x-ray exposure is especially undesirable in these groups.

Contrast-enhanced, thin-section (0.5 mm) CT scanning has become the preferred imaging technique in the diagnosis of acute appendicitis and its complications, with a high diagnostic accuracy of 95-98%. The literature suggests that limited helical CT scanning with rectal contrast is a highly accurate, time-efficient, cost-effective way to evaluate adult patients with equivocal presentations for appendicitis. CT scanning is particularly preferred in patients in whom appendiceal perforation is suspected, because the diagnostic accuracy remains high and because CT scanning is useful for characterizing periappendiceal inflammatory masses.

Other advanced radiologic examinations, such as magnetic resonance imaging (MRI), scintigraphy, and color Doppler US, have been used in the diagnosis of acute appendicitis (see the images below), with a diagnostic accuracy of approximately 91-95%. Currently, no practical role exists for MRI and scintigraphy in acute appendicitis.[3, 4]

Acute suppurative appendicitis in a 15-year-old bo Acute suppurative appendicitis in a 15-year-old boy; contrast-enhanced, fat-suppressed, T1-weighted, spin-echo coronal magnetic resonance image. A markedly enhanced and thickened inflamed appendix (arrows) with pericecal enhancement due to the extent of inflammation is shown.
Periappendiceal abscess; contrast-enhanced, fat-su Periappendiceal abscess; contrast-enhanced, fat-suppressed, T1-weighted, spin-echo coronal magnetic resonance image. Fluid collections (long arrows) and a markedly enhanced pericecal area (short arrows) are shown. b = bladder; c = cecum.
Acute suppurative appendicitis in a 27-year-old wo Acute suppurative appendicitis in a 27-year-old woman; scintigraphy study. Pathologic accumulation of technetium-99m human immunoglobulin on the right iliac fossa is observed at 4 hours.

Advantages of MRI include better visualization of abnormal appendices and adjacent inflammatory processes, visualization of the appendix in an atypical location, delineation of pathology, operator independence, and ease of examination of patients who are obese. MRI, similarly to enhanced CT scanning, can demonstrate the extent of inflammatory infiltration.

The decision to obtain US or CT scan studies depends on institutional preference and the available user expertise, although patient age, sex, and body habitus are important influencing factors. US and CT scanning have similar diagnostic value for detecting an alternative diagnosis in a patient in whom acute appendicitis is suspected.

In a meta-analysis of 6 prospective studies, CT demonstrated superior sensitivity (91%) and specificity (90%) over ultrasonography (sensitivity 78%; specificity, 83%).[5]

Delaying surgery to complete a radiologic investigation for appendicitis was found not to increase the rate of perforation or complications but did decrease the rate of negative appendectomies. The rate of negative appendectomy decreased significantly with CT compared to clinical evaluation only (9.3% vs 5%). Ultrasonography alone, however, did not result in a rate decrease.[6]

Limitations of techniques

Abdominal radiographs are normal in many patients with acute appendicitis and should not be obtained routinely. An appendicolith is the most specific sign on plain radiographic films, but it is observed in only 10% of patients with appendicitis. Disadvantages of barium enema include a high incidence of nondiagnostic examinations, radiation exposure, insufficient sensitivity, and invasiveness.

A significant disadvantage of US is that it is operator dependent. Intestinal peristalsis, pulsations of the iliac artery (when it is close to the appendix), deep respiration in noncooperative patients, and difficulty maintaining the probe at the same location for a long time are disadvantages of color Doppler US in detecting increased vascularity of the appendix.

Disadvantages of CT scanning include radiation exposure, the potential for anaphylactoid reaction if intravenous (IV) contrast is used, lengthy preparation time if oral contrast is used, and patient discomfort if rectal contrast is used.

Disadvantages of MRI include high cost, use of IV contrast, the requirement that patients fully cooperate, difficulty with patients who are claustrophobic, the inability to observe an appendicolith in the lumen (an important finding in acute appendicitis), and the inability to differentiate between gas and an appendicolith in the perforation site.

Disadvantages of radionuclide scanning include long acquisition times (approximately 5 h) and the lack of availability of this modality.

For patient education information, see eMedicineHealth's Digestive Disorders Center, as well as Appendicitis, Abdominal Pain in Adults, and Abdominal Pain in Children.

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Radiography

Abdominal radiographs are normal in many patients with acute appendicitis. Therefore, plain radiographic films rarely add to the diagnosis. In one study, plain-film findings consistent with acute appendicitis were observed in only 20% of patients with appendicitis.[7]

The presence of a calcified appendiceal fecalith, which is the most specific plain-film sign, occurs in fewer than 10% of patients.

Other plain-film findings include convex lumbar scoliosis, obliteration of the right psoas margin, RLQ air-fluid levels, air in the appendix, and pneumoperitoneum.

Barium enema can be performed on an unprepared bowel quickly and safely by using the single-column technique. Complete filling of a normal appendix effectively excludes the diagnosis of appendicitis; however, nonfilling or incomplete filling of the appendix, coupled with pressure effect or spasm in the cecum, suggests appendicitis (see the image below).

Normal appendix; barium enema radiographic examina Normal appendix; barium enema radiographic examination. A complete contrast-filled appendix is observed (arrows), which effectively excludes the diagnosis of appendicitis.

Degree of confidence

The consensus in the literature is that plain radiography is insensitive and nonspecific. Plain radiographs should not be obtained routinely, except to evaluate for obstruction of free air.

Appendicoliths may be found in individuals without appendicitis, and other plain-film signs of appendicitis can be observed in other abdominal diseases.

Although the diagnostic accuracy of a barium enema is reported to be 80-100%, this technique has several drawbacks, such as nonfilling of the appendix, which can be observed in 15-20% of patients without appendicitis.

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Computed Tomography

CT scanning has the advantage of direct visualization of the appendix, as well as the periappendiceal and other intra-abdominal structures. CT scanning can be used to evaluate an abnormal appendix and the nature, severity, and extent of the associated inflammatory process.[8]

In a 22-year retrospective study of 2108 patients with appendicitis, CT use increased more than 20-fold, but there was no statistically significant trend for increased use of ultrasound or MRI.[9]

Advantages of CT scanning include its superior sensitivity and accuracy compared with those of other imaging techniques, ready availability, noninvasiveness, and potential to reveal alternative diagnoses. In a study by Pickhardt et al, CT scanning is confirmed as a valuable test for confirming acute appendicitis in adults.[10] During this study of 2871 patients, 675 had acute appendicitis. Multidetector CT scanning had a sensitivity value of 98.5%, a specificity value of 98%, a negative value of 99.5%, and a positive predictive value of 93.9%. Multidetector CT scanning also suggested an alternative diagnosis in 893 patients without appendicitis or appendectomy. Disadvantages include radiation exposure, potential for anaphylactic reaction if intravenous contrast agent is used, lengthy acquisition time if oral contrast is used, and patient discomfort if rectal contrast is used.[11, 12]

The typical findings are a nonfilling appendix with distension and thickened walls of the appendix and the cecum, enlarged mesenteric nodes, and periappendiceal inflammation or fluid (see the image below).[13, 14]

Computed tomography scan reveals an enlarged appen Computed tomography scan reveals an enlarged appendix with thickened walls, which do not fill with colonic contrast agent, lying adjacent to the right psoas muscle.

Note that one study of asymptomatic volunteers undergoing pelvic CT scanning found that 42% of these individuals had an "abnormal" appendiceal diameter of greater than 6 mm and that 78% of appendices did not fill after oral contrast. Thus, findings on CT scanning must be correlated with the clinical scenario.[15, 12, 16]

CT scanning techniques

In evaluating patients with suspected appendicitis, a number of techniques have been advocated, including abdominal and pelvic CT scanning without oral or IV contrast, focused CT scanning of the cecum after administration of rectal contrast, or use of oral or IV contrast, with a delay of 45 minutes to 1 hour following oral contrast administration to permit passage of the contrast into the colon.

Patient acceptance of retrograde instillation of barium per rectum may limit the use of this focused technique. A limited scanning volume may be more appropriate in young, particularly female, patients in consideration of reducing radiation exposure to the internal and reproductive organs.

Visualization of the appendix is optimized in CT scanning with use of bowel opacification, IV contrast, fine collimation (< 5 mm), and/or thin-section reconstruction. The postacquisition reformatting capabilities of multislice technology should limit the necessity for rescanning a nonvisualized or poorly visualized appendix, although at a somewhat higher cost in the initial radiation dose.

CT scan findings in the normal appendix

The appendix can be visualized in approximately 50% of patients without appendicitis, although a higher visualization rate is expected in patients who are scanned with thin-section, multislice CT scanning technology (see the image below).

Normal appendix; computed tomography (CT) scan. A Normal appendix; computed tomography (CT) scan. A normal appendix, visualized here at the base of the cecum (arrow), is observed in 44-51% of patients. Thin-section CT scans (5-mm collimation or less) are more useful in identifying the appendix. Oral or rectal contrast should be administered. Intravenous contrast is useful in enabling enhancement and edema of the appendiceal wall to be identified.

The appendix is demonstrated as a tubular structure when it lies in the plane of the CT scan section or a ringlike structure when it is scanned in a cross-sectional plane. The appendix occasionally contains air or barium, but it may be collapsed. The wall thickness should be very thin, and the normal external diameter is usually less than 6 mm, although this may be slightly greater in patients with an elongated, retrocecal appendix (see the image below).

Retrocecal appendix; computed tomography scan. Lef Retrocecal appendix; computed tomography scan. Left, the appendix occurs in a retrocecal location in 65% of patients. Right, in this young female, the appendix extends cranially as far as the posterior lobe of the liver. Appendicitis in a patient with a retrocecal appendix may present atypically, with less or poorly localized pain, discomfort on coughing or walking, or flank, rather than right lower quadrant, tenderness.

CT scan findings in appendicitis

With high-resolution CT scanning, an abnormal appendix can be observed, and variable CT scan findings can be evaluated in patients with acute appendicitis.

Specific CT scan findings of appendicitis include enlargement of the appendix (>10 mm in the outer diameter), hyperenhancement of the appendiceal wall, appendiceal wall thickening (>3 mm), lack of opacification in an enlarged appendix, increased intraluminal fluid, fat stranding in the periappendiceal region, and the presence of an appendicolith within the appendix. The appendicolith may be observed outside the appendix lumen, within an inflammatory mass or in a fluid collection. Appendiceal diameters of 6-10 mm are usually equivocal, and the other associated findings listed above are needed to confirm the diagnosis of appendicitis.

A few secondary findings often accompany acute appendicitis. Focal thickening of the cecum may occur. The inflammatory process can be observed to separate the cecal lumen from the base of the appendix or an appendicolith (cecal bar). Contrast medium is observed within the cecum channeling to the point of the appendiceal obstruction (arrowhead sign in the image below).[17]

Arrowhead sign; computed tomography scan. The pres Arrowhead sign; computed tomography scan. The presence of this sign indicates contrast outlining the cecum and funneling into the origin of the appendix, with obstruction of the lumen preventing retrograde flow of barium into the distal appendix.

Gangrenous appendicitis is recognized as enlargement of the appendix, with associated fluid and loculated air within the lumen (see the image below).

Acute gangrenous appendicitis with calcified appen Acute gangrenous appendicitis with calcified appendicolith; computed tomography (CT) scan. A calcified appendicolith in the lumen of an enlarged inflamed appendix is shown.

Distal appendicitis (seen in the image below) is diagnosed when CT scanning reveals appendicitis involving the distal appendix, with a normal-appearing proximal appendix.

Distal appendicitis; computed tomography scan. The Distal appendicitis; computed tomography scan. The appendiceal lumen may be normal proximally (left, arrow), but distension and inflammatory changes are noted distally (right, open arrow).

Detection of phlegmons, abscesses, and RLQ inflammation adjacent to the cecum is strongly suggestive of—but not pathognomonic for—acute appendicitis. Perforated appendicitis is usually accompanied by pericecal phlegmon or abscess formation. Free intra-abdominal air can be observed either under the right diaphragm or in a retroperitoneal location in patients with a perforated appendix. Associated CT scan findings include extraluminal air, marked ileocecal thickening, localized lymphadenopathy, peritonitis, and small-bowel obstruction (see the image below).

Perforated appendicitis with abscess; computed tom Perforated appendicitis with abscess; computed tomography scan. Note the appendicolith (arrow) and air within the abscess. The terminal ileum lies anterior to the appendiceal abscess, and inflammatory change is noted in its wall, which appears thickened (open arrow).

Degree of confidence

Conventional and helical CT scanning techniques have documented high accuracy (96-98%), sensitivity (96-100%), specificity (95-97%), positive predictive value (97-99%), and negative predictive value (88-100%).[18, 19, 20, 21]

Initial studies evaluated sequential (nonhelical) CT scanning in the diagnosis of appendicitis. In 1993, Malone evaluated nonenhanced, sequential CT in 211 patients and reported a sensitivity of 87% and a specificity of 97%.[22] The addition of intravenous and oral contrast agent increased sensitivity to 96-98%.

Thus, sequential CT scanning with oral and intravenous contrast enhancement is highly accurate. However, this examination is also time consuming and expensive; it is best used for equivocal presentations when helical CT scanning is not available.

In 1997, Lane et al evaluated helical CT scanning without contrast enhancement and found a sensitivity of 90% and specificity of 97%.[23] Other studies of noncontrast helical CT in adults with suspected appendicitis have shown a sensitivity of 91-96% and a specificity of 92-100% for this examination.[24, 25, 26, 27]

In a 2004 study of pediatric patients, Kaiser et al found that nonenhanced CT was 66% sensitive.[28] Sensitivity increased to 90% with the use of intravenous contrast material.

In a 2005 study of 112 pediatric patients, Hoecker and Bilman found that unenhanced CT achieved a sensitivity of 87.5%, a specificity of 98.7%, a positive predictive value of 91.3%, and a negative predictive value of 90.8%.[29]

In 1997, Rao et al found that focused (lower abdominal and upper pelvic) helical CT with 3% Gastrografin instilled into the colon (without intravenous contrast agent) had a superior sensitivity of 98% and a specificity of 98%.[20]

Focused helical scanning without intravenous contrast agent eliminates the risk of anaphylaxis and reduces the cost to about $230. Acquisition time is less than 15 minutes. Radiation exposure is less than that of a standard obstruction series. Alternative diagnoses are revealed in up to 62% of patients and include diverticulitis, nephrolithiasis, adnexal pathology, RLQ tumor, small-bowel hernias, and ischemia.

The literature suggests that limited helical CT scanning with rectal contrast enhancement is a highly accurate, time-efficient, cost-effective way to evaluate adults with equivocal presentations for appendicitis.

Two studies of focused helical CT scanning with rectal contrast in children suggest a sensitivity of 95-97%. This is an excellent diagnostic approach in patients with equivocal presentations who are poor candidates for intravenous contrast.

A retrospective study of 173 adults found that helical CT scanning with intravenous contrast, but no rectal or oral contrast, had a sensitivity of 100%, a specificity of 97%, a positive predictive value of 95%, and negative predictive value of 100%.[30]

Another study that used only intravenous contrast in the CT scan diagnosis of appendicitis, this time on 78 patients, found the examination to have a sensitivity of 91.9%, a specificity of 87.5%, and an accuracy of 91%.[31]

In a 2005 retrospective review of 23 published reports, Anderson et al found that CT scanning without oral contrast was at least as accurate as CT scanning with oral contrast, achieving a sensitivity of 95%, a specificity of 97%, a positive predictive value of 97%, and a negative predictive value of 96%.[32] Elimination of oral contrast reduces emergency department length of stay and delay to operative intervention.

In a 2015 meta-analysis  of 7 prospective studies, the pooled sensitivity and specificity of noncontrast CT for detecting acute appendicitis were 90% and 94%, respectively.[33]

CT scanning is readily available, operator independent, and relatively easy to perform, and it provides results that are easy to interpret. Furthermore, CT scanning helps clinicians to diagnose other intra-abdominal conditions in 50-80% of patients who do not have acute appendicitis (see the images below).

Crohn disease in a young woman; computed tomograph Crohn disease in a young woman; computed tomography scan. The patient presented with acute right lower quadrant pain and fever. She had a normal-appearing appendix, but thickening of the wall of the terminal ileum was noted (arrow) in addition to sclerotic changes of both sacroiliac joints, that was consistent with sacroiliitis in association with Crohn disease.
Severe acute pancreatitis in a young man; computed Severe acute pancreatitis in a young man; computed tomography scans. The patient presented with peripancreatic effusions that resulted in right lower quadrant pain. Fluid had tracked down the right paracolic gutter (left, arrow, coronal section) in addition to the anterior pararenal space (right, axial view).

CT scanning has high diagnostic accuracy in detecting complications, particularly in patients in whom appendiceal perforation is suspected. This modality can help clinicians to accurately differentiate mild inflammation from phlegmons and abscesses, as well to identify the extent of the disease. CT scanning can be used to guide surgical or percutaneous abscess drainage.

False positives/negatives

Some CT scan findings that are suggestive of or often accompany acute appendicitis are nonspecific and can be observed with other RLQ conditions, such as Crohn disease, ulcerative colitis, pancreatitis, perforation of a duodenal ulcer, and cholecystitis. Misinterpretation of these signs as indicative of appendicitis can lead to a false-positive result.

Conversely, specific signs can be misapplied. Without optimal cecal opacification, a distended, inflamed appendix can be mistaken for a small-bowel loop. Rarely, an appendiceal lumen filled with appendicoliths can mimic an opacified lumen on CT scans.

Distal appendicitis can potentially be the cause of a false-negative interpretation.

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Magnetic Resonance Imaging

Two studies regarding the use of MRI in evaluating acute appendicitis support different techniques. A study by Incesu et al described significant enhancement of the inflamed appendix and surrounding fat on gadolinium-enhanced, fat-suppressed, T1-weighted, spin-echo images (see the first image below).[34] Mild enhancement was observed in the normal appendix and gut (see the second image below). Using fat-saturation techniques, contrast differences were observed between the inflamed appendix and the surrounding fat. Fat-suppressed, T2-weighted, axial and coronal images also helped in the detection and evaluation of appendicitis and its complications.

Acute suppurative appendicitis; contrast-enhanced, Acute suppurative appendicitis; contrast-enhanced, fat-suppressed, T1-weighted, spin-echo axial magnetic resonance image. A markedly enhanced and thickened inflamed appendix (arrows) is shown. a = iliac artery; c = cecum; p = psoas muscle; v = iliac vein.
Normal appendix; contrast-enhanced, fat-suppressed Normal appendix; contrast-enhanced, fat-suppressed, T1-weighted, spin-echo coronal magnetic resonance image. Mild enhancement in the unenlarged appendix, ileum (arrowhead), and cecum is shown.

In another study, Hormann et al suggested that unenhanced, axial, T2-weighted, spin-echo imaging was the most sensitive sequence for the diagnosis of acute appendicitis.[35] The authors obtained axial, T1-weighted, turbo, spin-echo sequences; axial and coronal, T2-weighted, turbo, spin-echo sequences; and axial, fat-suppressed, short inversion-time, inversion-recovery, turbo, spin-echo sequences. In the study, on T2-weighted, ultraturbo, spin-echo images, acute appendicitis demonstrated a markedly central hyperintensity and markedly hyperintense periappendiceal tissue, as well as a slightly hyperintense thickened wall.

In a meta-analysis of 30 studies and 2665 patients, the sensitivity and specificity of MRI for the diagnosis of acute appendicitis were 96% and 96%, respectively. In pregnant patients, sensitivity was 94% and specificity was 97%; in children, sensitivity was 96% and specificity was 96%.[36]

Gadolinium-based contrast agents have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans.

Degree of confidence

Fat-suppressed, gadolinium-enhanced MRI scans are sensitive (97%) and accurate (95%) in the detection of acute appendicitis; however, this technique is not routinely used in the diagnosis of acute appendicitis. Unenhanced MRI scanning is also used for the evaluation of appendicitis with an accuracy of 100%. When the results of the studies by Hormann et al and Incesu et al are compared, unenhanced MRI is found to be the more appropriate imaging modality.

A single retrospective study assessed the accuracy of MRI in 51 pregnant patients with suspected appendicitis in whom ultrasonography was nondiagnostic. Sensitivity, specificity, positive and negative predictive values, and accuracy for MRI was 100%, 93.6%, 91.4%, 100%, and 94.0%, respectively.[37]  In another multicenter restrospective study of pregnant women with confirmed acute appendicitis, sensitivity, specificity, accuracy, positive predictive value, and negative predictive values were 96.8%, 99.2%, 99.0%, 92.4%, and 99.7%, respectively.[38]

False positives/negatives

False-negative results in MRI usually result from technique-related limitations, such as inefficient fat saturation that causes the appendiceal wall enhancement to be obscured by mesenteric fat.[39]

Inflammatory diseases of the gut, such as ileal diverticular abscess and inflamed ileal segments of Crohn disease that may mimic appendicitis, have been reported as false-positive results on enhanced MRI.

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Ultrasonography

US is a widely available and inexpensive modality that has the potential for highly accurate imaging in patients with suspected acute appendicitis.[40, 41, 42]  With the introduction of graded-compression US by Puylaert in 1986, the diagnostic use of this modality in acute appendicitis has increased dramatically.[43, 44]

The advantages of US include its noninvasiveness, short acquisition time, lack of radiation exposure, and potential for the diagnosis of other causes of abdominal pain, particularly in the subset of women of childbearing age. Many authorities believe that US should be the initial imaging test in pregnant women and in pediatric patients, because radiation exposure is particularly undesirable in these groups.

A retrospective study, carried out on 1,228 children with suspected appendicitis during 2003-2008, evaluated the use of a staged protocol using first ultrasound, and subsequently CT, only if the findings were equivocal.[45] Results showed that, in children with suspected acute appendicitis, the protocol of US first and then CT was highly accurate and may reduce the need for CT and thus exposure to radiation (sensitivity, 98.6%; specificity; 90.6%). The negative appendectomy rate was 8.1% (19 of 235 patients). The missed appendicitis rate was less than 0.5% (1 of 631 patients). CT was avoided in more than half (333 of the 631 patients) in whom the protocol was followed and the US findings were definitive, representing a substantial reduction in radiation exposure to this population.

One study suggests that ultrasonography should be incorporated as a first-line imaging modality for the diagnosis of acute appendicitis in adults. In this study, 151 patients with suspected appendicitis underwent the designed protocol. Graded-compression US was performed first. Patients with positive results on graded-compression US underwent surgery.

Patients in this study who had inconclusive or negative results underwent contrast-enhanced, multidetector CT scanning. Patients with positive findings on CT scanning also underwent surgery. Patients with negative CT scan findings were admitted for observation. Positive ultrasonographic results were confirmed at surgery in 71 of 79 patients, and positive CT scan results were confirmed in 21 patients. Thirty-nine patients with normal CT scan results recovered and did not require surgery. The sensitivity and specificity of this protocol was 100% and 86%, respectively.

Poortman et al concluded that this diagnostic pathway, using primary graded-compression US and complementary multidetector CT scanning, yields a high diagnostic accuracy for acute appendicitis, without adverse events from delay in treatment. Although US is less accurate than CT scanning, it can be used as a primary imaging modality and avoids the disadvantages of CT scanning. Observation is safe for patients with negative findings on US or CT scanning.[46]

Bedside ultrasound may be an appropriate initial test to evaluate patients with suspected acute appendicitis in the emergency department. One study found bedside ultrasound had a sensitivity of 67.65% and a specificity of 98.41%.[47]

The principal disadvantage is that US is operator dependent. Because nonvisualization is interpreted as a noninflamed appendix, technical expertise and commitment to a thorough examination are essential in obtaining maximum sensitivity.[41, 42, 43, 47, 48, 49, 50]

Ultrasonographic technique

Ultrasonographic examination should begin with a thorough evaluation of the abdominal and pelvic organs.

In women with low pelvic tenderness in whom the appendix is not visualized on transabdominal US or in whom the diagnosis is not evident after abdominal and pelvic examinations have been performed, add an endovaginal ultrasonographic examination. Pelvic appendicitis is best demonstrated in women with endovaginal US; a posterolateral approach is suggested to evaluate the retrocecal area for retrocecal appendicitis.

In 1986, Puylaert described a graded-compression technique for evaluating the appendix with transabdominal US.[43] A 5-MHz transducer is used. Gentle, but firm, pressure is applied on the RLQ to displace intervening bowel gas and to decrease the distance between the transducer and the appendix, improving image quality. An outer diameter of greater than 6 mm, noncompressibility, lack of peristalsis, or periappendiceal fluid collection characterizes an inflamed appendix. The normal appendix is not visualized in most cases. A posterolateral approach is suggested to evaluate the retrocecal area. Scattered case reports endorse transvaginal US in women with low pelvic tenderness, if the appendix is not visualized on transabdominal scans.

Graded-compression US allows successful examination of a patient who may have peritoneal irritation and sensitivity. During the compression, maximal tenderness of an abdominal point can provide an important diagnostic clue, which is often useful in focusing the ultrasonographic examination on the correct area in a patient with suspected appendicitis.

Ultrasonographic findings

Major ultrasonographic findings in acute appendicitis in the RLQ include the following:

  • An aperistaltic, noncompressible, blind-ended, sausage-shaped structure that arises from the base of the cecum
  • Distinct appendiceal wall layers
  • An outer diameter greater than 6 mm
  • A target appearance
  • Appendicolith(s) (See the images below.)
  • Periappendiceal fluid collection
  • Echogenic, prominent pericecal fat
    Phlegmonous appendicitis; oblique-axial ultrasonog Phlegmonous appendicitis; oblique-axial ultrasonogram. A pericecal fluid collection, which is walled off by small-bowel loops (arrowheads) is shown, and an appendicolith with an acoustic shadow (arrow) is observed.
    Suppurative appendicitis in a 15-year-old boy; lon Suppurative appendicitis in a 15-year-old boy; longitudinal view, pathologic specimen. An inflamed appendix with appendicoliths in the lumen (arrow) is demonstrated.

Normal appendix

A normal appendix is infrequently observed using gray-scale US, but this structure can be visualized as a blind-ended, tubular, compressible intestinal loop that is continuous with the cecum and has a diameter of less than 6 mm, particularly in thin patients (see the image below).

Normal appendix; longitudinal ultrasonogram. A com Normal appendix; longitudinal ultrasonogram. A compressible tubular appendiceal structure with an outer diameter of less than 6 mm (arrows) is shown. A = iliac artery; V = iliac vein.

Suppurative appendicitis

The longitudinal ultrasonographic view demonstrates a nonperforated, inflamed appendix that is characterized by an aperistaltic, noncompressible, blind-ended, tubular structure with a laminated wall that arises from the base of the cecum. When the inflammation is mild and visualization is optimal, 5 distinct appendiceal wall layers can be identified (see the image below).

Suppurative appendicitis in a 15-year-old boy; lon Suppurative appendicitis in a 15-year-old boy; longitudinal ultrasonogram. An aperistaltic, noncompressible, blind-ended, fluid-filled, tubular appendiceal structure is shown, and distinct wall layers (arrows) arising from the base of the cecum are observed.

In the transverse view, the abnormal appendix often has a target appearance, and its outer diameter is in excess of 6 mm in the RLQ. Researchers have studied the thickness of the appendix wall; walls surpassing 3 mm in thickness have been evaluated as pathologic.

An appendicolith, which is identified as an intraluminal echogenic focus with posterior shadowing, can be detected by US in approximately 30% of patients with acute appendicitis (see the images below).

Gangrenous appendicitis

Generalized or focal loss of the echogenic submucosal layer of the appendiceal wall, as well as the prominent, surrounding, echogenic fat, is consistent with gangrenous appendicitis (see the images below).

Gangrenous appendicitis; longitudinal ultrasonogra Gangrenous appendicitis; longitudinal ultrasonogram. A markedly distended appendix (arrows), loss of mucosa and submucosal layers, and prominent echogenic pericecal fat are shown.
Distended gangrenous appendix; pathologic specimen Distended gangrenous appendix; pathologic specimen.

Perforated appendicitis

In the diagnosis of a perforated appendicitis, gray-scale US is also a valuable diagnostic tool, despite the fact that the perforated appendix may not be visualized in the RLQ. Irregularity of and damage to the contour of the appendix by the presence of periappendiceal fluid and hyperechoic, prominent pericecal fat are diagnostic of perforation (see the image below). Gas bubbles occur within a fluid collection in cases of perforation or as a result of gas-forming organisms. A localized perforation of the appendiceal tip may also demonstrate gas pockets in the perforation site.

Perforated appendix; longitudinal ultrasonogram. A Perforated appendix; longitudinal ultrasonogram. A defect on the tip (large arrow, right side) of the enlarged appendix (short arrows, left side) is observed. c = cecum.

Periappendiceal phlegmon and abscess

A phlegmon appears as a localized fluid collection, which is walled off by the adjacent greater omentum and small-bowel loops. An appendiceal abscess appears as a complex, hypoechoic mass adjacent to the cecum or appendix. In these patients, the inflamed appendix may not be visualized (see the image below).

Periappendiceal abscess formation; oblique-axial u Periappendiceal abscess formation; oblique-axial ultrasonogram. A thick-walled, complex, hypoechoic mass adjacent to the cecum (arrows) is shown. The inflamed appendix was not visualized.

Alternative disease

Ultrasonographic examination is also useful for diagnosing alternative pathology, such as a tubo-ovarian abscess, ovarian torsion, ovarian cyst, or mesenteric adenitis, especially in women of childbearing age. Establishment of an alternative diagnosis does not exclude appendicitis. However, it is a double benefit when appendicitis can be excluded by US and an alternative diagnosis is made.

Color Doppler ultrasonographic findings

Color Doppler US is beneficial in the evaluation of inflammatory conditions of the intestinal tract, and according to most authors, this modality is a useful adjunct to conventional US in the assessment of acute appendicitis.[51, 48]

A normal appendix seldom shows findings of mild hyperemia on Doppler ultrasonographic examination. However, an inflamed appendix uniformly shows greater flow than a normal appendix, and circumferential color in the wall of the inflamed appendix (seen in the image below) as observed on color Doppler ultrasonographic images is a strong indicator of acute appendicitis.

Suppurative appendicitis; transverse view, color D Suppurative appendicitis; transverse view, color Doppler ultrasound image. Circumferential colors are observed in the wall of the inflamed appendix (arrows), a strong indicator of acute appendicitis.

A flowing appearance with Doppler US has been reported to be suggestive of a pathologic appendix, but absence of flow cannot differentiate a normal from an abnormal appendix.

Peripheral vascularity of the inflamed mesentery and omentum can be demonstrated; however, detection of hyperemia in the appendix wall is not possible in patients with gangrenous appendicitis because of the vascular necrosis adjacent to the appendix wall that has resulted from inflammation.

Degree of confidence

Numerous studies have documented that, in experienced hands, US has a sensitivity of 75-90%, a specificity of 86-100%, an accuracy of 87-96%, a positive predictive value of 91-94%, and a negative predictive value of 89-97% for the diagnosis of acute appendicitis. However, US is extremely operator dependent.

Five studies of graded-compression US in children showed overall sensitivities of 85-95% and specificities ranging from 47-96%. One study found a sensitivity of 35% and a specificity of 98% in pediatric patients with perforated appendicitis.

One study indicated that in cases of appendicitis, US has a sensitivity and specificity of 77% and 86%, respectively (although other studies have reported higher figures for these), as compared with 100% sensitivity and specificity for CT scanning.

Similarly, a literature review from the Netherlands found CT scanning to be superior to graded-compression ultrasonography for the diagnosis of acute appendicitis.

One author reported the ability to identify a normal appendix in as many as 82% of patients without appendicitis. When a normal appendix cannot be demonstrated and when no pericecal fluid or echogenic mass is observed, the examination is usually considered not to be diagnostic for appendicitis.[52]

In a 2001 study by Rettenbacher et al, in which several hundred patients in whom appendicitis was suspected, as well as control subjects, were evaluated, the range of appendiceal diameters as measured by US was found to vary from 2-13 mm, with a diameter of greater than 6 mm in 23% of control subjects.

Ultrasonographic examination is especially limited in obese patients or those who are in significant pain. Another important limitation of US is in the diagnosis of appendiceal perforation; in this scenario the diagnosis depends on secondary findings, such as free pericecal fluid, echogenic pericecal fat, and gas bubbles in the perforation site.

Color Doppler US increases accuracy in the diagnosis of acute appendicitis, although potential limitations exist in using this modality for this purpose.

If a graded-compression ultrasonographic examination of the RLQ is positive for appendicitis, appendectomy should be performed. However, if the examination results are negative, this finding is not sufficiently sensitive to rule out the possibility of appendicitis. Consideration should be given to further observation and focused helical CT scanning with rectal contrast enhancement.

Tzanakis and others proposed a clinical scoring system that assigns 6 points if the results from an appendiceal ultrasonographic examination are positive, 4 points for RLQ tenderness, 3 points for rebound tenderness, and 2 points for a white blood cell (WBC) count of greater than 12,000.[53]

In their prospective study of 303 adults, using a total score cut-off of 8 points or greater, the authors reported that the scoring system had a sensitivity, a specificity, and an accuracy of 95.4%, 97.4%, and 96.5%, respectively. These findings should be confirmed by additional studies before routine clinical use.

The main limitation of US is that its reliability is completely user dependent.

False positives/negatives

Several major pitfalls are involved in the overdiagnosis of appendicitis with use of US, including misinterpretation of the terminal ileum as the appendix and misinterpretation of a normal appendix as an inflamed appendix.

The appendix may be inflamed secondarily as a result of a variety of inflammatory processes. In cases of intrinsic neoplasms, the appendix may be enlarged and noncompressible.

Some false-positive US findings have resulted from spontaneously resolving appendicitis.

Fluid-filled bowel loops and fecal and gaseous distension of the colon interfere with adequate visualization of the appendiceal area. Approximately 30% of appendicitis is missed by US as the result of a retrocecal appendix. This problem may be partially overcome by scanning in the coronal plane (with the transducer parallel to the iliac wing) to visualize posterior to the cecum.

A gas-filled appendix may cause diagnostic difficulty and may be misinterpreted as either a small-bowel loop or gas in a periappendiceal abscess.

False-positive results may occur in patients with Crohn disease.

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Nuclear Imaging

Although several investigators have explored the potential of radioactive isotope imaging in patients with acute appendicitis, no practical role currently exists for this imaging modality in this patient population.

Indium-111 (111In)–labeled leukocytes are very sensitive and specific in the detection of appendicitis, with an overall accuracy of 91-95%.[54] However, indium is expensive, the optimal time for imaging is long (17-24 h after injection), and the technique is not always readily available.

Several techniques exist for labeling leukocytes with technetium-99m (99mTc), an inexpensive and readily available isotope.[55] In this technique, whole blood is withdrawn, and neutrophils and macrophages are labeled with 99mTc, which is administered intravenously. Then, nuclear images of the abdomen and pelvis are obtained serially over 4 hours. Localized uptake of tracer material in the RLQ suggests appendiceal inflammation.

One study used 99mTc albumin colloid–labeled leukocytes for scanning and reported the sensitivity for this technique to be 89%.[56]

Another study used Tc-99m-hexamethylpropyleneamine oxime–labeled leukocytes to scan for acute appendicitis and reported the sensitivity to be 81% and the overall accuracy to be 89%.

Technetium-99m human immunoglobulin uptake has also been suggested as an accurate and safe method in the detection of acute appendicitis (see the image below).[57]

Acute suppurative appendicitis in a 27-year-old wo Acute suppurative appendicitis in a 27-year-old woman; scintigraphy study. Pathologic accumulation of technetium-99m human immunoglobulin on the right iliac fossa is observed at 4 hours.

Scintigraphic techniques are usually completed within 5 hours, a time period that can delay operative treatment longer than the delay occasioned by the use of US and CT scanning.

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Contributor Information and Disclosures
Author

Lutfi Incesu, MD Professor, Department of Radiology, Ondokuz Mayis University School of Medicine; Chief, Neuroradiology, Department of Radiology, Ondokuz Mayis University Hospital, Turkey

Disclosure: Nothing to disclose.

Coauthor(s)

Caroline R Taylor, MD Associate Professor, Department of Diagnostic Radiology, Yale University School of Medicine; Chief, Diagnostic Imaging Service, Veterans Affairs Connecticut Health Care System

Caroline R Taylor, MD is a member of the following medical societies: Radiological Society of North America

Disclosure: Nothing to disclose.

Specialty Editor Board

Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand

Disclosure: Nothing to disclose.

Chief Editor

Eugene C Lin, MD Attending Radiologist, Teaching Coordinator for Cardiac Imaging, Radiology Residency Program, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine

Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, Society of Nuclear Medicine and Molecular Imaging

Disclosure: Nothing to disclose.

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Suppurative appendicitis; transverse view, color Doppler ultrasound image. Circumferential colors are observed in the wall of the inflamed appendix (arrows), a strong indicator of acute appendicitis.
Atypical presentation of appendicitis in a young woman; computed tomography scan. The patient presented with an elevated white blood cell count and right upper quadrant pain. Left, there is pericholecystic fluid and free fluid in the right paracolic gutter, which is caused by retrocecal appendicitis. Right, the appendix, observed in axial section, has an increased diameter and an enhancing thickened wall.
Appendicitis in a young physician; computed tomography (CT) study. Intravenous (IV) contrast was administered to the patient, who had gram-negative sepsis but no abdominal pain on examination. Left, an inconclusive CT scan after administration of oral contrast but no IV contrast. Right, a repeat CT scan study following administration of IV contrast demonstrates the thickened, enhanced appendiceal wall and periappendiceal changes. The retrocecal location of the appendix may have attenuated abdominal symptoms.
Acute suppurative appendicitis in a 15-year-old boy; contrast-enhanced, fat-suppressed, T1-weighted, spin-echo coronal magnetic resonance image. A markedly enhanced and thickened inflamed appendix (arrows) with pericecal enhancement due to the extent of inflammation is shown.
Acute suppurative appendicitis in a 27-year-old woman; scintigraphy study. Pathologic accumulation of technetium-99m human immunoglobulin on the right iliac fossa is observed at 4 hours.
Periappendiceal abscess; contrast-enhanced, fat-suppressed, T1-weighted, spin-echo coronal magnetic resonance image. Fluid collections (long arrows) and a markedly enhanced pericecal area (short arrows) are shown. b = bladder; c = cecum.
Normal appendix; barium enema radiographic examination. A complete contrast-filled appendix is observed (arrows), which effectively excludes the diagnosis of appendicitis.
Normal appendix; computed tomography (CT) scan. A normal appendix, visualized here at the base of the cecum (arrow), is observed in 44-51% of patients. Thin-section CT scans (5-mm collimation or less) are more useful in identifying the appendix. Oral or rectal contrast should be administered. Intravenous contrast is useful in enabling enhancement and edema of the appendiceal wall to be identified.
Distal appendicitis; computed tomography scan. The appendiceal lumen may be normal proximally (left, arrow), but distension and inflammatory changes are noted distally (right, open arrow).
Retrocecal appendix; computed tomography scan. Left, the appendix occurs in a retrocecal location in 65% of patients. Right, in this young female, the appendix extends cranially as far as the posterior lobe of the liver. Appendicitis in a patient with a retrocecal appendix may present atypically, with less or poorly localized pain, discomfort on coughing or walking, or flank, rather than right lower quadrant, tenderness.
Arrowhead sign; computed tomography scan. The presence of this sign indicates contrast outlining the cecum and funneling into the origin of the appendix, with obstruction of the lumen preventing retrograde flow of barium into the distal appendix.
Acute gangrenous appendicitis with calcified appendicolith; computed tomography (CT) scan. A calcified appendicolith in the lumen of an enlarged inflamed appendix is shown.
Perforated appendicitis with abscess; computed tomography scan. Note the appendicolith (arrow) and air within the abscess. The terminal ileum lies anterior to the appendiceal abscess, and inflammatory change is noted in its wall, which appears thickened (open arrow).
Crohn disease in a young woman; computed tomography scan. The patient presented with acute right lower quadrant pain and fever. She had a normal-appearing appendix, but thickening of the wall of the terminal ileum was noted (arrow) in addition to sclerotic changes of both sacroiliac joints, that was consistent with sacroiliitis in association with Crohn disease.
Severe acute pancreatitis in a young man; computed tomography scans. The patient presented with peripancreatic effusions that resulted in right lower quadrant pain. Fluid had tracked down the right paracolic gutter (left, arrow, coronal section) in addition to the anterior pararenal space (right, axial view).
Acute suppurative appendicitis; contrast-enhanced, fat-suppressed, T1-weighted, spin-echo axial magnetic resonance image. A markedly enhanced and thickened inflamed appendix (arrows) is shown. a = iliac artery; c = cecum; p = psoas muscle; v = iliac vein.
Normal appendix; contrast-enhanced, fat-suppressed, T1-weighted, spin-echo coronal magnetic resonance image. Mild enhancement in the unenlarged appendix, ileum (arrowhead), and cecum is shown.
Normal appendix; longitudinal ultrasonogram. A compressible tubular appendiceal structure with an outer diameter of less than 6 mm (arrows) is shown. A = iliac artery; V = iliac vein.
Suppurative appendicitis in a 15-year-old boy; longitudinal ultrasonogram. An aperistaltic, noncompressible, blind-ended, fluid-filled, tubular appendiceal structure is shown, and distinct wall layers (arrows) arising from the base of the cecum are observed.
Phlegmonous appendicitis; oblique-axial ultrasonogram. A pericecal fluid collection, which is walled off by small-bowel loops (arrowheads) is shown, and an appendicolith with an acoustic shadow (arrow) is observed.
Suppurative appendicitis in a 15-year-old boy; longitudinal view, pathologic specimen. An inflamed appendix with appendicoliths in the lumen (arrow) is demonstrated.
Gangrenous appendicitis; longitudinal ultrasonogram. A markedly distended appendix (arrows), loss of mucosa and submucosal layers, and prominent echogenic pericecal fat are shown.
Distended gangrenous appendix; pathologic specimen.
Perforated appendix; longitudinal ultrasonogram. A defect on the tip (large arrow, right side) of the enlarged appendix (short arrows, left side) is observed. c = cecum.
Periappendiceal abscess formation; oblique-axial ultrasonogram. A thick-walled, complex, hypoechoic mass adjacent to the cecum (arrows) is shown. The inflamed appendix was not visualized.
Computed tomography scan reveals an enlarged appendix with thickened walls, which do not fill with colonic contrast agent, lying adjacent to the right psoas muscle.
 
 
 
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