Arabinda Pani, HMS III

Gillian Lieberman, MD

January 2005

Radiologic Diagnosis of
Appendicitis
Arabinda Pani,
Harvard Medical School, Year III
Gillian Lieberman, MD

Arabinda Pani, HMS III

Gillian Lieberman, MD

Overview

Introduction: Epidemiology, Pathophysiology

Role of Radiologic diagnosis
Normal anatomy
Appearance in various modalities
Criteria for radiologic diagnosis
Patient Case: Appendicitis in Pregnancy

Arabinda Pani, HMS III

Gillian Lieberman, MD

Epidemiology
Appendicitis-associated abdominal pain is a
common presentation to ED
Peak Incidence: 10 30 years of age
Lifetime incidence: 7% in United States
Historically, high rate of false negatives and
false positives
20% of diagnoses initially missed
20% of appendectomies revealing a normal
appendix
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Arabinda Pani, HMS III

Gillian Lieberman, MD

Pathophysiology
The lumen of the appendix becomes obstructed,
leading to increased intraluminal pressure
resulting in inflammation, ischemia, and infection
Obstruction is most often secondary to:

Appendicoliths
Lymphoid hyperplasia
Parasite infections
Tumors (carcinoid, metastatic)
Foreign bodies
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Arabinda Pani, HMS III

Gillian Lieberman, MD

Complications of Appendicitis

Perforation
Abscess formation
Generalized peritonitis
Small bowel obstruction
The rate of complications increases with time
until diagnosis and treatment.

Arabinda Pani, HMS III

Gillian Lieberman, MD

Classic Presentation
Dull, generalized
abdominal pain,
migrates to RLQ over
24 hours
Nausea, Vomiting,
Anorexia

Low-grade fever
Abdominal tenderness
Guarding
Rebound tenderness
Obturator and Psoas
Signs
Elevated WBC

Arabinda Pani, HMS III

Gillian Lieberman, MD

Role of Radiologic Diagnosis

Appendicitis is highly
prevalent
Often presents
atypically especially in
children, women and
the elderly
Complications are
common and timedependent

Radiologic Diagnosis:
Is effective in significantly
increasing diagnostic
accuracy
Decreases morbidity and
mortality by:
preventing complications
avoiding unnecessary
surgeries
Lowers the overall cost of
healthcare
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Arabinda Pani, HMS III

Gillian Lieberman, MD

Anatomy

Grays Anatomy
adam.com

Arabinda Pani, HMS III

Gillian Lieberman, MD

Normal Appendix

contrast-filled appendix on barium study

http://www.emedicine.com/radio/topic47.htm

contrast in appendix (CT)

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Arabinda Pani, HMS III

Gillian Lieberman, MD

Ultrasound: Normal Appendix

Longitudinal ultrasonography shows compressible

tubular structure with an outer diameter of less than
6 mm. A=Iliac artery; V=Iliac vein.
http://emedicine.com/radio/topic47.htm

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Arabinda Pani, HMS III

Gillian Lieberman, MD

Normal Appendix: MR

Low Signal Intensity

Non-distended
Courtesy Dr. Eric Zeikus, PACS:BIDMC

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Arabinda Pani, HMS III

Gillian Lieberman, MD

Radiologic Findings of Appendicitis

Inflammatory changes
Lumenal obstruction
Appendicoliths

Plain Film

Barium Enema

Film is normal in > 50% of

patients with appendicitis

Diagnostic criteria requires

visualization of a nonfilling appendix

Only 10% demonstrate a

calcified, laminated
appendicolith(s)
Other findings are nonspecific

Often non-diagnostic with

low sensitivity
Invasive
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Arabinda Pani, HMS III

Gillian Lieberman, MD

Plain Film: Calcified Appendicolith

http://telesalud.ucaldas.edu.co

13

Arabinda Pani, HMS III

Gillian Lieberman, MD

Graded Compression Ultrasound

Blind-ended, tubular, noncompressible, aperistaltic structure
Diameter > 6 mm, laminated wall
Increased periappendiceal echogenicity
Appendicolith: echogenic with distal shadowing
Doppler: increased circumferential flow
Perforation/Abscess: thickening of adjacent bowel wall, fluid
collections, hypoechoic mass
Overall diagnostic accuracy: 85%
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Arabinda Pani, HMS III

Gillian Lieberman, MD

Appendicitis on Ultrasound

Non-compressible, blind-ended
8mm diameter
Laminated wall
Birnbaum B A, and Wilson S R. Appendicitis at the Millennium. Radiology 2000 215: 337-348.

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Arabinda Pani, HMS III

Gillian Lieberman, MD

Color Doppler Ultrasound

Circumferential Flow,
suggestive of hypervascularity
and inflammation
Birnbaum B A, and Wilson S R. Appendicitis at the Millennium. Radiology 2000 215: 337-348.

16

Arabinda Pani, HMS III

Gillian Lieberman, MD

Appendicolith on US

Bright, echogenic
focus
Clean distal
acoustic shadowing
Birnbaum B A, and Wilson S R. Appendicitis at the Millennium. Radiology 2000 215: 337-348.

17

Arabinda Pani, HMS III

Gillian Lieberman, MD

Perforated Appendix on US

Perforated Appendix with Free

Peritoneal Fluid (FF) surrounding
loops of bowel (B).

http://lunis.lumc.edu/radiology/Appendicitis

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Arabinda Pani, HMS III

Gillian Lieberman, MD

CT Diagnosis
Primary Criteria:
Enlarged, inflamed
appendix
diameter >6 mm in
adults
> 8mm in children

Appendicolith
Non-contrast filled

Secondary Criteria:

Wall enhancement
Fat stranding
Abscess formation
Focal thickening of the
cecum (arrow-head sign)
Adenopathy
Small bowel obstruction
Free fluid in the pelvis

Overall Accuracy: 98%

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Arabinda Pani, HMS III

Gillian Lieberman, MD

Uncomplicated Appendicitis: CT

Non-contrast filled
Enlarged appendix,
14 mm in diameter
Adjacent fat stranding

Courtesy of Dr. Michael Geary, PACS: BIDMC

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Arabinda Pani, HMS III

Gillian Lieberman, MD

Coronal CT: Enhancing Wall

PACS: BIDMC

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Arabinda Pani, HMS III

Gillian Lieberman, MD

CT: Appendicolith

http://www.madisonradiologists.com/SvcCTAbdominalPain.htm

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Arabinda Pani, HMS III

Gillian Lieberman, MD

Arrowhead Sign

Mural thickening of the cecum at the

base of an obstructed appendix
http://lunis.lumc.edu/radiology/Appendicitis/ctfindings.htm

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Arabinda Pani, HMS III

Gillian Lieberman, MD

Periappendiceal Abscess

Courtesy of Dr. Damon Soeiro; PACS: BIDMC

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Arabinda Pani, HMS III

Gillian Lieberman, MD

Coronal CT: Abscess

PACS: BIDMC

25

Arabinda Pani, HMS III

Gillian Lieberman, MD

Our Patient
Otherwise healthy, 33 year old female at 20 weeks
gestation, presented to ED with 6 days of abdominal
pain.
Pain was described as epigastric and crampy in nature.
Denied nausea, vomiting. Reported loss of appetite,
chills, and a low-grade fever.
Temp 99.4 WBC: 10.2
Abdomen: soft, gravid, diffusely tender to palpation;
no rigidity or rebound tenderness
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Arabinda Pani, HMS III

Gillian Lieberman, MD

Diagnostic Complications in Pregnancy

Pregnancy alters the
position of the appendix
Atypical clinical
presentation
Increased risk of
perforation
Association with
premature labor,
decreased birth weight

Ultrasound is modality
of choice but diagnosis
can be impeded by body
habitus and anatomic
displacement of the
appendix
CT exposes the fetus to
radiation

27

Arabinda Pani, HMS III

Gillian Lieberman, MD

Patient Evaluation by Ultrasound

Focal rounded area of
increased echogenicity
with a hypoechoic rim and
increased vascularity
suspicious for an inflamed
appendix
Localized to the patients
area of tenderness
Noncompressible

PACS: BIDMC

28

Arabinda Pani, HMS III

Gillian Lieberman, MD

Doppler Ultrasound Findings

Transverse view demonstrated

increased circumferential flow
in the wall of the appendix,
suggestive of hypervascularity
secondary to inflammation

PACS: BIDMC

29

Arabinda Pani, HMS III

Gillian Lieberman, MD

Diagnosis of Appendicitis in Pregnancy

Advantages of MR
Visualize an abnormal
appendix in atypical
locations
Visualize adjacent
inflammatory processes
Different sequences +/contrast
No known biologic risks to
fetus

Diagnostic Findings
Enlarged appendix >
6mm
Periappendiceal
inflammatory changes
T2/fat-suppressed
images: high signal
intensity of an inflamed
appendix
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Arabinda Pani, HMS III

Gillian Lieberman, MD

HASTE Sequence, Coronal View

Appendix location:
posterior and superior
to the uterus
Distended at:
10 mm in the middle;
18 mm at tip
Associated fat
stranding

Courtesy of Dr. Eric Zeikus, PACS: BIDMC

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Arabinda Pani, HMS III

Gillian Lieberman, MD

Sagittal View

Fluid-filled lumen
Thickened wall

PACS: BIDMC

32

Arabinda Pani, HMS III

Gillian Lieberman, MD

Conclusion of Case
Patient proceeded to surgery for a laparoscopic
appendectomy, performed without complications.
On gross appearance, the appendix was inflamed
and gangrenous.
Post-op ultrasound demonstrated a normal,
unchanged fetus.
Pathology: specimen consistent with acute
appendicitis with evidence of perforation
The mother carried fetus to term, delivered
without complications.
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Arabinda Pani, HMS III

Gillian Lieberman, MD

Acknowledgements

Michael Geary, MD
Arati Khanna, MD
Damon Soeiro, MD
Atif Zaheer, MD
Eric Zeikus, MD
Gillian Lieberman, MD
Pamela Lepkowski
Larry Barbaras
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Arabinda Pani, HMS III

Gillian Lieberman, MD

References

Birnbaum B A, and Wilson S R. Appendicitis at the Millennium. Radiology 2000

215: 337-348.
Checkoff JL, Wechsler RJ, Nazarian LN. Chronic Inflammatory Appendiceal
Conditions That Mimic Acute Appendicitis on Helical CT. Am. J. Roentgenol. 2002
179: 731-734
Cobben LP, Groot I, Haans L et al. MRI for Clinically Suspected Appendicitis
During Pregnancy. Am. J. Roentgenol. 2004 183: 671-675
Eyvazzadeh AD, Pedrosa I, Rofsky N M et al. MRI of Right-Sided Abdominal Pain
in Pregnancy. Am. J. Roentgenol. 2004 183: 907-914
Lee J, Jeong YK, Hwang JC, et al. Graded Compression Sonography with
Adjuvant Use of a Posterior Manual Compression Technique in the Sonographic
Diagnosis of Acute Appendicitis Am. J. Roentgenol. 2002 178: 863-868.
Novelline, RA. Helical CT in Emergency Radiology. Radiology 1999 213: 321339.
Rosen MP, Sands DZ, Esterbrook H, et al. Impact of Abdominal CT on the
Management of Patients Presenting to the Emergency Department with Acute
Abdominal Pain. Am. J. Roentgenol. 2000 174: 1391-1396
Somani R, Gordon C, McArthur R. Appendicitis in pregnancy: a rare
presentation. CMAJ 2003 168: 1020
Wise SW, Labuski MR, Kasales CJ, et al. Comparative Assessment of CT and
Sonographic Techniques for Appendiceal Imaging Am. J. Roentgenol. 2001 176:
933-941
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