Emergency Radiology (2001) 8: 267271

Am Soc Emergency Radiol (ASER) 2001

O R I GI N A L A RT IC LE

Scott S. Tsai Bret F. Coughlin Frederick E. Hampf

Imtiaz A. Munshi Jeannette M. Wolfe

Diagnosing appendicitis with CT and ultrasound using prospective

patient stratification by body mass index

Abstract Purpose: To determine the accuracy of CT

and ultrasonography (US) in diagnosing appendicitis in
adults stratified to either modality on the basis of body
mass index (BMI), a measure of body habitus. Methods:
Seventy-two adults with suspected appendicitis and
demonstrating atypical clinical features were prospectively stratified to either appendiceal CT or US based
on BMI. Patients with BMI < 30 underwent US and
with BMI 30 underwent CT. Outcomes were determined by surgery, the medical record, and clinical follow-up after 3 months. Results: Of the 72 patients enrolled, 30 (24 women and 6 men) underwent CT and 42
(35 women and 7 men) underwent US. The average
BMI was 34  4 among patients who had CT and 24  3
among patients who had US. Of the patients who had
CT scans, 4 had positive scans for appendicitis and all
of these were proven at surgery to have appendicitis.
The remaining 26 patients had negative CT scans for appendicitis. Twenty-two of these were subsequently proven either by surgery or clinical follow-up not to have appendicitis, while 4 were lost to follow-up. This corresponds to a sensitivity, specificity, positive predictive
value, and negative predictive value of 100 %. Twelve

S. S. Tsai B. F. Coughlin ( ) F. E. Hampf

Department of Radiology, Baystate Medical Center,
The Western Campus of Tufts University School of Medicine,
759 Chestnut St., Springfield, MA 01199, USA
Tel.: + 1-4 13-7 94 33 33
Fax: + 1-4 13-7 94 59 88
I. A. Munshi
Department of Surgery, Baystate Medical Center,
The Western Campus of Tufts University School of Medicine,
759 Chestnut St., Springfield, MA 01199, USA
J. M. Wolfe
Department of Emergency Medicine, Baystate Medical Center,
The Western Campus of Tufts University School of Medicine,
759 Chestnut St., Springfield, MA 01199, USA
Present address: S. S. Tsai, Department of Radiology,
Boston University Medical Center, Boston, MA, USA

ultrasound examinations were positive for appendicitis.

Nine of these patients had appendicitis proven at surgery, 1 had a perforated Meckel's diverticulum, and 2
did not have appendicitis after clinical follow-up. Twenty-seven patients had negative ultrasound exams for appendicitis. However, 6 of these had appendicitis proven
at surgery, 17 did not have appendicitis, and 4 were lost
to follow-up. Three patients had ultrasound exams that
were equivocal for appendicitis; of these, 1 had appendicitis and 2 did not. For US, this corresponds to a sensitivity of 60 %, specificity of 85 %, PPV of 75 %, and
NPV of 74 %. Conclusion: This study suggests that CT
is an accurate method of evaluating adults with suspected appendicitis who have BMI 30. Stratifying patients
with BMI < 30 to US did not reproduce the results already reported in the literature.
Keywords Appendicitis Body mass index CT Ultrasonography

Introduction
Appendicitis is a common disease and is the most common cause of the acute abdomen in the United States
[1].
The clinical manifestations of appendicitis may be
atypical, at times making the diagnosis difficult. On the
other hand, prompt diagnosis is desirable to avoid the
complications of perforation, which increases morbidity
and mortality. The postoperative complication rate in
nonperforated appendicitis has been reported to be
8 %, but it increases to 39 % in the presence of perforation [2]. The overall incidence of perforation is reported
to be 1639 %, with the highest rates in the very young
(4057 %) and the elderly (5570 %) [3].
Many studies have demonstrated the utility of computed tomography (CT) and ultrasonography (US) in
diagnosing appendicitis. CT has been shown to be accurate in diagnosing appendicitis, it is readily available, is
operator-independent, and is relatively easy to perform

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[3]. A study directly comparing CT with US showed CT

to be more accurate in diagnosing appendicitis [4].
From that study, the sensitivity and specificity of diagnosing appendicitis were respectively 96 % and 89 %
for CT and 76 % and 91 % for US. In addition, the use
of focused appendiceal CT has been shown to reduce
use of hospital resources [5].
US has certain advantages over CT including lack of
ionizing radiation, multiplanar capability, no requirement for contrast material, and relatively lower cost.
However, the US examination is dependent upon technique and operator skill [3]. One aspect of the examination includes the use of graded compression [6] to displace normal bowel loops from the field of view or to
compress normal bowel between the anterior and posterior abdominal walls. Compression also allows the use
of a high-frequency transducer, which permits higher resolution but a smaller depth of view, and therefore better
anatomic detail in the areas closest to the skin. An abnormal appendix, in contrast, would not be compressible
and would not be easily displaced from the field of view.
Intuitively, one would expect US to be a modality
better suited to evaluating thinner patients, since more
effective graded compression can be achieved. Similarly, CT may be better suited to evaluating heavier patients who have internal fat contrast. This study evaluates the accuracy of diagnosing appendicitis with US or
CT by prospectively stratifying patients to either modality on the basis of a measure of body habitus, the body
mass index (BMI). The object was to determine whether
stratifying patients with lower BMI to US resulted in
improved accuracy of diagnosing appendicitis with US
compared with the results already published in the literature, and, similarly, whether stratifying patients with
higher BMI to CT reproduced or improved the accuracy
of diagnosing appendicitis by CT compared with the results already published in the literature.

Materials and methods

Adults from the emergency department or physician offices with
suspected appendicitis and atypical clinical features requiring imaging by CT or US were eligible for the study. Patients were prospectively stratified on the basis of BMI to CT or US. The BMI is
a common measure of body habitus and is calculated by dividing
the body mass (in kilograms) by the square of the height (in meters). A BMI cutoff of 30 was arbitrarily assigned; if the BMI was
30 or more, then the patient underwent CT, whereas if the BMI
was below 30, the patient underwent US. Patients under 16 years
of age and pregnant patients were excluded from the study. The
study received full institutional review board approval.
Patients stratified to CT underwent helical examinations of the
abdomen and pelvis with 5-mm collimation through the appendix
and 10-mm collimation through the remainder of the abdomen and
pelvis, at least 90 min after oral administration of contrast. Following on-line review of initial images, rectal contrast was administered
at the discretion of the radiology resident or staff radiologist.
Patients stratified to US had examinations performed using linear 7.5- or 10-MHz transducers with graded compression. In addition, all women in this group underwent transvesical and/or transvaginal US examinations of the pelvis. Examinations were initially

Table 1 Characterization of study patients in each modality

Number
Female/male ratio
Age: mean  SD/range (years)
BMI: mean  SD/range

CT

US

30
24/6
41  19/1684
34  4/3044

42
35/7
28  8/1651
24  3/1829

performed by sonographers and each was subsequently repeated

by a radiology resident and/or staff sonologist.
Initial results of the examinations were given to the clinicians
by either attending or resident radiologists. The final reports of
the CT and US examinations were used as the official study results.
The reports were classified into one of five categories: definitely
appendicitis, probably appendicitis, equivocal, probably not appendicitis, and definitely not appendicitis. For the purposes of
analysis, reports of CT or US were considered positive for appendicitis if they were classified as definitely or probably appendicitis
and considered negative if they were classified as definitely not or
probably not appendicitis.
Outcomes were determined on the basis of intraoperative findings, histopathology, chart reviews, and telephone follow-up with
primary care physicians at least 3 months after the initial presentation.

Results
Between February 1999 and September 1999, 172 patients presenting to the emergency department or physician offices underwent either CT or US for appendicitis.
Of these 172 patients, 72 were enrolled in the study and
were stratified on the basis of BMI to either CT or US.
The remaining 100 patients were not included in the
study because they were not stratified to the correct modality or the physicians caring for them were not participants in the study.
Table 1 summarizes the characteristics of the study
patients. Thirty patients had CT and 42 had US. Fiftynine women and 13 men were enrolled in the study.
The average BMI of the patients stratified to CT and
US was 34  4 and 24  3, respectively.
The CT and US findings of acute appendicitis have
been well described and were the criteria used in this
study [3, 4,6]. CT findings of acute appendicitis include
dilated appendix (515 mm), periappendiceal inflammation, and appendicolith (Fig. 1). Similarly, findings of
ruptured appendicitis include pericecal phlegmon or abscess, ectopic gas, and ileocecal thickening. The diagnosis of acute appendicitis by US is made by visualizing
a noncompressible, blind-ended, aperistaltic, tubular
structure with a laminated wall emerging from the cecal
base (Fig. 2).
Table 2 lists the clinical outcomes of the 30 patients
stratified to CT. Four patients had positive CT scans for
appendicitis and all were proven at surgery to have
acute appendicitis. Twenty-six patients had negative
CT scans. In follow-up, 22 of these patients did not
have acute appendicitis and 4 were lost to follow-up after the 3-month period (although none were either ad-

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Table 2 Outcomes of patients stratified to CT (P positive for appendicitis, N negative for appendicitis)

Fig. 1 A 46-year-old man (BMI = 30) with acute perforating appendicitis with appendicolith and periappendiceal phlegmon. Helical CT image shows an inflammatory mass (arrow) medial to the
cecum with a central appendicolith. This was a true positive result

mitted or had surgery at the time of presentation).

There were no equivocal CT reading results. Excluding
the 4 patients lost to follow-up, these results correspond
to a sensitivity of 100 %, specificity of 100 %, positive
predictive value (PPV) of 100 %, and negative predictive value (NPV) of 100 % (see Table 4).
Table 3 summarizes the clinical outcomes of the 42
patients stratified to US. Twelve US examinations were
positive for appendicitis. Of these 12 patients, 9 had
acute appendicitis proven at surgery, 1 had a perforated
Meckel's diverticulum, and 2 did not have surgery (one
subsequently had a diagnosis of gastritis made at endoscopy and the other had nonspecific abdominal pain).
These 3 cases were false positive results. Twenty-seven
US examinations were negative for acute appendicitis.
Of these 27 patients, 6 had acute appendicitis proven at

Diagnosis

Number

CT result

Acute appendicitis
Nonspecific abdominal pain
Pelvic inflammatory disease
Diverticulitis
Diverticulosis
Cholecystitis
Renal stones
Irritable bowel syndrome
Ovarian cysts
Gastroenteritis
Lost to follow-up

4
13
2
1
1
1
1
1
1
1
4

4P
13 N
2N
1N
1N
1N
1N
1N
1N
1N
4N

surgery (false negatives) and 17 did not have appendicitis. Four patients were lost to follow-up after the 3month period but were not admitted and did not have
surgery at the time of presentation. These patients
were excluded from analysis. Three US results were
equivocal for appendicitis and the clinical outcomes
were acute appendicitis, pelvic inflammatory disease,
and nonspecific abdominal pain. For US, the sensitivity
was 60 %, specificity was 85 %, PPV was 75 %, and
NPV was 74 % (Table 4).

Discussion
This study attempts to evaluate the accuracy of CT or
US in diagnosing appendicitis by stratifying patients
with suspected appendicitis requiring imaging to either
modality by a measure of body habitus, the BMI. The
premise behind the study design was that body habitus
may allow appropriate triage to optimize imaging evaluation with heavier patients stratified to CT and thinner
patients to US. The results of this study are evaluated
by comparing the sensitivity, specificity, PPV, and NPV
with values already published in numerous studies.
Previous studies have determined the sensitivity,
specificity, PPV, and NPV of diagnosing appendicitis by
CT using various protocols to be 90100 %, 9199 %,

Fig. 2 a, b A 19-year-old man

(BMI = 21) with acute appendicitis. This was a true positive
result. a Longitudinal US image of a 10-mm-thick, noncompressible appendix (arrow) with
a small amount of periappendiceal fluid (arrowhead).
b Cross-sectional US image of
the same dilated and noncompressible appendix (arrow)

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Table 3 Outcomes of patients stratified to US (P positive for appendicitis, E equivocal for appendicitis, N negative for appendicitis)
Diagnosis

Number

US result

Acute appendicitis
Nonspecific abdominal pain
Pyelonephritis
Ovarian cysts
Gastroenteritis
Pelvic inflammatory disease
Perforated Meckel's diverticulum
Gastritis
Irritable bowel syndrome
Endometriosis
Urolithiasis
Lost to follow-up

16
6
3
3
3
2
1
1
1
1
1
4

9 P, 6 N, 1 E
1 P, 4 N, 1 E
3N
3N
3N
1 N, 1 E
1P
1P
1N
1N
1N
4N

Table 4 Sensitivity, specificity, positive predictive value, and negative predictive value of CT and US in the diagnosis of appendicitis
Sensitivity
Specificity
Positive predictive value
Negative predictive value

CT (%)

US (%)

100
100
100
100

60
85
75
74

9298 %, and 9298 %, respectively [3]. The results of

this study are consistent with these published results.
From previously published studies, the sensitivity,
specificity, PPV, and NPV of diagnosing appendicitis by
US are 7590 %, 86100 %, 9194 %, and 8997 %, respectively [3]. The results of this study are less accurate,
with decreased sensitivity, specificity, PPV, and NPV.
Stratifying patients to US using a BMI below 30 did not
yield results equal to those in the literature.
The 6 false negative results in the patients examined
by US all occurred in young women ranging in age
from 19 to 37 years with BMIs of 19, 20, 21, 23, 26, and
29. This indicates that most false negative results occurred in thinner patients (four patients with BMI 23)

and suggests that even a modest decrease in the arbitrarily assigned BMI threshold of 30 would not have changed the results. In one patient, the appendix was in a
retrocecal location, which is a described pitfall [7]. The
US examination is an operator-dependent technique,
and in this study, operators with varying levels of experience performed the US examinations, including radiology residents and staff sonologists. This may be one
reason for the wider variance in our US results. However, the practice pattern at our institution is not unusual
and most likely reflects that of many radiology departments. It is possible that the number of times rectal contrast was administered for CT was related to level of experience also, but this was not specifically studied.
There were three false positive findings in the US arm
of the study. One patient had a Meckel's diverticulum
that perforated. While this would seem to be a difficult
pitfall to avoid, though somewhat uncommon, a laparotomy would still be the necessary treatment. However, the
remaining two patients had studies that were called positive, yet did not undergo surgery due to lack of clinical
support for appendicitis (Fig. 3). In addition, neither patient had a diagnosis of appendicitis at follow-up at least
3 months after initial presentation. The literature describes several reasons for false positive results, including
misinterpretation of the terminal ileum as the appendix or
mistaking a normal appendix for an inflamed appendix
[3]. Alternatively, spontaneously resolving appendicitis
has been described, although many cases recur within a
year [8]. However, the two remaining patients did not return within a year of initial presentation at our institution
with recurrent acute right lower quadrant pain.
It was evident during patient enrollment that a BMI
cutoff of 30 was probably too high and there were
many patients with BMIs below 30 who probably were
suboptimally suited to US. Performing US only on patients with a BMI below 25, for example, may improve
the performance of US; however, it is noted that of the
6 patients with false negative results, 4 had BMIs equal
to 23 or less. Conceivably, stratifying patients with lower
BMI to CT would adversely affect the performance of

Fig. 3 a, b A 35-year-old man

(BMI = 21) with false positive
US for acute appendicitis.
a Longitudinal US image of a 6mm, blind-ending hollow viscus
in the right lower quadrant (arrow) with a small amount of
surrounding fluid (arrowhead)
interpreted as an abnormal appendix suggestive of appendicitis. b Transverse US image of
the same structure (arrow) medial to the iliac vessels measuring 6 mm in thickness

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CT as these patients would have less inherent fat contrast.

There was a disparity in the gender distribution in
this study, with 59 women enrolled compared with
13 men. This probably reflects the clinical difficulty in
evaluating women of child-bearing age with right lower
quadrant pain, in whom gynecologic disorders can mimic acute appendicitis. These patients are at greater risk
of misdiagnosis, leading to higher rates of excision of
normal appendices [9]. Additionally, women who have
had prior pelvic surgery may have had an incidental appendectomy. This possibility may account for false positive imaging in young women who in fact do not even
have an appendix but have no recollection of its having
been removed. One patient initially stratified to CT
had a cystic left adnexal mass. Subsequent evaluation
by US showed a pyosalpinx, confirmed at surgery, and
therefore a diagnosis of pelvic inflammatory disease
was made. This case illustrates the value of US in evaluating young women with suspected appendicitis [10].
A limitation of this study is the small number of patients enrolled. This may have exaggerated the relatively poor results in the US arm of the study. Similarly, the
effectiveness of the CT arm of the study may have been
overestimated as CT is not perfect in diagnosing appendicitis. With larger numbers of patients stratified to CT,
there would certainly be false negative and false positive
results. The large number of patients evaluated for appendicitis who were not included in the study is related
to the facts that the data were not available to determine
whether the patients were properly stratified or that the
physicians involved in caring for them were not participating in the study. The Institutional Review Board did
not allow telephone contact to assess the weight of the
patients after the initial examinations. There was no systemic bias during the study that might have preferentially directed one habitus type toward CT or US.
The results of the study suggest that helical CT is an
accurate method of evaluating patients with suspected

appendicitis who have a BMI of 30 or more. The sensitivity, specificity, PPV, and NPV were all similar to results already published in the literature. In contrast,
stratification of patients with a BMI below 30 to US did
not match the results already reported by several investigators. In conclusion, the results do not support triaging patients to CT or US based on BMI. Based upon
our results, at our institution we have altered our practice pattern to favor CT for diagnosis of appendicitis.

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