Plain film from www.learningradiology.

com

CT, US, MRI all PACS BIDMC

Diagnosing Appendicitis
in the Emergency Department

with Imaging
Heather Burns Gunn, HMS III
Gillian Lieberman, MD
Radiology Core
BIDMC
November 2007

Lets meet our patient in the emergency room

Patient CH: History

24 yo woman
presents to ED with 2 days of abdominal pain
initially diffuse, crampy pain in epigastric area
pain migrated to RLQ 12 hours ago and became
sharper
several episodes of N/V in last 12 hours
denies diarrhea, constipation, melena, BRBPR
endorses reduced appetite

Patient CH: Physical Exam & Labs

Physical exam normal except abdominal
exam
Soft, non-distended, tender RLQ
No rebound tenderness
+ Rovsings sign (pain in RLQ during
palpation of LLQ)

Labs of note:
WBC: 16.6 with 83% Neutrophils
Creatinine: 0.9

DDx of RLQ pain

GI

Appendicitis
Crohns
Right sided diverticulitis
Mesenteric adenitis
Epiploic appendagitis
Bowel ischemia
Right colonic neoplasia
Infectious ileocolitis
Mucocele of the appendix
Typhilitis
Sigmoid diverticulitis
Intussusception
Pseudomembraneous or
cytomegalovirus colitis
Perforated peptic ulcer
Perforated cholecystitis
Pancreatitis

Renal
Acute pyelonephritis
Renal and urinary tract obstruction

Gynecological

Pelvic inflammatory disease

Hemorrhagic ovarian cyst
Ovarian vein thrombosis
Ovarian dermoid
Necrotic uterine leiomyoma
Ovarian torsion
Endometriosis
Ruptured ectopic pregnancy

Yu J et al. Helical CT evaluation of acute right lower

quadrant pain. AJR 2005.

DDx of RLQ pain

GI

Appendicitis
Crohns
Right sided diverticulitis
Mesenteric adenitis
Epiploic appendagitis
Bowel ischemia
Right colonic neoplasia
Infectious ileocolitis
Mucocele of the appendix
Typhilitis
Sigmoid diverticulitis
Intussusception
Pseudomembraneous or
cytomegalovirus colitis
Perforated peptic ulcer
Perforated cholecystitis
Pancreatitis

Renal
Acute pyelonephritis
Renal and urinary tract obstruction

Gynecological

Pelvic inflammatory disease

Hemorrhagic ovarian cyst
Ovarian vein thrombosis
Ovarian dermoid
Necrotic uterine leiomyoma
Ovarian torsion
Endometriosis
Ruptured ectopic pregnancy

Yu J et al. Helical CT evaluation of acute right lower

quadrant pain. AJR 2005.

 COMMON
Appendicitis is the most
common cause of acute
abdomen.1
EXPENSIVE:
In 2004, 300,000 cases
in US alone, total
healthcare cost of 5.8
billion.2
DANGEROUS:
Before universal
acceptance of
appendectomy as
standard of care,
mortality for appendicitis
was more than 50%.3
1Davies G et al. The burden of appendicitis related
hospitalizations in the United States in 1997. Surg Infect
2004.
2 Otero

H et al. Imaging utilization in the management of

appendicitis and its impacton hospital charges. Emerg
Radiol 2007.
http://history1900s.about.com/library/photos/blywwiip251.htm

Weyant MJ et al. Is imaging necessary for the diagnosis

of acute appendicitis? Adv Surg 2003.

Before 1997, because of appendicitis

high mortality rate, surgeons agreed
that a 20% negative appendectomy
rate was acceptable.
That is no longer the case . . .

. . . because of advances in imaging in

emergency departments.

Colson M et al. High negative appendectomy rates are no longer acceptable. Am J Surg 1997.
Rhea J et al. The status of appendiceal CT in an urban medical center 5 years after its introduction: experience with 753 patients. AJR 2005.

Plain film from www.learningradiology.com

. . . because of advances in imaging in

emergency departments.

Colson M et al. High negative appendectomy rates are no longer acceptable. Am J Surg 1997.
Rhea J et al. The status of appendiceal CT in an urban medical center 5 years after its introduction: experience with 753 patients. AJR 2005.

PACS BIDMC

Before we consider our menu of imaging tests

to narrow our diagnosis . . . .
What additional lab test should we order for
our patient CH?
A pregnancy test!
+ A positive pregnancy test
will change our imaging
options.
- A negative pregnancy test
will remove ectopic pregnancy
from our differential.

ACR appropriateness criteria for RLQ Pain

fever, leukocytosis, and classic presentation for appendicitis in adults
Rating
Radiologic Procedure

(1 = least appropriate,
9 = most appropriate)

Relative Radiation Level

CT abdomen and pelvis with contrast

High

US abdomen RLQ graded compression

None

CT abdomen and pelvis without contrast

High

X-ray chest

Min

US pelvis transabdominal and transvaginal

None

X-ray abdomen supine and upright

Low

X-ray colon barium enema double-contrast

Med

X-ray colon barium enema single-contrast

Med

MRI abdomen and pelvis

None

X-ray small bowel series with barium

Low

NUC gallium scan abdomen

High

NUC WBC scan abdomen pelvis

Med

X-ray small bowel enteroclysis

Med
www.acr.org

ACR appropriateness criteria for RLQ Pain

fever, leukocytosis, pregnant woman
Rating
Radiologic Procedure

(1 = least appropriate,
9 = most appropriate)

Relative Radiation Level

US abdomen RLQ graded compression

None

MRI abdomen and pelvis

None

US pelvis transabdominal and transvaginal

None

CT abdomen and pelvis with contrast X-ray chest

High

CT abdomen and pelvis without contrast

High

X-ray chest

Min

X-ray abdomen supine and upright

Low

X-ray colon barium enema double-contrast

Med

X-ray small bowel enteroclysis

Med

X-ray colon barium enema single-contrast

Med

NUC WBC scan abdomen pelvis

Med

X-ray small bowel series with barium

Low

NUC gallium scan abdomen

High
www.acr.org

Comparison of Appropriate Tests

Not pregnant
1. CT C+ abd/pelv
2. US abd RLQ graded
compression
3. CT C- abd/pelv
4. X-ray chest
5. US pelvis transabd &
transvag

Pregnant
1. US abd RLQ graded
compression
2. MRI abd and pelvis
3. US pelvis transabd &
transvag
4. CT C+ abd/pelv
5. CT C- abd/pelv

Pregnant Woman and Appendicitis

COMMON:
Acute appendicitis is most
common surgical emergency
during pregnancy.1
TRICKY:
Clinical diagnosis can be difficult2
Appendix may have moved due to
gravid uterus pain may not
localize to RLQ
Leukocytosis can be physiological
during pregnancy
Nausea and vomiting common in
both pregnancy and appendicitis

DANGEROUS:
In appendicitis, fetal loss is more
than 30% with ruptured appendix
and 2% with unruptured
appendix.3

MR Abdomen Sagittal: PACS BIDMC

Cobben L et al. MRI for clinically suspected appendicitis during pregnancy. AJR 2004.
Birchard K et al. MRI of acute abdominal and pelvic pain in pregnant patients. AJR 2005.

2,3

Consideration in imaging the appendix

(besides whether or not patient is
pregnant or a child):
Where is the appendix?

Variability in the location of the appendix

Anterior view

Posterior view
Tamburrini S et al. CT appearance of the normal appendix
in adults. Eur Radiol 2005.

Variability in the location of the appendix

Most
common
locations

26%
18%
Anterior view

Posterior view
Tamburrini S et al. CT appearance of the normal appendix
in adults. Eur Radiol 2005.

Exploring the Menu of Tests

Plain films
Ultrasound
MRI
CT

Exploring the Menu of Tests

Plain films
Ultrasound
MRI
CT

Abdominal
Plain Films

Companion Patient 1: Abdominal Plain Film of Appendicitis

Abdominal plain films are

neither sensitive nor specific
for acute appendicitis.1
X-ray of chest often ordered
in acute abdomen
to check for free air under
diaphragm
because chest disease can
simulate abdominal
conditions.2

Some radiographic signs of

acute appendicitis:3

Appendicolith
Scoliosis
RLQ fluid levels
Ileus
Bowel wall edema

Abdominal plain film of appendicoliths from www.learningradiology.com

1Rao P et al. Plain abdominal radiography in clinically suspected appendicitis: diagnostic yield, resource use, and comparison with CT. American Journal
of Emergency Medicine 1999.
2Greene C. Indications for plain abdominal radiography in the emergency department. Annals of Emergency Medicine 1986.
3Olutola PS. Plain film radiographic diagnosis of acute appendicitis: an evaluation of the signs. Can Assoc Radiol J. 1988.

Abdominal
Plain Films
of Appendicitis

Upright abdominal plain film

Altering position of this pediatric

patient revealed two different
radiographic signs of appendicitis.

Companion
patient 2

Both images from http://www.hawaii.edu/medicine/pediatrics/pemxray/v4c10.html

Supine abdominal plain film

Abdominal
Plain Films
of Appendicitis

Altering position of this pediatric

patient revealed two different
radiographic signs of appendicitis.

Scoliosis due
to RLQ
splinting

Appendicolith

Upright abdominal plain film

Companion
patient 2

Both images from http://www.hawaii.edu/medicine/pediatrics/pemxray/v4c10.html

Supine abdominal plain film

Abdominal
Plain Films
of Appendicitis

Altering position of this pediatric

patient revealed two different
radiographic signs of appendicitis.

Scoliosis due
to RLQ
splinting

Appendicolith

Upright abdominal plain film

Companion
patient 2

Both images from http://www.hawaii.edu/medicine/pediatrics/pemxray/v4c10.html

Supine abdominal plain film

Exploring the Menu of Tests

Plain films
Ultrasound
MRI
CT

Ultrasound

No radiation exposure good for pregnant women and children

Patient need not be cooperative good for children
Sensitivity for diagnosing appendicitis = 0.861
Specificity for diagnosing appendicitis = 0.812
Findings on ultrasound:3
Appendiceal Findings

Diameter of appendix 6 mm MOST SENSITIVE AND SPECIFIC FINDING

Lack of compressibility of appendix 2ND MOST SENSITIVE AND SPECIFIC
Intraluminal fluid
Doppler flow in wall

Periappendiceal Findings

1,2 Terasawa

Inflammatory fat changes

Cecal wall thickening
Periileal lymph nodes
Peritoneal fluid

T et al. Systematic review: computed tomography and ultrasonography to detect acute appendicitis in adults and
adolescents. Ann Inten Med 2004.
3 Kessler N et al. Appendicitis: evaluation of sensitivity, specificity, and predictive values of US, Doppler US, and laboratory
findings. Radiology 2004.

Ultrasound of Appendicitis
Note how round
appendix is despite
compression with
ultrasound
transducer
non-compressible
appendix

Appendix diameter
is larger than 6 mm

Companion Patient 3
PACS BIDMC

Ultrasounds of Appendicitis

Companion Patient 4

Intraluminal fluid

Companion Patient 5

Doppler flow in wall

PACS BIDMC

Why would you ever use anything else

to diagnose appendicitis in pregnant women?
The Drawbacks to US:
Graded compression US is sometimes not
feasible because of enlarged uterus1
Negative predictive value of nonvisualized
appendix is .902

1Pedrosa

I et al. MR imaging evaluation of acute appendicitis in pregnancy. Radiology 2006.

N et al. Appendicitis: evaluation of sensitivity, specificity, and predictive values of US, Doppler US, and laboratory
findings. Radiology 2004.

2Kessler

Exploring the Menu of Tests

Plain films
Ultrasound
MRI
CT

MRI

No radiation exposure good for pregnant women

Sensitivity for diagnosing appendicitis = 1.001
Specificity for diagnosing appendicitis = 0.942
Findings on MRI:3
Diameter of appendix 6 mm
Thickening of appendiceal wall with high intensity on T2
weighted images
Dilated lumen filled with high intensity material on T2 weighted
images
Increased intensity of periappendiceal tissue on T2 weighted
images

1,2 Pedrosa
3

I et al. MR Imaging Evaluation of Acute Appendicitis in Pregnancy. Radiology 2006.

Nitta N et al. MR imaging of the normal appendix and acute appendicitis. Journal of Magnetic Resonance Imaging 2005.

MRI of appendicitis
in a pregnant woman
Appendix
diameter 6 mm
Dilated lumen
filled with high
intensity material

Companion Patient 6: MR T2
SSFSE (Single Shot Fast Spin Echo) Coronal
PACS BIDMC

MRI of appendicitis
in a pregnant woman
Appendix is dilated
Appendiceal walls are
thickened and high
intensity
Increased intensity of
periappendiceal tissue
indicating
inflammatory changes

Companion Patient 7: MR T2
SSFSE (Single Shot Fast Spin Echo) Coronal
PACS BIDMC

Exploring the Menu of Tests

Plain films
Ultrasound } for children and pregnant women
} for pregnant women
MRI
CT test of choice for non-pregnant adults

CT

Test of choice for non-pregnant adults and adolescents

CT is credited with drop in negative appendectomy rate from 20% to 3%1
Since CT provides view of entire abdomen and pelvis (unlike US), other
diagnoses may be made.
Sensitivity for diagnosing appendicitis = 0.992
Specificity for diagnosing appendicitis = 0.953
Findings on CT:4
Diameter of appendix 6 mm
Periappendiceal inflammatory changes

Fat stranding
Fluid collections
Phlegmon
Abscess formation

Wall thickness 3 mm
Extraluminal air
Adjacent adenopathy
Adjacent bowel wall thickening
Focal cecal wall thickening
1,2,3Rhea

J et al. The status of appendiceal CT in an urban medical center 5 years after its introduction: experience with 753 patients.
AJR 2005.
4Moteki T et al. New CT criterion for acute appendicitis: maximum depth of intraluminal appendiceal fluid. AJR 2007.

CT Coronal Reconstruction of Appendicitis:

Companion Patient 8

Focal cecal wall

thickening.
Extensive fat
stranding.
Dilated appendix.

PACS BIDMC

Axial CT of appendicitis: Companion Patient 9

PACS BIDMC

Wheres the appendix?

Axial CT of appendicitis: Companion Patient 9

PACS BIDMC

Dilated appendix, not filling with contrast

Axial CT of Appendicitis:
Companion Patient 10

Dilated appendix, not filling with contrast.

PACS BIDMC

Axial CT of Appendicitis:
Companion Patient 11

Appendix
not filling
with contrast

PACS BIDMC

Axial CT of Appendicitis:
Companion Patient 12

Fat
stranding

PACS BIDMC

Dilated appendix

Axial CT of Appendicitis:
Companion Patient 13
Where is this
mans inflamed
appendix?
Look for the fat
stranding.
PACS BIDMC

Axial CT of Appendicitis:
Companion Patient 13
An aside: do you
notice any other
abnormality in this
mans pelvis?

PACS BIDMC

CT Coronal
Reconstruction of
Appendicitis:
Companion Patient 13

A kidney
transplanted
into the
pelvis.

PACS BIDMC

Coronal
Reconstruction CT:
Companion Patient
14

Thats the appendix, but

is this appendicitis?
Wheres the
appendix in this
coronal
reconstruction?

PACS BIDMC

Appendix is filled
with contrast.
Appendix diameter
= 5.0 mm (less than
6.0 mm)
No periappendiceal
inflammatory
changes to be seen!
Normal appendix

PACS BIDMC

Coronal Reconstruction CT: Companion Patient 14

Back to our patient CH . . .

she wasnt pregnant
her renal function was fine (creatinine was 0.9)

. . . so she was given a CT scan

with contrast.

Patient CH: Axial CT

PACS BIDMC

Patient CH: Axial CT

PACS BIDMC

Patient CH: Axial CT

PACS BIDMC

Patient CH: Axial CT

PACS BIDMC

Patient CH: Axial CT

PACS BIDMC

Patient CH: Axial CT

PACS BIDMC

Patient CH: Axial CT

PACS BIDMC

Patient CH: Axial CT

PACS BIDMC

Patient CH: Axial CT

Lets find the appendix.

PACS BIDMC

Patient CH:
Axial CTs

An elongated and
dilated appendix.

Considerable fat
stranding (as
well as air in
appendiceal
lumen)
PACS BIDMC

Patient CH:
Axial CTs

Diagnosis:
acute
appendicitis!

An elongated and
dilated appendix.

Considerable fat
stranding (as
well as air in
appendiceal
lumen)

PACS BIDMC

We have our diagnosis but

lets look at the coronal
reconstructions as well.

Patient CHs CT: Coronal Reconstruction

PACS BIDMC

Patient CHs CT: Coronal Reconstruction

PACS BIDMC

Patient CHs CT: Coronal Reconstruction

PACS BIDMC

Patient CHs CT: Coronal Reconstruction

PACS BIDMC

Patient CHs CT: Coronal Reconstruction

PACS BIDMC

Patient CHs CT: Coronal Reconstruction

PACS BIDMC

Patient CHs CT: Coronal Reconstruction

Some individual
coronal slices.
PACS BIDMC

Patient CHs CT: Coronal Reconstruction

PACS BIDMC

PACS BIDMC

The appendix pops in

and out of plane in this
slice.

Dilated appendix
Air bubble
Plenty of fat stranding

Patient CHs CT: Coronal Reconstruction

Air in
appendix
lumen does
not rule out
appendicitis.
Air is present
in lumen of
appendix in
over 15% of
cases of
appendicitis
imaged on
CT.1

PACS BIDMC

1Rao

P et al. Appendiceal and peri-appendiceal air at CT: prevalence,

appearance, and clinical significance. Clin Radiol 1997.

 The patient CH was taken to OR

Laparoscopic appendectomy
Pathological findings: erythematous
appendix, measuring 9.5 cm in length,
average of 1.2 cm in diameter. Dilated
lumen of up to 0.8 cm containing some
fecal material.
After removing the appendix and
irrigating the abdomen, the surgeons
turned the case over to a different team
can you guess which kind?

Take another look at the CT

coronal reconstruction . . . .

CHs CT: Coronal Reconstruction

Retrocecal appendix

Right ovarian dermoid cyst

PACS BIDMC

 Ob/Gyn service felt it was not prudent to

remove dermoid at this time.
Patient was discharged from hospital two
days later with plans for Ob/Gyn follow
up.

Many thanks to . . .

Gillian Lieberman, MD
Melissa Gerlach, MD
Bettina Siewert, MD
Anne Catherine Kim, MD
Rich Rana, MD
Andrew Hines-Peralta, MD
Maria Levantakis

Bibliography
American College of Radiology (2007) ACR appropriateness criteria. Acute right lower quadrant pain. Available at www.acr.org. Last accessed November
2007.
Birchard KR, Brown MA, Hyslop WB, Firat Z, Semelka RC. MRI of acute abdominal and pelvic pain in pregnant patients. American Journal of Roentgenology
2005; 184: 452-458.
Colson M, Skinner KA, Dunnington G. High negative appendectomy rates are no longer acceptable. American Journal of Surgery 1997; 174: 723-726.
Cobben LP, Groot I, Haans L, Blickman JG, Puylaert J. MRI for clinically suspected appendicitis during pregnancy. American Journal of Roentgenology 2004;
183: 671-675.
Davies GM, Dasback EJ, Teutsch S. The burden of appendicitis related hospitalizations in the United States in 1997. Surgical Infections 2004; 5: 160-165.
Greene C. Indications for plain abdominal radiography in the emergency department. Annals of Emergency Medicine 1986; 15: 257-260.
Kessler N, Cyteval C, Gallix B, Lesnik A, Blayac PM, Pujol J, Bruel JM, Taourel P. Appendicitis: evaluation of sensitivity, specificity, and predictive values of
US, Doppler US, and laboratory findings. Radiology 2004; 230: 472-478.
Moteki T, Horikoshi H. New CT criterion for acute appendicitis: maximum depth of intraluminal appendiceal fluid. American Journal of Roentgenology 2007;
188: 1313-1319.
Nitta N, Takahashi M, Furukawa A, Murata K, Mori M, Fukushima M. MR imaging of the normal appendix and acute appendicitis. Journal of Magnetic
Resonance Imaging 2005; 21: 156-165.
Olutola PS. Plain Film radiographic diagnosis of acute appendicitis: an evaluation of the signs. Canadian Association of Radioliogists Journal 1988; 39: 254-6.
Otero HJ, Ondategui-Parra S, Erturk SM, Ochoa RE, Gonzalez-Beicos A, Ros PR. Imaging utilization in the management of appendicitis and its impact on
hospital charges. Emergency Radiology 2007.
Pedrosa I, Levine D, Eyvazzadeh AD, Siewert B, Ngo L, Rofsky NM. MR Imaging Evaluation of Acute Appendicitis in Pregnancy. Radiology 2006; 238: 891899.
Rao PM, Rhea JT, Novellline RA. Appendiceal and peri-appendiceal air at CT: prevalence, appearance, and clinical significance. Clinical Radiology 1997; 52:
750-754.
Rao PM, Rhea JT, Rao JA, Conn AKT. Plain abdominal radiography in clinically suspected appendicitis: diagnostic yield, resource use, and comparison with
CT. American Journal of Emergency Medicine 1999; 17: 325-328.
Rhea JT, Halpern EF, Ptak T, Lawrason JN, Sacknoff R, Novelline RA. The status of appendiceal CT in an urban medical center 5 years after its introduction:
experience with 753 patients. American Journal of Roentgenology 2005; 184: 1802-1808.
Tamburrini S, Brunetti A, Brown M, Sirlin CB, Casola G. CT appearance of the normal appendix in adults. European Radiology 2005; 15: 2096-2103.
Terasawa T, Blackmore CC, Bent S, Kohlwes RJ. Systematic review: computed tomography and ultrasonography to detect acute appenditicitis in adults and
adolescents. Annals of Internal Medicine 2004; 141: 537-546.
Weyant MF, Eachempati Sr, Maluccio MA, Barie PS. Is imaging necessary for the diagnosis of acute appendicitis? Advances in Surgery 2003; 37: 327-345.
Yu J, Fulcher AS, Turner MA, Halvorsen RA. Helical CT evaluation of acute right lower quadrant pain: part I, common mimics of appendicitis. American
Journal of Roentgenology 2005; 184: 1136-1142.
Yu J, Fulcher AS, Turner MA, Halvorsen RA. Helical CT evaluation of acute right lower quadrant pain: part II, uncommon mimics of appendicitis. American
Journal of Roentgenology 2005; 184: 1143-1149.
Additional images from the following websites:
http://history1900s.about.com/library/photos/blywwiip251.htm
www.learngingradiology.com
http://www.hawaii.edu/medicine/pediatrics/pemxray/v4c10.html