Index terms: Appendicitis Barium enema

The

barium

enema

in appendicitis:
and pitfalls

Spectrum

of appearances

Reed
SQ

P. Rice,

M.D.*
M.D.t

William Peter David Frederick Margaret

M. Thompson,

I.-

J.

Fedyshin,

M.D.* M.D.* M.D.* M.D.*

F. Merten,

M. Kelvin, E. Williford,

In the patients a variety

diagnosis with of other

of appendicitis, atypical abnormalities.

the

barium and

enema may

is useful demonstrate

in

clinicalpresentations,

EXHIBIT, A SELECtiON OF THE GAS. TROINTESTINAL RADIOLOGY PANEL, WAS DISPLAYED AT THE 69TH SCIEN11FIC AS. SEMBLY AND ANNUAL MEETING OF THE RADIOLOGICAL SIETY OF NORTH AMERICA, NOVEMBER 13-18, 1983, SiUCAGO,
THIS

Introduction
From 15 to 30% of patients operated upon with a clinical diagnosis of acute

ILLINOIS.

From
Duke

the Department
University

of RadiCenter,

appendicitis
false positive
of uncertain

have normal appendices (2, 3, 7). In women of childbearing age, this exploration rate is as high as 45% (5). In patients with abdominal pain
etiology in whom appendicitis is a consideration, an urgent barium (1)

ology,

Medical

Durham,
ology,

North
the

Carolina.
Department of Radi-

t From

enema
confirm

without

preparation

may be useful.

The examination
some other

is safe and may:

etiology for the

Hospital,

Durham \Teteram Administration Durham, North Carolina.

reprint requests to R. P.

dominal

the diagnosis of appendicitis, (2) identify symptoms or (3) exclude appendicitis.

ab-

Address

Rice, M.D., Department of Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710.

Volume

4, Number

May

1984

RadioGraphics

393

The

barium

enema

in appendicitis

Rice

et al.

Technique
When performing emergency or semiemergency

of Examination
out of the colon, and then to raise the bag to refill the colon

barium enemas in patients necessary to prepare the

laxatives After
flow slowly

(8). insertion Filming

Laxatives

suspected of appendicitis, it is not colon with cleansing enemas or may actually be contraindicated. tip, the barium
under careful

in an effort be repeated
completely. also facilitate

to obtain maximal appendiceal filling. This can several times when the appendix does not fill
Intravenous appendiceal glucagon filling. (0.5 mg Rarely, to 1.0 mg) a pericecal may in-

of the enema
around

is permitted
fluoroscopic

to

to the cecum

control. involvement. portant obliquity

of the sigmoid

colon

should

be performed it is imof
is

flammatory process will be apparent only when the patient is prone and a compression paddle is inflated under the right
lower quadrant (Figure 10). It is also useful to obtain a post

if the fluoroscopic
Once

appearances
the barium

suggest
reaches

any inflammatory
the cecum,
mass

evacuation
only after

film

as the appendix

may

be completely
to be sure that

filled
the

to evaluate the cecum in a variety in order to determine if an extrinsic

of degrees

evacuation.

It is impossible

present.
barium

It may

be useful

to lower

the enema

bag

to siphon

appendix tip.

is entirely

filled

unless

one can

see a globular

Radiographic The
demonstrated complete filling cecal inflammatory

Findings findings
enema include

classic

radiographic
by barium

of appendicitis
nonfilling with a pen-

as
or in-

of the appendix in association mass (1 8, 9).

,

PERICECAL

INFLAMMATORY

MASSES

Inflammatory flammatony and some may instances, disease be limited the

masses may to the actual

associated be only penicecal a few tip of the

with cecum

appendiceal (Figure

inin size 1). In mass is

centimeters

inflammatory tethering

small,
extended

but there
into

is radiographic
the pelvis 2). with

evidence
resultant

that the abscess

has

of the sig-

moid

colon

(Figure

394

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1984

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Rice

et a!.

The

barium

enema

in appendicitis

Figure 1. Acute Appendicitis

Nonfilling of the at the tip of the appendix cecum and a small filling were due to acute defect (arrow) appendicitis.

Figure 2 Appendiceal Abscess The small extrinsic mass arrow) and the associated
(curved arrows) were due

at the cecal tip (straight tethering of the sigmoid

to appendiceal abscess and

pelvic

extension.

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395

The barium

enema

in appendicitis

Rice

et al.

In other extrinsic

patients,

the pericecal of the cecum,

mass

itself is lange with (Figures

and of ileal 3 and 4). obvious inassociated

compression

displacement

loops
When

and
there

involvement
is nonfilling

of the sigmoid
of the appendix with

volvement

of the tip of the cecum,

or without

deformity of loops of ileum usually straightforward.

or sigmoid,

the diagnosis

is

Figure 3 AppendicealAbscess The large pericecal mass (arrowheads) with displacement of the terminal ileum was due to appendiceal abscess. There was a history of abdominal pain for one week.

Figure 4 Appendiceal Abscess This large pericecal mass (arrowheads) was due to a perforated appendix and abscess in a 47 year old woman with a two week history of abdominal pain.

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et a!.

The

barium

enema

in appendicitis

In

some

patients,

however,

a large

appendiceal

in-

flammatory
When

process

may

not involve

the tip of the cecum.

position and the in-

with sparing of the cecal tip when the appendix is medially positioned and only the tip of the appendix is involved in the
inflammatory process (Figure 8). Retrocecal appendicitis

the appendix

is in a retrocecal

flammatory process is limited to the tip of the appendix, there may be a large mass posterolateral to the cecum but with sparing of the cecal tip (Figures 5, 6 and 7) (4, 8). Similarly, there may be a large abscess medial to the cecum

may be difficult to diagnose be relatively little tenderness

(4).

clinically because there may in the right lower quadrant

. .

4k.

#{149}

Figure5A

Flgure5B

Figure 5 AppendicealAbscess Supine (A) and oblique (B) radiographs from a barium enema show posterolateral extrinsic mass that was due to a retrocecal appendiceal abscess. The cecal tip is normal.

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The

barium

enema

in appendicitis

Rice

et al.

Figure 6 Appendiceal Abscess This posterolateral extrinsic mass (arrows) was due to an ascending retrocecal appendiceal abscess sparing the cecal tip, C.

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The

barium

enema

in appendicitis

Figure

FIgure

Figure 7 AppendicealAbscess This abscess spares the cecal tip. When the appendix may be minimal right lower quadrant tenderness.

is retrocecal

there

Figure 8 Appendiceal Abscess In this patient, a large abscess was present medial to the ascending colon (arrows) and cecum, C, with barium extravasation (arrowhead) into the abscess from perforation of the appendix. Post drainage radiographs showed no residual barium. The clinical signs and symptoms in this 13 year old girl were not sufficient to warrant surgical exploration prior to this barium enema.

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The barium

enema

in appendicitis

Rice

et a!.

INFLAMMATORY REMOTE FROM THE

MASSES CECUM

In some

patients,

an appendiceal

abscess

may

tirely

pelvic

in location and/or
(Figures

with
9 and

an extrinsic but with

10). When

process
performing

be eninvolving
pericecal barium

some

other

source. abscesses quadrant appendix

to the pelvis.

Appendiceal
the right the cecum of the
monly

may be in locations
because (Figure of positional Appendiceal
The inflammatory

remote
anomalies

from
of cornmay

the rectum
component

sigmoid,

no detectable

lower and inflammatory

extend

1 1) or as a result

of spread

enemas
to look
flammatory

in patients carefully
masses

with possible appendicitis, at the sigmoid colon.

frequently involve the

it is important Appendiceal insigmoid, and in

process. from

abscesses
process

extend

superiorly

the pelvis.

Extension in right (Figure

into

the right subdi-

patients sible

in whom radiographically

the cecal

tip is normal,

it may

be impos-

to exclude

the possibility

of an abscess

or left paracolic gutter may result aphragmatic or subhepatic abscesses

or left 12).

arising

from

diverticulitis,

pelvic

inflammatory

disease

or

FIgure9A

Figure9B

Figure 9 Appendiceal Abscess This supine radiograph (A) from a barium enema shows a normal cecum, C, and tethering of the sigmoid (arrows) in a four year old boy with a three day history of abdominal pain. A lateral view (B) shows a mass anterior to the rectum R. Surgery confirmed that these findings were due to a perforated appendix with pelvic abscess.

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The barium

enema

in appendicitis

Figure

1OA

Figure

lOB

Figure 10 Chronic AppendicealAbscess This supine radiograph (A) showed an apparently normal cecum, C, and terminal ileum, but there was a mass extrinsic to the sigmoid (arrowheads). An oblique spot radiograph (B) showed the mass extrinsic to the sigmoid (arrowheads) to better advantage. A prone radiograph (C) with compression shows a pericecal mass. A large appendiceal abscess anterior to the cecum with pelvic extension was confirmed at surgery. This double contrast examination was performed on a 50 year old woman who was on steroid therapy for a vasculitis, and who had nonspecific abdominal pain. There was no clinical suspicion of appendicitis, however.

Figure

1OC

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1984

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401

The

barium

enema

in appendicitis

Rice

et al.

-p

Figure

ilA

Figure

liB

Figure 11 Appendiceal Abscess This small bowel examination (A) shows an extrinsic mass (arrows) involving several loops of ileum suggesting abscess. The post evacuation radiograph (B) from a barium enema shows incomplete filling of the appendix (arrowhead) associated with an anomalously positioned cecum. Surgery confirmed the presence of an appendiceal abscess. This 33 year old woman had had diarrhea for several days prior to the localization of pain and tenderness in her left lower abdomen.

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enema

in appendicitis

Figure 12 Appendiceal Abscess with Extension to the Left Subdiaphragmatic Space This is the post evacuation film from a barium enema performed on a four year old boy who had a ten day history of a febrile illness. There is a pericecal extrinsic appendiceal abscess (arrow) and tethering (arrowheads) of the left colon owing to a paracolic abscess that extended into the left subdiaphragmatic space. Surgery confirmed a ruptured appendix with pelvic abscess and extension up the left paracolic gutter.

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1984

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The

barium

enema

in appendicitis

Rice

et al.

NONFILLING

OR

INCOMPLETE

FILLING

OF Unless cannot without the appendix

THE

APPENDIX is filled out to a globular tip, one with or to insure and lowfilms and the ap-

exclude the possibility of acute appendicitis an associated abscess. The techniques of the appendix bag, obtaining glucagon. include raising post evacuation Sometimes, when

complete filling ering the enema pendix in the suggesting or incomplete appendicitis. however,

the use of intravenous

is partially filled, there area of the appendix the diagnosis filling

is associated point tenderness which is of some value in appendicitis. may Nonfilling be suggestive of appendicitis, the appendix
13, 14 and 15)

of acute of the appendix

of

This is an unreliable criterion since in 5-10% of normal patients, a barium enema (Figures

will not fill during

(6).

Figure

13

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et al.

The

barium

enema

in

appendicitis

Figure

14

Figures 13, 14 and 15 Acute Appendicitis These spot radiographs from the barium three different patients with appendicitis complete filling of the appendix.

enemas show

of in-

Figure

15

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The

barium

enema

in appendicitis

Rice

et al.

DIFFERENTIAL Pericecal or pelvic inflammatory by conditions other than appendicitis. disease associated with tubo-ovarian variety

DIAGNOSIS masses may be caused Pelvic inflammatory abscesses as well as a ap-

pendicitis
disease

of other gynecologic mass lesions may mimic (Figures 16, 17, 18 and 19). Pelvic inflammatory is usually the bilateral. of Careful pelvic physical inflammatory examination,

ultrasound
confirm

examination
diagnosis

and, occasionally,

laparoscopy

may
disease.

Figure

16

Figure

17

Figures 16 and 17 Tubo-ovarian Abscess These are radiographs of two different patients with inflammatory masses (arrows) in their right lower quadrants and nonfilling of their appendices. Both patients had tubo-ovarian abscesses. It may be impossible to differentiate a tubo-ovarian abscess from an appendiceal abscess by barium enema. Clinical examination, ultrasound and laparoscopy may establish the diagnosis of pelvic inflammatory disease, however.

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enema

In appendicitis

Figure 18 Endometriosis A spot film from a barium enema shows an extrinsic mass and nonfilling of the appendix. These findings to be due to an endometrioma.

cecal proved

Figure 19 Ovarian Cyst This spot radiograph shows an extrinsic cecal mass (arrows) and displacement of the terminal ileum associated with nonfilling of the appendix. Laparotomy revealed the mass to be due to hemorrhage into a benign ovarian cyst. The appendix was normal.

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The

barium

enema

in appendicitis

Rice

et at.

Yersinia clinically

enteroco!itis

is notorious

for mimicking

appendicitis

and,

on occasion,

may

be associated

with

an inabscess of right

flammatory process (Figure 20). Crohns lower quadrant

suggesting an disease is a well

appendiceal known cause and

inflammatory

processes

occasionally

may mimic appendicitis radiographically tients with distal small bowel obstruction
fluid the mass. filled cecum loops that of ileum may causing mimic extrinsic a pericecal

(Figure 21). Pamay have dilated,

compression inflammatory of

Figure 20 Yersinia Enterocolitis This is a spot radiograph of the cecum in a young man with acute right lower quadrant pain, fever and leucocytosis. There is evidence of inflammation of the cecum. A small bowel examination demonstrated similar changes in the terminal ileum. Stool cultures confirmed the diagnosis of Yersinia enterocolitis.

Figure 21 Crohn 5 Disease Here there was an inflammatory mass involving the medial aspect of the cecum (arrows). There was partial filling of the appendix (arrowhead). This mass was a chronic abscess resulting from Crohns disease involving the terminal ileum and cecum.

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The

barium

enema

in appendicitis

Summary
The urgent use of the barium enema in the diagnosis matory pendix. Nonfilling
mass

mass

is remote

from

the

usual and

location

of the extrinsic

ap-

of appendicitis is useful in patients with an atypical clinical presentation. The classic findings of nonfilling of the appendix associated with a pericecal inflammatory mass provide valuable support for the diagnosis of appendiceal inflammation. The barium enema may variety of other abnormalities that are These include the demonstration of an lateral or medial to the ascending colon, with some maximal patients, involvement the cecum of the itself
less

of the appendix

an associated

demonstrate a well recognized. inflammatory mass or deep in the pelvis or sigmoid. and the inflamIn

also

involving the cecum are not specific for appendiceal inflammation; they may also be seen in a variety of other entities including tubo-ovarian abscess, other gyncologic masses, of these patients easy, safe enterocolitis occasional with and and small bowel obstruction. pitfalls, the use of the barium clinical presentation In spite enema in is quick,

a nonspecific rewarding.

rectum

is normal

References
1. Figiel LS, Figie! SJ. Barium examination dicitis. Acta Radiol 1962; 57:469-480.
2. Gilmore OJA, Browett JP, Griffin PH, of cecum in appenand

et a!. Appendicitis

mimicking

conditions.

A prospective

study.

Lancet

1975; SepPro-

tember 6:421-424. 3. Jess P, Bjerregaard

spective
4. Meyers

B, Brynitz 141:232-234.

5, et al. Acute accuracy

appendicitis. and complications.

trial
MA,

concerning 1981; 1974;

diagnostic

Am J Surg Radiology 5. Rajagopalan

Oliphant

M. Ascending

retrocecal

appendicitis.

110:295-299.

AE, Mason JH, Kennedy M, Pawlikowski J. The enema in the diagnosis of acute appendicitis. Arch Surg 1977; 112:531-533.

value of the barium

RP, Del

6. Sakover

Fava

RL.

Frequency

of visualization

of the

normal
7. Silberman

appendix
VA.

with
Appendectomy

the barium

enema

examination.

AJR
hospital.

1974; 121:312-317.
in a large metropolitan

Retrospective
615-618. 8. Soter
410-415.

analysis

of 1,013

cases.

Am

J Surg
of acute

1981;

142:

CS. The

use of barium

in the diagnosis

appendi-

ceal disease:
9. Soter CS. The

A new

radiological

sign.

Clin

Radiol

1968;

19:
of

contribution

of the radiologist Med Radiogr

to the diagnosis Photogr 1969; 45:2-

acute appendiceal
14.

disease.

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1984

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