When Appendicitis Is Suspected in

Children

Oleh :
Dynna Akmal
 Introduction
Acute appendicitis is the most common
condition requiring emergency abdominal
surgery in the pediatric population, with
60,00080,000 cases annually in the United
States.
It is one of the major causes of hospitalization
in children. The condition typically develops
in older children and young adults. It is rare
under the age of 2 years. The lifetime risk of
acute appendicitis ranges from 7% to 9%.
In this article, we review current
practice with respect to the assessment
of suspected acute appendicitis in
children, including the role of imaging
in patient assessment, the diagnostic
efficacy of graded-compression
ultrasonography (US) and helical
computed tomography (CT) for
diagnosis, the characteristic imaging
appearance of acute appendicitis at US
and CT, and the effect of cross-
sectional imaging on patient outcomes.
 Clinical Assessment
of Acute Appendicitis

Clinical signs and symptoms

associated with acute appendicitis
include crampy, periumbilical or right
lower quadrant pain; nausea;
vomiting point tenderness in the
right lower quadrant; rebound
tenderness; and leukocytosis with a
left shift.
Various objective clinical scoring systems
havebeen devised to stratify patient risk
of appendicitis. The most widely used
clinical scoring system is the MANTRELS
score (Table). It incorporates eight
clinical and laboratory factors that were
found to be useful in making the
diagnosis of acute appendicitis.
The MANTRELS score has been shown to
be useful in discriminating between
children with acute appendicitis and
those without the disease.
 The MANTRELS Score
Characteristic Points
M igration of pain to 1
right lower quadrant
A norexia 1
N ausea and vomiting 1
T enderness in 2
right lower quadrant
R ebound pain 1
E levated temperature 1
L eukocytosis 2
S hift of white blood cell 1
count to left
Total 10
 Complications

Reported complications include

perforation, abscess formation,
peritonitis, wound infection, sepsis,
infertility, adhesions, bowel
obstruction, and death.
 Imaging Assessment
of Acute Appendicitis
Routine use of abdominal radiography
in these children has little value
unless bowel obstruction or
perforation is suspected. Therefore,
conventional radiography is not
discussed here, and we focus on the
cross-sectional imaging assessment
of acute appendicitis with graded-
compression US and helical CT.
 The goals of imaging in this condition
are to
(a) facilitate an earlier diagnosis of
acute appendicitis or other
conditions that it may mimic,
(b) reduce negative laparotomy and
perforation rates, and
(c) reduce the intensity and cost of
care.
 ultrasonography (US)
At the start of the examination, the patient is asked
to point to the site of maximal tenderness. This is
useful to expedite the examination and to aid in
locating a retrocecal appendix. On longitudinal
images, the inflamed, nonperforated appendix
appears as a fluid-filled, noncompressible,blind-
ending tubular structure (Fig 1).
The maximal appendiceal diameter, from outside
wall to outside wall, is greater than 6 mm. In early
nonperforated appendicitis, an inner echogenic
lining representing submucosa can be identified
(Fig 1).
Figure 1. Acute appendicitis. Longitudinal (a)
and transverse (b) US scans through an
inflamed appendix
(between electronic calipers) show that it is enlarged.
Note the central echogenic mucosal lining.
Figure 2. Acute appendicitis with target sign.
Transverse
US scan through an inflamed appendix shows an
intact
echogenic submucosal layer and a fluid-filled lumen
(F), resulting in a target appearance.
Other findings of appendicitis include an appendicolith,
which appears as an echogenic foci withacoustic
shadowing (Fig 3)

Figure 3. Acute appendicitis with an appendicolith.

Longitudinal (a) and transverse (b) US scans through
an inflamed appendix show an echogenic appendicolith
with acoustic shadowing.
 pericecal or periappendiceal fluid; increased
periappendiceal echogenicity representing fat
infiltration (Fig 4); and enlarged mesenteric lymph
nodes. The only US sign that is specific for
appendicitis is an enlarged, noncompressible
appendix measuring greater than 6 mm in maximal
diameter.

Figure 4. Acute appendicitis

with increased
periappendiceal echogenicity.
Longitudinal US scan through the
righ lower quadrant shows an
area of increased echogenicity
(arrows) representing infiltration
of mesenteric fat surroundingan
enlarged appendix (between
electronic calipers).
Figure 5. Acute appendicitis with loss of the
echogenic submucosal layer. Longitudinal (a)
and transverse (b) US
scans through an inflamed appendix show a diffuse
hypoechoic and enlarged appendix (between
electronic calipers),
with loss of the normally echogenic submucosal
layer. At surgery, appendiceal perforation was
noted.
The use of color Doppler US provides a useful adjunct in the
evaluation of suspected acute appendicitis. Although color
Doppler US does not increase the sensitivity of the
examination, it makes interpretation of the gray-scale US
findings easier and can increase observer confidence in the
diagnosis of acute appendicitis. Color Doppler US of
nonperforated appendicitis typically demonstrates peripheral
wall hyperemia, reflecting inflammatory hyperperfusion (Fig 8)

Figure 8. Acute appendicitis at color Doppler US. Longitudinal (a) and transverse
(b) US images through an inflamed appendix demonstrate marked hyperemia
along the periphery.
 Helical CT
Helical CT has been shown to be a highly
sensitive and specific modality for the
diagnosis of acute appendicitis in
children and adults.
The normal appendix can be identified at
CT in over three-fourths of children . The
appendix arises from the posteromedial
aspect of the cecum, approximately 12
cm below the ileocecal junction (fig 11).
Figure 11. Normal appendix. (a) Axial CT scan obtained
through the lower abdomen with thin collimation following the
intravenous and rectal administration of contrast material
demonstrates the normal terminal ileum (arrows). (b) Axial
CT scan obtained 2 cm below a demonstrates the
normal proximal appendix (arrow) originating from the
cecal apex. (c) Axial CT scan obtained 2 cm below b
demonstrates the normal distal appendix (arrow). Note
that the appendix does not fill with
a.
contrast material. b.
c. The relationship of the base
of the appendix to the
cecum is constant, but the
free end of the appendix is
mobile and can be directed
medially, caudally,
laterally, or retrocecally.
The appendix is usually
curved and may be
tortuous. A segment of the
appendix is commonly
noted at a level higher than
the ileocecal valve. The
maximal normal
appendiceal diameter is
quite variable; although it
usually is 7 mm or less, it
may occasionally be larger
 The only CT findings specific for
appendicitis are an enlarged
appendix and cecal apical changes,
which represent contiguous spread of
the inflammatory process to the
cecum. The identification of cecal
apical changes is particularly useful
in allowing a confident diagnosis of
acute appendicitis if there is difficulty
in identifying an enlarged appendix
(Fig 21).
Figure 21. Acute appendicitis with cecal apical thickening. (a) Axial
CT scan obtained through the upper pelvis
with thin collimation following the intravenous and rectal administration of
contrast material demonstrates focal cecal apical thickening (arrow). (b) Axial
CT scan obtained 1 cm below a demonstrates an enlarged curvilinear
appendix (arrow). Note that there is not a good plane of separation between
the appendix and adjacent unopacified small bowel loops. The cecal apical
thickening was helpful in calling attention to the abnormal appendix.
a b