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PPENDICITIS is one of the most Michael Reese Hospital for the past 2
frequent intnaperi toneal inflammatory years (1970 and 1971) with questionable
processes involving the pediatric popula- findings of in tnapeni toneal inflammatory
tion. Although in many instances the diag- disease were reviewed. The patients had
nosis of appendicitis in children is obvious had at least supine and upright noentgeno-
by simple clinical and laboratory investiga- grams of the abdomen and a barium enema
tion, many cases present with unusual examination in the course of their evalua-
findings and make the diagnosis dificult. flon. The noentgenognams were reviewed
A small proportion of patients are tin- and specific plain film and barium enema
necessarily operated upon because of the findings were documented. The specific
clinical signs; others are operated upon and findings on each patient are listed in
pathologic findings other than appendicitis Table I. The criteria used for the diag-
are uncovered. nosis of appendicitis were derived from
Roentgenognams of the abdomen may past experience with barium enema in
suggest an i ntnapeni toneal abnonmali tv, patients with appendicitis and from the
but most do not specifically demonstrate literature. The criteria used to make the
unequivocal findings of appendicitis. diagnosis of appendicitis were: (i) non-
The barium enema examination may be filling of the appendix with a local impnes-
diagnostic of appendicitis, highly sugges- sion on the cecum; (2) partial filling of the
tive, on diagnostic of other disease processes appendix with a local impression on the
which simulate appendicitis. The study cecum on juxtaposed small bowel; () non-
may also definitely exclude the presence filling of the appendix with other evidence
of appendicitis. of a mass in the pelvis (hazy clouding in the
The purpose of this paper is to: (i) es- right lower quadrant on displaced small
tablish criteria useful in making the diag- bowel loops); and (.) irregular mucosal
nosis of appendicitis b a barium enema pattern of the appendix on a cut-off sign
study; (2) apply those criteria to a number indicating a non-tapered abrupt halt to the
of cases in which a barium enema examina- flow of barium in the appendix. The diag-
tion was used to include on exclude the nosis made by barium enema examination
diagnosis of appendicitis; (,) evaluate was compared to the surgical findings or
some plain film noentgenognaphic findings clinical course.
to test their value relative to the barium Plain film roentgenographic findings were
enema study findings; (4) evaluate the analyzed (as noted in Table i) in an at-
* Presented at the Fifteenth Annual Meeting of the Society for Pediatric Radiology, Washington, D.C., October u-I, 1972.
tDirector, Pediatric Radiology, Michael Reese Hospital, Chicago, Illinois; Assistant Professor, Pritzker 5chool of Medicine, Uni-
versity of Chicago, Chicago, Illinois.
95
96 William L. Schev MAY, u97
TABLE I
CASES i-6
Case I 2 3 4 S 6
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Adynamic Ileus + + + + +
5coliosis - - - - + -
Calcifications - - + - - -
Mass - - - - - -
Regular Mucosa - + + +
Mas, + ++ + -
Cut-OffSign - ++ -
Didnt Fill + +
Buttock Sign + -
Mass Large - -
Mass Small -
Ileum
Filled + + + + + +
DidntFill - - - - - -
Disposition Not operated: Operated: normal Operated:twisted Xot operated: Operated: appen- Not operated:
antibiotics for 3 appendix; later ovarian cyst-der- appendicitis; dicitis with gan- probable corpus
days; discharged diagnosis ulcer- moid home without grenous base luteum cyst
ative colitis antibiotics
CASES 7-12
Case 7 8 9 so ii 12
Calcifications - - - ? appendicolith - -
Mass - - - - - -
Regular Mucosa + +
Mass -
Cut-Off Sign -
Didnt Fill ++ ++ ++ + ++
ButtockSign - - - -
MassLarge ? +++ -
PressureUponlt? - + - + - -
Disposition Not operated: Operated: appen- Operated: ap- Operated: ovar- Not operated: Operated: inter-
antibiotics for diceal abscess pendicitis Ian dermoid home in 3 days val appendec-
peritonitis; home, tomy; localized
well appendiceal ab-
scess
VoL. uu8, No. u Diagnosis of Appendicitis in Children 97
TABLE I-(Continued)
CASES 13-18
Case 53 14 15 i6 17 u8
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Calcifications - - - - - -
Mass - ? ?+ - - +!-?
Regular Mucosa - - +
Mass + - -
Cut-Off5ign + + -
Didnt Fill + + - -
Buttock Sign - - + -
Mass Large - - - +
MassSmall ++ - - -
Ileum
Filled + + + + + +
Didnt Fill - - - - - -
Disposition Operated: acute Operated: ileitis Operated: acute Observed 24 Operated: twisted Operated: acute
and subacute ap- and appendicitis appendicitis hours. home ovarian cyst appendix with
pendicitis abscess
CASES 19-25
Case xc 20 21 22 23 24 25
Calcifications - - - - - - +
Mass - ? pelvic mass - - - - 1 -
RegularMucosa - + - - +
Mass - - - - -
Cut-Off Sign -
Didnt Fill + +
Buttock Sign - -
Mass Large - +
MassSmall - -
fleum
Filled + + + + +
Didnt Fill - - + + - - -
1110.-I yr. 6 0
One patient was diagnosed as non_ap-
pendiceal inflammatory disease, most likely
I vr.-2 yr. 6 1 pelvi c i llfl am m atorv di sease. Roen tgeno-
grams demonstrated 11011-filling of tile ap-
2 vr.-5 yr. 7 0
pendix, 1)Ut l1() masses, impressions, or
5 yr-b yr. 11 2 otller evidence of appendicitis. An i 8
cm. long appendix witFi :111 illflamed tip
10 yr. 9 I was found surgically.
lilerefore, of 25 cases, 2 1 (84 per cent)
Total 46
4 were diagnosed correct1 as either ap-
pendicitis or 110 appendicitis. Of tile re-
also evaluated. Special efforts to fill the maining 4, 2 may llave been appendicitis,
appendix in these children were made. Tile but were managed by antibiotics, I had
ages of the patients are indicated in Table definite surgical disease (a mass) proven
ii, as are tile results. by barium enema study and ill only i case
was the barium enema examination not
RESU LIS
llelpful in adding more information.
PATIENTS IN WHOM A BARIUM ENEMA Of tile control group 50 cases were
EXAMINATION WAS PERFORMED
evaluated. Non-filling of the appendix oc-
Of 24 children with undiagnosed but curred 8 per cent of tile time. Age did not
suspected intrapenitoneal inflammatory dis- seem to be a collSideratioll relative to the
ease the correct diagnosis of appendicitis ease with wilich the appelldix filled.
was made preopenativelv, by virtue of the
PLAIN FlINt ROENTGENOGRAIHIC FINDINGS
barium enema examination, in 9.
The incorrect diagnosis of appendicitis Of the 9 patients with proven appendici-
was made in I patient who had a twisted
ovarian dermoid, which was inflamed. The
appendix did not fill and a lange mass
impression on the cecum was evident.
In ii cases the barium enema examina-
tion demonstrated filling of the appendix,
no mass, no unusual impressions or sep-
aration of small bowel juxtaposed to the
cecum and appendix. These patients were
followed as non-appendicitis patients, were
treated conservatively, and did well.
Two patients were believed to have ap-
pendicitis by barium enema study findings.
Surgical consultants disagreed and they
were treated with antibiotics. Their symp-
toms disappeared in 3 to 4 days and they
were discharged. 11G. I. A cecal tip impression (arrow) and non-filling
One patient demonstrated a mass im- of the appendix.
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100 William L. Schey MA\, 1973
I
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110. T. A schematic representation of the appearance of the appendix, terminal ileum, and cecum in the
normal and abnormal conditions considered. LGE=large; RLQ=right lower quadrant.
Vot. uu8, No. I Diagnosis of Appendicitis in Children 103
Pediatric Radiology
barium enema examination. 1\Iichael Reese Hospital
Although suggestions of possible con- and Medical Center
tnaindications to the use of the barium 29th Street and Ellis Avenue
enema study have been noted,2 we know Chicago, Illinois 6o6i6
of no complications as we applied it.
RE FERENCES
CONCLUSIONS AND SUMMARY
1. BECK, W. S., and WINTER, 1. Acute appendicitis
The use of the barium enema examina- and retained barium. Gut/irie C/in. Ru/i., 1964,
33, I0-I07.
tion to define the presence on absence of
2. lIGIEL, I. S., and 1IGIEL, S. J. Barium examina-
appendiceal disease has proven to be of
tion ofcecum in appendicitis. 4cta radio/., 1962,
significant value. This evaluation in a 57, 469479.
series of patients with appendicitis and in 3. KUZNETSON, A., P0DOINY, 1., and BRATUS, I. I.
a group of patients without appendicitis Roentgen diagnosis of chronic appendicitis.
conclusively demonstrates the excellent Vrach. (/t/O., Kiev., 1971, 12, 54-56.
results obtained. 4. 1,ASSRICH, M. A. Radiological examination in
chronic appendicitis in children. 4nn. radio/.,
Findings in tile barium enema study of
1964, 7, ,95399.
(I) non-filling of the appendix, plus a mass, . RULPS, D. M., and 1ISHER, R. G. Radiographic
(2) non-filling of the appendix with asso- findings in acute appendicitis. Texas Med.,
ciated findings, () partial filling with and 1971, 67, 89-9.
without a mass, and (4) irregular filling on 6. SOTER, C. Use of barium in diagnosis of acute
a cut-off sign are strongly suggestive, if appendiceal disease: new radiological sign.
C/in. Radio/., 1968, i, 410-415.
not diagnostic, of acute appendicitis.
7. SOTER, C., and MALMED, L. A. Contribution of
Non-filling of the appendix occurs about radiologist in diagnosis of acute appendicitis.
8 pen cent of the time and should be consid- Northwest Community Hosp. Med. Ru/i., 1968,
ered suspicious of an appendiceal problem. 5, 35-360.
Plain film noen tgenographic findings, 8. TEGTMEVER, C. J., THISTLETHWAITE, J. R., and
other than an appendicolith or gas within SNEED, T. 1. Roentgen findings in acute appen-
dicitis. Med. ilnn., 1969, 38, 127-130.
the appendix, are inconclusive and cannot
9. \VILKINSON, R. H., BARTLETF, R. H., anti
indicate the nature of the problem in as ERAKLIS, A. J. I)iagnosis of appendicitis in
specific a manner as the barium enema infancy. A.M.A. Am. 7. Dis. Child., 1969, zz8,
examination. 687-690.