Pediatr Radiol (2011) 41:993999

DOI 10.1007/s00247-011-2018-2

ORIGINAL ARTICLE

Revised ultrasound criteria for appendicitis in children

improve diagnostic accuracy
Adam B. Goldin & Paritosh Khanna & Mahesh Thapa &
Jennifer A. McBroom & Michelle M. Garrison &
Marguerite T. Parisi

Received: 11 October 2010 / Revised: 21 January 2011 / Accepted: 7 February 2011 / Published online: 16 March 2011
# Springer-Verlag 2011

Abstract
Background Use of CT in the evaluation of suspected
appendicitis in children is common. Expanding the use of
US would eliminate the radiation exposure associated with
CT.
Objective We describe new criteria that improve USs
diagnostic accuracy for appendicitis, making it more
comparable to CT in terms of sensitivity and specificity.
Materials and methods We conducted a retrospective
review of 304 consecutive patients undergoing US for the
diagnosis of appendicitis in our institution during 2006. The
sensitivity, specificity and accuracy of the maximal outer
diameter (MOD) at various measurements was calculated
and compared to pathology results. Additional variables

(appendiceal wall thickness, fecalith, hyperemia, fat stranding, free fluid, age and weight) were also evaluated.
Results The highest sensitivity (98.7%) and specificity
(95.4%) were identified when MOD was 7 mm or wall
thickness was >1.7 mm. These values resulted in correctly
classifying 96.6% of cases, with 1 (0.5%) false-negative
and 6 (2.9%) false-positive studies. Incorporating secondary signs of appendicitis, age or weight did not alter
accuracy.
Conclusion These findings identify new US criteria that
compare favorably to CT. In children with suspected
appendicitis, using US as the initial imaging study will
ultimately lead to improved accuracy, lower cost and the
elimination of ionizing radiation exposure.

A. B. Goldin (*)
Department of Pediatric General and Thoracic Surgery,
Seattle Childrens Hospital,
4800 Sand Point Way NE, M/S W-7729, P.O. Box 5371, Seattle,
WA 98105, USA
e-mail: adam.goldin@seattlechildrens.org

Keywords Ultrasound . Appendicitis . Sensitivity .

Specificity

A. B. Goldin
Department of Surgery, University of Washington,
Seattle, WA, USA
P. Khanna : M. Thapa : J. A. McBroom : M. T. Parisi
Department of Radiology, Seattle Childrens Hospital,
University of Washington,
Seattle, WA, USA
M. T. Parisi
Department of Pediatrics, Seattle Childrens Hospital,
University of Washington,
Seattle, WA, USA
M. M. Garrison
Center for Child Health, Behavior, and Development,
Seattle Childrens Hospital,
Seattle, WA, USA

Introduction
While US and CT have nearly identical specificities for the
diagnosis of appendicitis, US is reported to have a lower
sensitivity related to variables such as the skill of the
operator, the skill of the radiologist, and the body habitus
and age of the child. Given its lower risk profile, however,
some have argued that it should be the preferred first-line
imaging modality [1]. The traditionally accepted primary
criterion for the US diagnosis of appendicitis is an
appendiceal maximal outer diameter (MOD) enlargement
beyond 6 mm (most specific sign). Secondary criteria
include peri-appendiceal hypoechoic halo associated with
wall edema, appendiceal wall thickness 3 mm, wall
hyperemia on color Doppler exam, echogenic edematous
mesenteric fat stranding, and the presence of an appendi-

994

colith [212]. Historically, we have used similar criteria for

diagnosing appendicitis at our institution.
A retrospective review of our data, performed as part of
a quality improvement project, suggested that increased US
sensitivity and specificity for the diagnosis of appendicitis
would be achieved if the diagnostic criteria were defined as
a MOD of 7.5 mm alone, or a MOD ranging between 6.0
and 7.4 mm with at least one secondary US sign, such as
appendiceal hyperemia, focal fluid collection, presence of a
fecalith, and/or hyperechoic or inflamed mesenteric fat. In
addition, we hypothesized that wall thickness alone might
be an important variable affecting outcomes.
In this article, we compared the diagnostic accuracy,
sensitivity and specificity of these new criteria to the
sensitivity and specificity of the traditionally accepted US
criteria for the diagnosis of appendicitis. We additionally
evaluated appendiceal wall thickness along with the other
secondary signs discussed above in the hopes of further
refining the diagnostic criteria, and thereby our diagnostic
accuracy, using this modality [2, 13].

Materials and methods

After IRB approval and according to HIPAA guidelines, a
retrospectively collected de-identified dataset was created
from 304 consecutive patients undergoing US for the
diagnosis of appendicitis, including those who were
simultaneously evaluated for ovarian torsion, in our
institution between Jan. 1 and Dec. 31, 2006.
A strict technique for US of appendicitis is utilized at our
institution; the procedure is considered incomplete if the
technique is not met. This technique requires visualizing the
complete appendix, including the tip, with measurements of
MOD and wall thickness at the base, midsection and tip of
the appendix. Secondary signs (fecalith, fluid, hyperemia,
fat stranding) were also recorded as present or absent. All
US were performed on Philips (Bothell, WA) model iU22
US machines with 12-5 megahertz linear high-resolution
transducers (L9-3 or curve 9-3 transducers in obese
patients) by one of four technologists with years of
experience varying between 2 and 32 years. Studies were
read by attending staff radiologists with results recorded
prior to knowledge of outcome by surgery or pathology.
US findings were compared to pathology reports if the
patient ultimately went on to surgery. Criteria evaluated
included appendiceal diameter and wall thickness, as well
as the presence of a fecalith, peri-appendiceal fat stranding,
peri-appendiceal hyperemia, or excess fluid within the
abdomen or pelvis. Sensitivity, specificity and the percentage of correctly classified cases by US were identified by
each of the criteria individually at varying measurements,
with and without adjusting for patient age and weight, as

Pediatr Radiol (2011) 41:993999

well as in combination. Clinical factors were intentionally not

used in the model in order to evaluate the predictive value of
US alone. For those patients who did not have surgery, followup based on chart review over the 12-month period following
the US was used to determine clinical outcome.

Results
During calendar year 2006, we identified 304 patients who
underwent US to evaluate for appendicitis. Of these,
dedicated right-lower quadrant ultrasounds were performed
in 193, and pelvic ultrasounds for appendicitis and ovarian
torsion were performed in 111. The appendix was visualized in 68% of all cases. Of these, 204 patients (mean age
10.4 years, SD 4.2; 62% female) had complete studies,
including measurements of the appendix diameter and wall
thickness at its origin, midpoint and tip. Eighty-two patients
(42%) had surgery. By pathological diagnosis, 24% (20/82)
of the patients had perforated, and 6% (5/82) were
histologically normal. Only one of the patients with normal
US findings re-presented with appendicitis. We used these
data to evaluate levels of sensitivity, specificity and
diagnostic accuracy of US at various measurements when
the appendix is identified.
The findings on US varied by pathology group in
measurable indices. Median diameters for normal, acute
and perforated appendices were 5.0 mm, 9.0 mm and
9.8 mm (Fig. 1). Median wall thicknesses were 0.9 mm,
2.2 mm and 3.5 mm, respectively (Fig. 2). Results are
reported as median and inter-quartile ranges given the
skewed distribution (Table 1). Figure 3 illustrates the
typical US appearances of patients with a normal, acutely
inflamed and perforated appendix.
Independent of clinical variables, in this cohort had we
used the historically accepted criteria of MOD >6 mm alone,
we would have correctly classified only 84% of appendicitis
cases, resulting in 7 cases of missed appendicitis and 26
unnecessary surgeries. Using the criteria identified previously
at our institution (appendiceal diameter >7.5, or 6.07.5 with
at least one secondary finding), we would have improved
overall results by increasing sensitivity to 89%, specificity to
95% and correctly classifying 92% of cases. This would have
decreased the number of unnecessary surgeries to 7 cases but
slightly increased the number of cases of appendicitis missed
to 9 (Table 2). Predictably, increasing the required diameter
would have resulted in a progressive decrease in sensitivity
and increase in specificity as shown. Similarly, of the 204
cases in which wall thickness was measured, we identified a
similar predictable pattern with the extremes for sensitivity
and specificity at 1.0 mm and 1.7 mm, respectively. Taken in
isolation, secondary signs of appendicitis demonstrated poor
sensitivity.

Pediatr Radiol (2011) 41:993999

995

Fig. 1 Distribution of measurements of appendix diameter (in

millimeters) of patients with and
without appendicitis

Combining criteria significantly improved our findings.

Using diagnostic criteria of appendiceal diameter 7.0 mm
or a wall thickness of >1.7 mm, sensitivity would have
improved to 99%, and specificity to 95% resulting in 97%
of the cases being classified correctly with only 1 case of
missed appendicitis and 6 unnecessary operations. Neither
adjusting for age nor weight, nor adding findings of any of
the secondary signs improved the diagnostic characteristics
of our models.

Discussion
Along with malrotation with midgut volvulus and intussusception, appendicitis remains one of the true gastrointestinal
emergencies in the pediatric population. With approximately 70,000 cases diagnosed annually in the Western world,
appendicitis is the most common cause of acute abdominal
pain requiring urgent surgery in children [14]. Appendicitis
is suspected in approximately 5% of all children seen in
emergency rooms and 1% of these patients is found to have
appendicitis [15].
Since the 1980s, numerous articles have described and
compared the respective sensitivities and specificities of US
and CT in correctly diagnosing appendicitis [1623]. Of
these imaging modalities, CT has become the favored
diagnostic modality in the United States resulting in an
Fig. 2 Distribution of measurements of wall thickness (in
millimeters) of patients with and
without appendicitis

increase in its use for the diagnosis of appendicitis in both

adults and children. The preference for CT has been
attributed to its technical reproducibility as well as its high
sensitivity and specificity for this diagnosis. Additionally,
its use as a diagnostic adjunct has been described as
resulting in significant cost advantages [2428]. A 2006
study reported that 23 million CT scans were performed
annually, with a seven-fold increase over the previous
10 years [24]. Martin et al. [29] have suggested that CT has
replaced US as a diagnostic tool in this condition.
According to their results, the use of CT for the diagnosis
of appendicitis increased from 17% to 51% with a
concurrent decrease in US use from 20% to 7% at their
institution between 1998 and 2001.
Associated with the increased use of CT, many clinicians
have begun to grow concerned about the radiation exposure
to their patients associated with this test. This concern
stems from reports of the development of radiation-induced
malignancies resulting from diagnostic imaging procedures.
Brennan et al. [14] project that between 150 and 250 deaths
per year are caused by radiation-induced malignancies
resulting from the performance of diagnostic CT imaging
of appendicitis alone. Radiologists have long been aware of
the need to reduce radiation exposure to as low as
reasonably achievable. Practicing these principles is
particularly important in the vulnerable pediatric population. These patients are at greater risk for the development

996

Pediatr Radiol (2011) 41:993999

Table 1 Median and inter-quartile ranges of diameter and wall

thickness (in millimeters)

of radiation-induced malignancies as they are more radiosensitive than adults and have more remaining years of life
for such a cancer to develop [30]. These increased risk
factors have led to clear recommendations by the National
Cancer Institute as well as the American Pediatric Surgical
Association Education Committee to minimize use of CT,
to minimize the dosage of radiation when CT is essential
and to educate physicians regarding these risks given the
generally poor understanding of these risks by most
physicians [31, 32]. Given these risks, US has been used
as the diagnostic imaging modality of choice at our
institution for evaluating appendicitis over the past decade.
The ability to image rapidly without the use of IV or oral
contrast, sedation or ionizing radiation makes US, in our
opinion, the preferred diagnostic modality for children with
suspected acute appendicitis.

The diagnosis of appendicitis remains difficult despite

advances in radiology. In 2001, Flum et al. [33] performed
a population-based study identifying that among more than
63,000 patients who underwent non-incidental appendectomies during a 12-year time interval, 15.5% had negative
appendectomies. They identified that the rate of negative
appendectomies did not change despite the increased
utilization of CT, US or laparoscopy. Another recent study
from Finland described a randomized controlled trial for
children presenting to an emergency room with abdominal
pain who were evaluated for appendicitis [34]. Patients
were randomized to use of a clinical scoring tool versus a
standard approach. This study concentrated on only clinical
characteristics, without the use of adjunctive radiological
imaging. While their results showed that the use of the tool
significantly improved their negative appendectomy rate
(29% v. 17%, p=0.05), this study demonstrates that even
the most rigorous and evidence-based clinical approach
used in isolation of imaging leads to a high negative
appendectomy rate. The high cost of hospitalizations, either
for clinical observation when diagnosis is uncertain or for a
complication related to a delay in diagnosis such as
appendiceal perforation, could be decreased through early,
accurate diagnosis via a combination of evidence-based
clinical and radiological work-up leading to more prompt
surgical intervention.
During the calendar year 2006 during which the data for
this study were collected, our institution experienced
negative appendectomy rates between 2.7% and 4.7%,
depending on the quarter reviewed. During this same period
of time, of the patients who underwent imaging, 75% had
US, and the vast majority of patients who had CT scans had

Fig. 3 Longitudinal right lower-quadrant US appearances of pediatric

patients with a normal appendix (a), acute appendicitis (b) and
perforated appendicitis (c). a Right lower-quadrant US in a 9-year-old
girl with right lower-quadrant pain reveals a normal-sized, compressible, thin-walled appendix. b In this 8.5-year-old girl, US reveals an
enlarged, non-compressible appendix with MOD of 8.7 mm and

abnormal appendiceal wall thickness of 1.9 mm. There is adjacent

echogenic fat. Findings are compatible with acute non-perforated
appendicitis, confirmed pathologically. c A 15-year-old girl with right
lower-quadrant pain. US demonstrates a markedly enlarged, noncompressible perforated appendix measuring 1.17 cm with thickened
wall and complex peri-appendiceal fluid collection adjacent to the tip

Total
Diameter (mm)
median
5.7
IQR
4.38.0
range
1.320.0
Wall Thickness (mm)
median
1.2
IQR
0.822.1
range
0.149.0

Normal

Appendix Status
Appendicitis

Perforated

5.0
4.05.7
2.011.0

9.0
7.810.0
1.320.0

9.8
7.514.0
1.320.0

0.9
0.721.1
0.141.6

2.2
1.82.7
1.06.6

3.5
2.35.3
1.89.0

IQR inter-quartile range

Pediatr Radiol (2011) 41:993999

997

Table 2 Sensitivity, specificity and classification of cases by ultrasound findings

Sensitivity

Specificity

Correctly classified

7
26
11
6
4

88.5%
91.0%
91.0%
89.7%
76.9%

94.6%
79.8%
91.5%
95.4%
96.9%

92.2%
84.1%
91.3%
93.2%
89.4%

57

100.0%

55.1%

72.1%

92.2%

100.0%

97.1%

52
34
62
23

5
2
1
0

33.3%
56.4%
20.5%
70.5%

96.1%
98.5%
99.2%
100.0%

72.3%
82.6%
69.6%
88.9%

207
10
Diameter 7.0
207
10
Wall thickness 1
204
1
Wall thickness >1.7
204
9
Weight-adjusted measures
Diameter standarda
200
11
Diameter 7.0
200
9
Wall thickness 1
197
2
Wall thickness >1.7
197
9
Diameter 7.0 or wall thickness >1.7
Combined criteria
207
1
Using age-adjusted
207
2

8
8
53
0

87.2%
87.2%
98.7%
88.3%

93.8%
93.8%
58.3%
100.0%

91.3%
91.3%
73.5%
95.6%

14
14
68
6

85.7%
88.3%
97.4%
88.2%

88.6%
88.6%
43.8%
95.0%

87.5%
88.5%
64.5%
92.4%

6
8

98.7%
97.4%

95.4%
93.8%

96.6%
95.2%

16
14

96.1%
98.7%

87.0%
89.2%

90.5%
92.8%

Diameter (mm)
SCH criteriaa
6.0b
6.5
7.0
7.5
Wall thickness (mm)
1.0
>1.7
Secondary signs
Fecalith
Hyperemia
Excess fluid
Fat stranding
Age-adjusted measures
Diameter standarda

Using weight-adjusted
Using any secondary

Appy cases missed

Unnecessary surgeries

207
207
207
207
207

9
7
7
8
18

204
204
207
207
207
207

200
207

3
1

Diameter 7.5 or Diameter 6.57.4 plus at least one secondary sign

Traditionally accepted criteria for appendicitis

those performed at outside institutions prior to referral to

our hospital.
At our institution, we have a large group of patients who
underwent primary US for the objective evaluation of
appendicitis upon which to base these new criteria as well
as a standardized approach in terms of the technique.
During the past decade, we have evaluated the majority of
our patients by US and periodic reviews of our data have
affected our institutional criteria used to diagnose appendicitis. The traditionally accepted US criteria for diagnosing
appendicitis is a MOD of 6 mm. A preliminary review of
our own data in 2006 suggested redefining the US criteria
for appendicitis to include a MOD 7.5 mm or a diameter
of 6.07.4 mm with at least one secondary sign would
increase sensitivity and specificity while decreasing negative laparotomy rates. This current study included a more

rigorous statistical analysis, and added data including

wall thickness that further increased the accuracy of our
institutional criteria, leading to the results described
above.
Our data demonstrate that when the appendix is
identified and the appropriate criteria are used, US can
compare favorably to CT without incurring the radiation
risk incumbent with the latter examination. Prior studies
that have evaluated US findings do not clearly identify a
protocol technique in terms of steps for the study. Our
intention is to validate these findings within our own
institution, as well as validate the exportability of the
criteria and technique to other institutions.
Multiple important concepts arise from these data. First,
we must identify the best use of health care dollars while
optimizing patient care. While there were increased costs

998

associated with imaging versus no imaging in the Finnish

study, there are other studies to support that CT scans save
hospital resources by decreasing inpatient hospital days
through decreasing both the frequency of negative appendectomies and the number of patients admitted for
observation [28]. If standardized technique and criteria for
US can compare favorably with CT, it seems safe to
conclude that routine use of US would result in similar
resource conservation. Second, we must balance the costbenefit risk ratio between negative appendectomy, the risk
of development of radiation-induced malignancies and a
delay in diagnosis. Arguably, US compares favorably to CT
and inpatient observation in terms of cost. Similarly, US
compares favorably to anesthesia, CT and inpatient observation in terms of patient-level risk of negative appendectomy, radiation-induced malignancies and delay in
diagnosis leading to perforation. We therefore recommend
using CT in patients in whom US is non-diagnostic as
suggested by Pena and others [26, 35, 36].
The limitations of this study include the retrospective
nature of the data as well as the isolation of the data from
individual patient clinical variables. While the accuracy of
imaging findings strongly influences the decision to
perform a surgical intervention, clinical data remain critical
to the accurate diagnosis of appendicitis. Additionally, only
data from a single institution were evaluated. Though it is
possible that patients who were provided false-negative
results re-presented to outside institutions for appendectomy, we believe it is more likely that patients would return
to our institution given its status as the pediatric referral
center for our region.
Future studies will be designed to further validate our
newly defined US criteria. We will then identify a
prospective cohort in which to evaluate the added impact
of clinical and radiological variables in optimizing the
diagnosis of appendicitis.

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