Gastrointestinal Imaging Original Research

Chang et al.
Positioning Algorithm During Ultrasound for Appendicitis

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Gastrointestinal Imaging
Original Research

Three-Step Sequential Positioning

Algorithm During Sonographic
Evaluation for Appendicitis
Increases Appendiceal Visualization
Rate and Reduces CT Use
Stephanie T. Chang1
R. Brooke Jeffrey 1
Eric W. Olcott 1,2
Chang ST, Jeffrey RB, Olcott EW

Keywords: appendicitis, diagnostic imaging, radiation

protection, sonography, spiral CT
DOI:10.2214/AJR.13.12334
Received December 3, 2013; accepted after revision
February 17, 2014.
1
Department of Radiology, Stanford University
School of Medicine, 300 Pasteur Dr, H1307, Stanford, CA
94305-5105. Address correspondence to E. W. Olcott
(eolcott@stanford.edu).
2

Veterans Affairs Palo Alto Health Care System,

Palo Alto, CA.

AJR 2014; 203:10061012

0361803X/14/20351006
American Roentgen Ray Society

1006

OBJECTIVE. The purpose of this article is to examine the rates of appendiceal visualization by sonography, imaging-based diagnoses of appendicitis, and CT use after appendiceal
sonography, before and after the introduction of a sonographic algorithm involving sequential
changes in patient positioning.
MATERIALS AND METHODS. We used a search engine to retrospectively identify
patients who underwent graded-compression sonography for suspected appendicitis during
6-month periods before (period 1; 419 patients) and after (period 2; 486 patients) implementation of a new three-step positional sonographic algorithm. The new algorithm included initial conventional supine scanning and, as long as the appendix remained nonvisualized, left
posterior oblique scanning and then second-look supine scanning. Abdominal CT within 7
days after sonography was recorded.
RESULTS. Between periods 1 and 2, appendiceal visualization on sonography increased
from 31.0% to 52.5% (p < 0.001), postsonography CT use decreased from 31.3% to 17.7% (p<
0.001), and the proportion of imaging-based diagnoses of appendicitis made by sonography increased from 63.8% to 85.7% (p = 0.002). The incidence of appendicitis diagnosed by imaging (either sonography or CT) remained similar at 16.5% and 17.3%, respectively (p = 0.790).
Sensitivity and overall accuracy were 57.8% (95% CI, 44.870.1%) and 93.0% (95% CI, 90.1
95.3%), respectively, in period 1 and 76.5% (95% CI, 65.885.2%) and 95.4% (95% CI, 93.1
97.1%), respectively, in period 2. Similar findings were observed for adults and children.
CONCLUSION. Implementation of an ultrasound algorithm with sequential positioning significantly improved the appendiceal visualization rate and the proportion of imagingbased diagnoses of appendicitis made by ultrasound, enabling a concomitant decrease in abdominal CT use in both children and adults.

ne of the main limitations of

graded-compression sonography
is its substantially lower rate of
detection of the appendix when
compared with CT [16]. A major advantage
of graded-compression sonography is the absence of ionizing radiation, especially among
pediatric patients, who are at particularly high
risk for radiation effects [14, 6, 7]. Some observers have noted that positional changes, especially coronal scanning in the left posterior
oblique (LPO) position, may assist in the
sonographic detection of a retrocecal appendix [713]. To date, however, no study to our
knowledge has specifically addressed the incremental benefit of routine additional LPO
imaging in a large group of patients.
When Lee et al. [12] used LPO imaging, they did so on an intermittent basis and
scanned only 1% (7/675) of the patients in

their sample in this fashion. Those investigators achieved an 89% appendiceal visualization rate by scanning in the supine position
alone and a 99% visualization rate (a figure
that has not been achieved in a North American study) by using a variety of additional
operator-dependent maneuvers, including
intermittent scanning in the LPO position.
The sonographic visualization rates in North
American reports have ranged from 31% to
88% [1215] to as low as 2.4% among patients without appendicitis [16].
Because the appendix lies in a retrocecal
position in 2565% of patients [1719], we
postulated that the routine additional use of
scanning in the LPO position may be very
beneficial in our North American patient
population in whom supine-only scanning
provides visualization rates lower than those
reported in the study of Korean individuals

AJR:203, November 2014

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Positioning Algorithm During Ultrasound for Appendicitis

by Lee et al. [12]. Furthermore, we postulated that rescanning in the supine position after LPO scanning (i.e., a second-look supine scan) could take advantage of a new
acoustic window created by rotation of the
patient into and out of the LPO position; this
latter postulate was based on early anecdotal
experience after LPO scanning in our laboratory. To evaluate in a systematic way the
potentially improved visualization provided
by these positional changes, we developed a
sequential positioning algorithm involving
supine, then LPO, and finally second-look
supine imaging. The purpose of our study
was to assess the potential impact of this
three-step algorithmic graded-compression
sonography approach on patients referred for
sonographic evaluation of suspected appendicitis, including examination of the appendiceal visualization rates produced by each
step of the algorithm after its routine implementation in our laboratory and observation
of the corresponding effects on subsequent
postsonography CT.

Fig. 1Photograph
showing scanning
parallel to psoas
muscle with patient
in left posterior
oblique position, as
implemented during
training period and
conducted throughout
period 2.

A search engine operating on the institutional

radiology information system identified patients
referred for graded-compression sonography evaluation of possible appendicitis during the 6 months
before (period 1) and the 6 months after (period
2) a 3-month training interval during which the
new three-position scanning algorithm was intro-

duced and implemented in our ultrasound laboratory; the training interval began on June 1, 2012.
Both pediatric patients (18 years old or younger)
and adults were included. In period 1, a total of
419 patients were thus identified, with a mean age
of 17 years (range, < 1 to 81 years), including 154
adult patients (28 men and 126 women) and 265
pediatric patients (138 boys and 127 girls). In period 2, a total of 486 patients were identified, with
a mean age of 16 years (range, 187 years), including 156 adult patients (25 men and 131 women) and 330 pediatric patients (156 boys and 174
girls). Review of the radiology PACS identified
which of these patients underwent abdominopelvic CT within 7 days of their graded-compression
sonography examinations.
At our institution, graded-compression sonography is the first-line modality for the evaluation of suspected appendicitis. CT, the secondline modality, is used when graded-compression
sonography does not provide a diagnosis and there
is ongoing clinical concern for appendicitis. Di-

agnoses of appendicitis made by either gradedcompression sonography or CT were considered

imaging-based diagnoses. A long-standing policy formulated in conjunction with our emergency
department excludes patients for graded-compression sonography of appendicitis if any one of three
exclusion criteria are met according to evaluation
by emergency department personnel: obesity with
body mass index greater than 30; evidence of peritonitis on physical examination, with rebound tenderness; and suspicion for appendiceal perforation
based on history, laboratory findings, or physical
examination. Accordingly, patients meeting any
of these criteria were not included, and all included patients had a body mass index of 30 or less.
Patients excluded from graded-compression sonography for these reasons were referred to CT.

Materials and Methods

This retrospective study was performed in compliance with the HIPAA. Informed consent was
waived by approval of our institutional review board.

Patient Selection

Baseline Conventional Ultrasound Protocol

(Period 1)
Each sonogram was performed by one of six
licensed sonographers, each with a minimum of

Fig. 219-year-old man with acute retrocecal appendicitis visualized only on coronal scanning in left posterior oblique (LPO) position.
A, Transverse sonogram of right lower quadrant in initial supine position shows acoustic shadowing from gas in cecum (C) but did not identify appendix.
B, Coronal sonogram acquired through right flank with patient in 45 LPO position shows psoas muscle (P) and noncompressible enlarged 9-mm appendix (arrow)
consistent with appendicitis. Despite sonographic diagnosis of appendicitis, attending surgeon requested CT.
C, Contrast-enhanced axial CT image confirms retrocecal appendicitis (arrow) and shows gas within cecum (C).

AJR:203, November 2014 1007

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Chang et al.
Fig. 38-year-old girl with normal retrocecal
appendix seen only on coronal imaging in left
posterior oblique (LPO) position.
A, Transverse right lower quadrant sonogram in initial
supine position shows small-bowel loops (SB) and
psoas muscle (P) but no visualization of appendix.
B, Coronal sonogram acquired through right flank
with patient in LPO position shows normal appendix
(arrow) posterior to cecum (C) and anterior to psoas
muscle (P). Calipers mark appendix.

A
5 years of clinical experience performing appendiceal graded-compression sonography. Sonographers were supervised on a case-by-case
basis by radiology residents, body imaging fellows, and attending radiologists in our abdominal imaging and pediatric imaging sections. All
scans were immediately reviewed by supervising
residents, fellows, or attending radiologists, who
performed additional scanning on an as-needed
basis for equivocal cases. Ultrasound equipment
included the Logiq 9 system (GE Healthcare) and
Sequoia System 512 (Siemens Healthcare) using
linear-array transducers ranging in frequency
from 8 to 15 MHz.
During period 1, all sonographers performed
standardized graded-compression sonography,
as described elsewhere [20, 21], with all patients
scanned only in the supine position. Whenever
possible, each patient was initially asked to indicate their site of maximal abdominal pain,
and this region was specifically scanned during
the study [22]. Scanning was initiated using the
highest frequency transducer providing penetration adequate to visualize the right psoas
muscle and external iliac artery [14], beginning
with the right kidney and the hepatorenal fossa
in the right flank, in the transverse plane, and
continuing inferiorly to the ascending colon. An
attempt was then made to visualize the insertion of the terminal ileum into the cecum, with
gradually increasing pressure applied with the
transducer to reveal the caput of the cecum and
the appendiceal origin. Transverse and longitudinal images were obtained of the cecal region,
as well as cine clips, with the patient remaining
in the supine position. In all female patients of
reproductive age in whom the appendix was not
visualized by transabdominal graded-compression sonography, endovaginal scanning of the
uterus and adnexa was performed using a 6- to
8-MHz endovaginal probe, as is routine for patients with suspected appendicitis at our institution, unless such scanning is contraindicated or
declined by the patient.

1008

B
Training Interval

CT Technique

Immediately after period 1, personnel in the

sonography laboratory were trained to perform the
new three-step graded-compression sonography
scanning algorithm and thereafter began using it
routinely. During the 3-month training period, all
six technologists initially received individualized
real-time hands-on instruction from the most experienced attending radiologist in the laboratory, each
executing the new three-phase positioning protocol
with five patients. Emphasis was placed on achieving the correct 45 LPO position and coronal imaging of the retrocecal area by scanning parallel to
the right psoas muscle. Subsequently, each technologist performed a minimum of 25 supervised triple-position studies that documented correct imaging in the supine, LPO, and repeat second-look
supine positions. There were 184 appendiceal ultrasound studies performed in this 3-month period,
including 118 pediatric patients and 66 adults. Instructive normal and abnormal appendiceal ultrasound studies, along with available CT and pathology results, were reviewed with the technologists
at bimonthly ultrasound teaching conferences presented by a senior radiologist.

Abdominopelvic CT was performed using 16or 64-row MDCT scanners (LightSpeed VCT, GE
Healthcare). IV contrast medium was used routinely in all patients, without oral or rectal contrast medium. For adult patients, 150 mL of iohexol medium (Omnipaque 350, GE Healthcare)
was injected via power injector at a rate of 3 mL/s.
For pediatric patients, 2 mL of contrast material
per kilogram of body weight was injected at a rate
of 2 mL/s. Portal venous phase images were obtained from the diaphragm through the pelvis with
collimation of 0.6251.25 mm. Axial images were
reconstructed at slice thicknesses of 1.255 mm,
and both coronal and sagittal images were reconstructed at 2-mm slice thickness.

New Three-Position Ultrasound Algorithm

(Period 2)
For period 2, the new graded-compression
sonography algorithm with sequential positioning
was used for all patients by the same group of sonographers who were involved in period 1. Each
examination began in the conventional fashion
with the patient lying supine [20, 21]. If the appendix was not visualized, the patient was then placed
into a 45 LPO position and scanned parasagittally through the right flank, in a coronal plane parallel to the long axis of the psoas muscle, in an
attempt to image a possibly retrocecal appendix
(Figs. 13). If the appendix still was not visualized, the patient was returned to the supine position and scanned to yield a second-look supine
acquisition. Patient positioning was annotated
throughout the examination by the sonographer.

Review of Imaging Examinations

Final clinical sonography reports and final clinical CT reports for patients who also underwent
CT evaluation were used to establish whether the
appendix was visualized by graded-compression
sonography and, for both modalities, whether imaging evidence of appendicitis was present. All reports
were generated with supervising attending radiologists who had 5 to more than 25 years of experience.
Diagnostic criteria for appendicitis on graded-compression sonography included a noncompressible
appendix with anteroposterior diameter greater
than 6 mm. Secondary sonographic findings included echogenic periappendiceal fat and mural hyperemia [15, 21, 23]. Diagnostic criteria for appendicitis on CT included two or more of the following
criteria: anteroposterior diameter of at least 7 mm,
periappendiceal fat stranding consistent with inflammation, and mural thickness greater than 2 mm
with abnormal mural hyperenhancement relative to
nearby bowel segments [21, 24]. Diagnostic criteria
for appendicitis on graded-compression sonography
included a noncompressible appendix measuring
greater than 6 mm in diameter; secondary sonographic findings included hyperemia of the appendiceal wall, thickening of the appendiceal wall, and
echogenic fat in the periappendiceal region [21].

AJR:203, November 2014

Positioning Algorithm During Ultrasound for Appendicitis

TABLE 1: Observations and Results for Patients Who Underwent Imaging for Suspected Appendicitis in Period 1
(All Supine Scanning) and Period 2 (New Three-Position Scanning)
Period 1
Total
(n = 419)

Adults
(n = 154)

Children
(n = 265)

Total
(n = 486)

Adults
(n = 156)

Children
(n = 330)

130 (31.0)

37 (24.0)

93 (35.1)

255 (52.5)

62 (39.7)

193 (58.5)

< 0.001

0.003

< 0.001

84 (17.3)

21 (13.5)

63 (19.1)

0.790

0.866

1.000

72 (85.7)

18 (85.7)

54 (85.7)

0.002

0.148

0.008

86 (17.7)

48 (30.8)

34 (10.3)

< 0.001

0.034

0.005

Observation
Patients with appendix visualized by sonography
No. (% of n)
p
Imaging-based diagnoses of appendicitis made by CT or
graded-compression sonography
No. (% of n)

69 (16.5)

19 (12.3)

50 (18.9)

p
Sonographic imaging-based diagnoses of appendicitis
No. (% of imaging-based diagnoses of appendicitis made by CT or
graded-compression sonography)

44 (63.8)

12 (63.2)

32 (64.0)

p
Patients who underwent abdominal CT within 7 days of sonography
No. (% of total n)

131 (31.3)

66 (42.9)

65 (24.5)

p
NoteThe p values relate findings in period 2 to corresponding findings in period 1.

Results
Patient Sample
Patients in periods 1 and 2 did not differ
significantly with respect to sex (166 male
and 253 female patients in period 1 vs 181
male and 305 female patients in period 2; p=
0.493), adults versus children (154 adults and
265 children in period 1 vs 156 adults and 330
children in period 2; p = 0.160), or mean age

Medical Record Review and Clinical Follow-Up

Period 1

January 2013

February 2013

December 2012

October 2012

November 2012

August 2012

Training
Period

September 2012

July 2012

May 2012

0.0

June 2012

15.0

April 2012

Fig. 4Graph showing

appendiceal visualization
rates (solid line) and
postsonography CT
use rates (dashed
line) during periods 1
and 2 and intervening
3-month training interval.
Appendiceal visualization
increased during period 2
compared with period 1,
whereas postsonography
CT use decreased.

30.0

March 2012

The Fisher exact test was used to compare demographic data and results between period 1 and
period 2, the exact binomial test was used to compare performance values with 95% CIs, and the
Student t test was used to compare ages. Analy-

45.0

January 2012

Statistical Analysis

Appendiceal Visualization by Sonography

The sonographic appendiceal visualization
rate increased significantly among all patients
from the baseline in period 1 (31.0%; 130/419)
to period 2 (52.5%, 255/486; p < 0.001) (Table
1 and Fig. 4). Statistically significant increases
were evident among both adults and children.

60.0

February 2012

For patients with imaging-based diagnoses of

appendicitis (i.e., appendicitis diagnosed by graded-compression sonography or CT), surgical pathology reports and discharge summaries were
reviewed to establish whether the diagnosis was
truly or falsely positive. For patients whose imaging studies were interpreted as negative for appendicitis or whose graded-compression sonography
examinations did not reveal the appendix, 6-week
follow-up chart reviews were performed to establish whether these represented true- or false-negative findings.

(17 years in period 1 vs 16 years in period 2;

p = 0.604). All patients had either histopathologic evaluation of the surgically removed appendix or 6 weeks of clinical follow-up.

ses were performed on the Stata software platform

(version 12.1, StataCorp).

December 2011

All clinical ultrasound examinations with visualization of the appendix during period 2 were
subsequently reviewed by a blinded independent
radiologist with over 25 years of experience in
performing graded-compression sonography to
define whether the appendix was first visualized
on the conventional supine images, the subsequent
LPO images, or the final second-look supine images. These assessments were facilitated by sonographers image annotations and were confirmed using visualized anatomic landmarks, such
as the psoas muscle and the external iliac vessels.

Rate (%)

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Period 2

Period 2

Month

AJR:203, November 2014 1009

Chang et al.
TABLE 2: Visualization of the Appendix in Period 1 (All Conventional Scanning) and First Visualization of the
Appendix in Period 2 (New Three-Step Algorithm)
Period 1

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Sonographic Position and Appendiceal Visualization

Period 2

Total
(n = 419)

Adults
(n = 154)

Children
(n = 265)

Total
(n = 486)

Adults
(n = 156)

Children
(n = 330)

130 (31.0)

37 (24.0)

93 (35.1)

147 (30.2)

39 (25.0)

108 (32.7)

0.828

0.895

0.601

69

13

56

216 (44.4)

52 (33.3)

164 (49.7)

< 0.001

0.079

< 0.001

39

10

29

255 (52.5)

62 (39.7)

193 (58.5)

< 0.001

0.003

< 0.001

Conventional supine position

No. visualized (% of n)
p
Left posterior oblique position
Incremental no. visualized
Cumulative no. visualized (% of n)
p
Second-look supine position
Incremental no. visualized
Cumulative no. visualized (% of n)
p
NoteThe p values relate findings in period 2 to findings in period 1.

Details of the increased appendiceal visualization rates achieved during each step of period 2 are presented in Table 2. The appendix
was first seen in the conventional supine position, the subsequent LPO position, and the
final second-look supine position in 30.2%
(147/486), 14.2% (69/486), and 8.0% (39/486)
of patients, respectively. Cumulative appendiceal visualization rates achieved during each
of the three steps of period 2 are presented in
Table 2 and significantly exceeded those of period 1 for all patients and for children; the LPO
step did not register a statistically significant
increase among the small sample of adults, although the second-look supine step did. No statistically significant differences were present
between visualization of the appendix during
the conventional all-supine scanning of period 1 and the initial conventional supine scanning step of period 2, a finding that was true for
all patients, both adults and children (Table 2).
Figures 2 and 3 provide representative clinical
images. Sonographers typically required 510
additional minutes to perform the new positional maneuvers in period 2 compared with
the conventional scanning in period 1.
Imaging-Based Diagnosis of Appendicitis
The incidence of appendicitis among all
patients, whether diagnosed by graded-compression sonography or CT, did not differ significantly between period 1 (16.5%; 69/419
patients) and period 2 (17.3%; 84/486 patients; p = 0.790) (Table 1). Similarly, no statistically significant differences were found
among adults and children.

1010

However, the proportion of imaging-based

diagnoses achieved by graded-compression
sonography, rather than CT, did increase significantly from period 1 (63.8%; 44/69 patients) to period 2 (85.7%; 72/84 patients; p =
0.002) among all patients (Table 1), also reaching statistical significance among children but
not among the smaller contingent of adults.
Use of CT After Sonography
The rate of CT scans performed within 7
days after graded-compression sonography
decreased from 31.3% (131/419) in period
1 to 17.7% (86/486; p < 0.001) in period 2
among all patients and remained statistically
significant for adults and children (Table 1
and Fig. 4).
Medical Record Review and Clinical Follow-Up
As shown in Table 3, the sensitivity, specificity, positive predictive value, negative
predictive value, and accuracy for appendicitis among all patients were 57.8%, 99.4%,
94.9% 99.4% and 93.0%, respectively, in period 1 and 76.5%, 99.2%, 95.4%, 98.8% and
95.4%, respectively, in period 2 (Table 3).
As indicated by their overlapping 95% CIs,
these statistics did not differ significantly between periods 1 and 2 whether considering
adults, children, or all patients together.
Among patients with sonographically visualized appendixes and sonographic evidence of appendicitis, surgical pathology results confirmed appendicitis in 37 patients in
period 1, one of which was visualized only
on endovaginal scanning, and 62 patients in

period 2; these were counted as sonographic

true-positives for appendicitis (Table 3).
Surgical pathology results indicated no evidence of appendicitis in two other patients
with sonographically visualized appendixes
and sonographic evidence of appendicitis in
period 1 and three other such individuals in
period 2; these were counted as sonographic
false-positives for appendicitis (Table 3).
Among patients with sonographically visualized normal appendixes, follow-up chart review revealed exactly two patients in period
1 and five patients in period 2 who presented
with recurrent symptoms and appendicitis on
pathologic examination; these were counted
as sonographic false-negatives for appendicitis (Table 3). Another 84 patients with sonographically visualized normal appendixes in
period 1 and 178 such patients in period 2 had
no evidence of appendicitis during follow-up,
or normal appendixes on pathologic examination after readmission during follow-up; these
were counted as sonographic true-negatives
for appendicitis (Table 3).
Among patients with sonographically
nonvisualized appendixes, 264 in period 1
and 217 in period 2 had no evidence of appendicitis during follow-up or normal appendixes on pathologic examination following
readmission; these were counted as sonographic true-negatives (Table 3). Another 25
patients with sonographically nonvisualized
appendixes in period 1 and 14 such patients
in period 2 had appendicitis confirmed on
pathologic examination; these were counted
as sonographic false-negatives (Table 3).

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Positioning Algorithm During Ultrasound for Appendicitis

TABLE 3: Diagnostic Performance of Sonography for Appendicitis in Periods 1 and 2
Period 1

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Value

All Patients

Period 2

Adults

Children

All Patients

Adults

Children

Appendix visualized on
graded-compression sonography
(no. of findings)
True positive

37

11

26

62

18

44

True negative

84

25

59

178

42

136

False positive

False negative

True negative

264

110

154

217

92

125

False negative

25

18

14

12

57.8 (44.870.1)

61.1 (35.782.7)

56.5 (41.171.1)

76.5 (65.885.2)

81.8 (59.794.8)

74.6 (61.685.0)

Appendix not visualized on

graded-compression sonography
(no. of findings)

Sensitivity, % (95% CI)

Specificity, % (95% CI)

99.4 (98.099.9)

100.0 (97.3100.0)

99.1 (96.799.9)

99.2 (97.899.8)

100.0 (97.3100.0)

98.9 (96.799.8)

Positive predictive value, % (95% CI)

94.9 (82.399.4)

100.0 (71.5100.0)

92.9 (76.599.1)

95.4 (87.199.0)

100.0 (81.5100.0)

93.6 (82.598.7)

Negative predictive value, % (95% CI)

99.4 (98.099.9)

100.0 (97.3100.0)

99.1 (96.799.9)

98.8 (97.199.6)

98.5 (94.899.8)

98.9 (96.799.8)

Accuracy, % (95% CI)

93.0 (90.195.3)

95.4 (90.898.1)

91.6 (87.594.6)

95.4 (93.197.1)

97.4 (93.699.3)

94.4 (91.396.7)

For one adult and four children in period 1

and seven children in period 2, graded-compression sonography visualized the appendix and appendicitis, but pathologic evaluation was unavailable because surgery was
declined, surgery was deemed inadvisable,
or the pathology report was not available for
review. Because unambiguous objective diagnoses were not available for these patients,
they were not counted as true- or false-positives or -negatives.

false-negatives included one child with an 8to 9-mm structure thought to be the terminal
ileum or possibly the appendix and another
child with a normal 5-mm appendix, both of
whom proved to have appendicitis on pathologic examination. The five false-negatives
in period 2 included two children and two
adults with noncompressible 6- to 7-mm appendixes and one child with a normal 6-mm
compressible appendix, all of whom had appendicitis on pathologic examination.

Sonographic False-Positive and

False-Negative Findings
Sonographic false-positives among patients with visualized appendixes reflected a
variety of causes. In Period 1, the two falsepositives were in children with enlarged,
hyperemic appendixes that were proven on
pathologic examination to reflect follicular
hyperplasia in one case and infestation with
Enterobius vermicularis (pinworms) in the
other case. In period 2, the three false-positive findings included one child with a 7-mm
enlarged and hyperemic appendix found to
represent only follicular hyperplasia on pathologic examination and two children with
noncompressible appendixes between 6 and
7.5 mm in diameter that were normal on
pathologic examination.
Sonographic false-negatives also reflected a variety of causes among patients with
visualized appendixes. In period 1, the two

Discussion
For both adult and pediatric patients with
suspected appendicitis, our data show that a
three-step graded-compression sonography
algorithm of sequential positioning can significantly improve visualization of the appendix compared with graded-compression sonography performed only in the supine position
and is associated with a decreased rate of subsequent CT use. Specifically, the appendiceal
visualization rate increased from 31.0% to
52.5% for all patients, while CT use decreased
from 31.3% to 17.7% (Table 1), and statistically significant changes were evident for both
children and adults. In addition, the proportion of imaging-based diagnoses achieved
by graded-compression sonography rather
than CT increased significantly among children; this proportion also increased among
the smaller contingent of adults but did not
achieve statistical significance. At our insti-

tution, ultrasound rather than CT is routinely

used as the first-line imaging modality for the
evaluation of suspected appendicitis.
In this three-step algorithm, when the appendix is not visualized during initial graded-compression sonography with the patient
in the conventional supine position, the patient is positioned 45 LPO and scanned coronally through the right flank, parallel to the
psoas muscle, to visualize a possibly retrocecal appendix. If the appendix is still not
identified, a second-look supine scan is performed, which, we hypothesize, can take advantage of an improved acoustic window
resulting from shifts in bowel contents that
occur during the LPO positioning step.
To our knowledge, the value of systematic
LPO scanning with repeat supine scanning
after unsuccessful conventional supine scanning [20] has not been systematically evaluated. Earlier reports mentioning scanning
through the flank and use of the left lateral
decubitus or right anterior oblique position
did not systematically evaluate the value of
these positional changes [713]. Lee and colleagues [12] used the left oblique lateral decubitus position intermittently as a discretionary maneuver and found that it increased
visualization by an increment of only 2%
(4/202) of healthy control individuals and
1% (7/675) of patients. The substantially
higher values achieved in the current study
likely reflect the systematic nondiscretion-

AJR:203, November 2014 1011

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Chang et al.
ary nature of our algorithm and, accordingly,
more accurately reflect the potential value of
these positional changes. Other maneuvers
have also been reported as helpful in visualizing the appendix [25].
During the 3-month training interval between periods 1 and 2, our sonographers reported increasing confidence in visualizing
the appendix in general, and small normal
appendixes in particular. Once familiar with
the new three-position algorithm, the sonographers typically required approximately
510 additional minutes to perform the additional LPO and second-look supine steps.
Although we cannot rigorously exclude a
contribution of the Hawthorne effect, in which
individuals perform better while under observation [26], the similar rates of appendiceal visualization during the all-supine scanning in
period 1 and the initial supine scanning step
in period 2 argue against this. Furthermore, although a significantly greater proportion of appendixes were visualized in period 2 compared
with period 1, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of graded-compression sonography did not differ significantly.
A number of limitations deserve mention
with respect to this investigation. First, we systematically evaluated the LPO scanning and
then second-look supine scanning after conventional supine scanning proved to be unrevealing, but it was not feasible to evaluate the
second and third steps alone or in the reverse
order. Next, our sonographers required 510
additional minutes for the new positional maneuvers, but this value may differ at other institutions. Although we cannot entirely exclude
the possibility that some of the improved performance with the additional positional maneuvers may simply reflect longer periods of
scanning, our long-standing experience has
been that prolonged supine scanning rarely, if
ever, provides visualization of an appendix that
was not evident during the conventional supine
examination. Although the phase of scanning
providing the first visualization of the appendix was generally clear on review of gradedcompression sonography images, the degree to
which images were annotated was slightly variable. Finally, this investigation is retrospective,
and prospective studies may help further define
the utility of the three-position algorithm.

1012

In summary, our sequential positioning algorithm significantly increased the appendiceal

visualization rate and the proportion of appendicitis diagnoses made by graded-compression
sonography rather than CT, for both adults and
children, while the rates of subsequent CT use
significantly decreased. Sequential positioning
during graded-compression sonography may,
therefore, help to address the lower appendiceal
visualization rate of graded-compression sonography compared with CT and may help to limit
the need for subsequent CT with its additional
costs and radiation exposure.
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