Download PDF
J Pediatr Infect Dis 2017; 12(01): 048-060
DOI: 10.1055/s-0037-1599119
Review Article
Georg Thieme Verlag KG Stuttgart · New York

Imaging of Acute Appendicitis in Children

Mark R. Ferguson
1   Department of Radiology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, United States
,
Jason N. Wright
1   Department of Radiology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, United States
,
Anh-Vu Ngo
1   Department of Radiology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, United States
,
Sarah M. Desoky
2   Department of Radiology, The University of Arizona College of Medicine, Tucson, Arizona, United States
,
Ramesh S. Iyer
1   Department of Radiology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, United States
› Author Affiliations
Further Information

Publication History

04 September 2016

04 October 2016

Publication Date:
01 March 2017 (online)

Also available at
    Permissions and Reprints

Abstract

Acute appendicitis is a common cause of abdominal surgery in children, and is the result of appendiceal luminal obstruction and subsequent inflammation. The clinical presentation is often variable, allowing imaging to play a central role in disease identification and characterization. Ultrasound is often the modality of choice for diagnosis of appendicitis in children. Ready availability and lack of ionizing radiation are attractive features of sonography, though operator dependence is a potential barrier. Computed tomography (CT) was historically the preferred modality in children, as in adults, but recent awareness of the risks of radiation has reduced its usage. The purpose of this article is to detail the imaging findings of appendicitis in children. The discussion will focus on typical signs of appendicitis seen on ultrasound, CT, and magnetic resonance imaging. Considerations for percutaneous drainage by interventional radiology will also be presented. Finally, the evolution of imaging algorithms for appendicitis will be discussed.

Keywords

appendicitis - ultrasound - CT - MR - interventional radiology drainage - imaging algorithm - appendectomy
 

  • References

  • 1 Carr NJ. The pathology of acute appendicitis. Ann Diagn Pathol 2000; 4 (1) 46-58
    CrossrefPubMedSearch in Google Scholar
  • 2 Henderson J, Goldacre MJ, Fairweather JM, Marcovitch H. Conditions accounting for substantial time spent in hospital in children aged 1-14 years. Arch Dis Child 1992; 67 (1) 83-86
    CrossrefPubMedSearch in Google Scholar
  • 3 Hale DA, Molloy M, Pearl RH, Schutt DC, Jaques DP. Appendectomy: a contemporary appraisal. Ann Surg 1997; 225 (3) 252-261
    CrossrefPubMedSearch in Google Scholar
  • 4 Reynolds SL. Missed appendicitis and medical liability. Clin Pediatr Emerg Med 2003; 4 (4) 231-234
    CrossrefPubMedSearch in Google Scholar
  • 5 Rothrock SG, Skeoch G, Rush JJ, Johnson NE. Clinical features of misdiagnosed appendicitis in children. Ann Emerg Med 1991; 20 (1) 45-50
    PubMedSearch in Google Scholar
  • 6 Puig S, Hörmann M, Rebhandl W, Felder-Puig R, Prokop M, Paya K. US as a primary diagnostic tool in relation to negative appendectomy: six years experience. Radiology 2003; 226 (1) 101-104
    CrossrefPubMedSearch in Google Scholar
  • 7 Fitz RH. Perforating inflammation of the vermiform appendix: with special reference to its early diagnosis and treatment. Am J Med Sci 1886; 92: 321-346
    PubMedSearch in Google Scholar
  • 8 Markar SR, Blackburn S, Cobb R , et al. Laparoscopic versus open appendectomy for complicated and uncomplicated appendicitis in children. J Gastrointest Surg 2012; 16 (10) 1993-2004
    CrossrefPubMedSearch in Google Scholar
  • 9 Amin P, Cheng D. Management of complicated appendicitis in the pediatric population: when surgery doesn't cut it. Semin Intervent Radiol 2012; 29 (3) 231-236
    Thieme ConnectPubMedSearch in Google Scholar
  • 10 Lee SL, Islam S, Cassidy LD, Abdullah F, Arca MJ ; 2010 American Pediatric Surgical Association Outcomes and Clinical Trials Committee. Antibiotics and appendicitis in the pediatric population: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review. J Pediatr Surg 2010; 45 (11) 2181-2185
    CrossrefPubMedSearch in Google Scholar
  • 11 Minneci PC, Sulkowski JP, Nacion KM , et al. Feasibility of a nonoperative management strategy for uncomplicated acute appendicitis in children. J Am Coll Surg 2014; 219 (2) 272-279
    CrossrefPubMedSearch in Google Scholar
  • 12 Minneci PC, Mahida JB, Lodwick DL , et al. Effectiveness of patient choice in nonoperative vs surgical management of pediatric uncomplicated acute appendicitis. JAMA Surg 2016; 151 (5) 408-415
    CrossrefPubMedSearch in Google Scholar
  • 13 Wiersma F, Toorenvliet BR, Bloem JL, Allema JH, Holscher HC. US examination of the appendix in children with suspected appendicitis: the additional value of secondary signs. Eur Radiol 2009; 19 (2) 455-461
    CrossrefPubMedSearch in Google Scholar
  • 14 Spear R, Kimmey MB, Wang KY, Sillery JK, Benjamin DR, Sawin RS. Appendiceal US scans: histologic correlation. Radiology 1992; 183 (3) 831-834
    CrossrefPubMedSearch in Google Scholar
  • 15 Chan L, Shin LK, Pai RK, Jeffrey RB. Pathologic continuum of acute appendicitis: sonographic findings and clinical management implications. Ultrasound Q 2011; 27 (2) 71-79
    CrossrefPubMedSearch in Google Scholar
  • 16 Birnbaum BA, Wilson SR. Appendicitis at the millennium. Radiology 2000; 215 (2) 337-348
    CrossrefPubMedSearch in Google Scholar
  • 17 Rettenbacher T, Hollerweger A, Macheiner P , et al. Outer diameter of the vermiform appendix as a sign of acute appendicitis: evaluation at US. Radiology 2001; 218 (3) 757-762
    CrossrefPubMedSearch in Google Scholar
  • 18 Goldin AB, Khanna P, Thapa M, McBroom JA, Garrison MM, Parisi MT. Revised ultrasound criteria for appendicitis in children improve diagnostic accuracy. Pediatr Radiol 2011; 41 (8) 993-999
    CrossrefPubMedSearch in Google Scholar
  • 19 Trout AT, Towbin AJ, Zhang B. Journal club: the pediatric appendix: defining normal. AJR Am J Roentgenol 2014; 202 (5) 936-945
    CrossrefPubMedSearch in Google Scholar
  • 20 Lardenoye SW, Puylaert JB, Smit MJ, Holscher HC. Appendix in children with cystic fibrosis: US features. Radiology 2004; 232 (1) 187-189
    CrossrefPubMedSearch in Google Scholar
  • 21 Simonovský V. Normal appendix: is there any significant difference in the maximal mural thickness at US between pediatric and adult populations?. Radiology 2002; 224 (2) 333-337
    CrossrefPubMedSearch in Google Scholar
  • 22 Puylaert JB. Acute appendicitis: US evaluation using graded compression. Radiology 1986; 158 (2) 355-360
    CrossrefPubMedSearch in Google Scholar
  • 23 Kessler N, Cyteval C, Gallix B , et al. Appendicitis: evaluation of sensitivity, specificity, and predictive values of US, Doppler US, and laboratory findings. Radiology 2004; 230 (2) 472-478
    CrossrefPubMedSearch in Google Scholar
  • 24 Sivit CJ, Siegel MJ, Applegate KE, Newman KD. When appendicitis is suspected in children. Radiographics 2001; 21 (1) 247-262 , 288–294
    CrossrefPubMedSearch in Google Scholar
  • 25 Sivit CJ. Imaging the child with right lower quadrant pain and suspected appendicitis: current concepts. Pediatr Radiol 2004; 34 (6) 447-453
    CrossrefPubMedSearch in Google Scholar
  • 26 Borushok KF, Jeffrey Jr RB, Laing FC, Townsend RR. Sonographic diagnosis of perforation in patients with acute appendicitis. AJR Am J Roentgenol 1990; 154 (2) 275-278
    CrossrefPubMedSearch in Google Scholar
  • 27 Marin D, Ho LM, Barnhart H, Neville AM, White RR, Paulson EK. Percutaneous abscess drainage in patients with perforated acute appendicitis: effectiveness, safety, and prediction of outcome. AJR Am J Roentgenol 2010; 194 (2) 422-429
    CrossrefPubMedSearch in Google Scholar
  • 28 Alaedeen DI, Cook M, Chwals WJ. Appendiceal fecalith is associated with early perforation in pediatric patients. J Pediatr Surg 2008; 43 (5) 889-892
    CrossrefPubMedSearch in Google Scholar
  • 29 Mittal MK, Dayan PS, Macias CG , et al; Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. Performance of ultrasound in the diagnosis of appendicitis in children in a multicenter cohort. Acad Emerg Med 2013; 20 (7) 697-702
    CrossrefPubMedSearch in Google Scholar
  • 30 Benjaminov O, Atri M, Hamilton P, Rappaport D. Frequency of visualization and thickness of normal appendix at nonenhanced helical CT. Radiology 2002; 225 (2) 400-406
    CrossrefPubMedSearch in Google Scholar
  • 31 Ramalingam V, Bates DD, Buch K , et al. Diagnosing acute appendicitis using a nonoral contrast CT protocol in patients with a BMI of less than 25. Emerg Radiol 2016; 23 (5) 455-462
    CrossrefPubMedSearch in Google Scholar
  • 32 Schumpelick V, Dreuw B, Ophoff K, Prescher A. Appendix and cecum. Embryology, anatomy, and surgical applications. Surg Clin North Am 2000; 80 (1) 295-318
    CrossrefPubMedSearch in Google Scholar
  • 33 Orscheln ES, Trout AT. Appendiceal diameter: CT versus sonographic measurements. Pediatr Radiol 2016; 46 (3) 316-321
    CrossrefPubMedSearch in Google Scholar
  • 34 Rao PM, Rhea JT, Novelline RA. Sensitivity and specificity of the individual CT signs of appendicitis: experience with 200 helical appendiceal CT examinations. J Comput Assist Tomogr 1997; 21 (5) 686-692
    CrossrefPubMedSearch in Google Scholar
  • 35 Mullins ME, Rhea JT, Novelline RA. Review of suspected acute appendicitis in adults and children using CT and colonic contrast material. Semin Ultrasound CT MR 2003; 24 (2) 107-113
    CrossrefPubMedSearch in Google Scholar
  • 36 Lowe LH, Penney MW, Scheker LE , et al. Appendicolith revealed on CT in children with suspected appendicitis: how specific is it in the diagnosis of appendicitis?. AJR Am J Roentgenol 2000; 175 (4) 981-984
    CrossrefPubMedSearch in Google Scholar
  • 37 Choi D, Park H, Lee YR , et al. The most useful findings for diagnosing acute appendicitis on contrast-enhanced helical CT. Acta Radiol 2003; 44 (6) 574-582
    CrossrefPubMedSearch in Google Scholar
  • 38 Alobaidi M, Shirkhoda A. Value of bone window settings on CT for revealing appendicoliths in patients with appendicitis. AJR Am J Roentgenol 2003; 180 (1) 201-205
    CrossrefPubMedSearch in Google Scholar
  • 39 McNeeley MF, Vo NJ, Prabhu SJ, Vergnani J, Shaw DW. Percutaneous drainage of intra-abdominal abscess in children with perforated appendicitis. Pediatr Radiol 2012; 42 (7) 805-812
    CrossrefPubMedSearch in Google Scholar
  • 40 Levin T, Whyte C, Borzykowski R, Han B, Blitman N, Harris B. Nonoperative management of perforated appendicitis in children: can CT predict outcome?. Pediatr Radiol 2007; 37 (3) 251-255
    CrossrefPubMedSearch in Google Scholar
  • 41 Bulas D, Goske M, Applegate K, Wood B. Image Gently: improving health literacy for parents about CT scans for children. Pediatr Radiol 2009; 39 (2) 112-116
    CrossrefPubMedSearch in Google Scholar
  • 42 Sidhu M, Goske MJ, Connolly B , et al. Image Gently, Step Lightly: promoting radiation safety in pediatric interventional radiology. AJR Am J Roentgenol 2010; 195 (4) W299-301
    PubMedSearch in Google Scholar
  • 43 ACR - Avoid CT to evaluate appendicitis in children | Choosing Wisely. Available at: http://www.choosingwisely.org/clinician-lists/american-college-radiology-ct-to-evaluate-appendicitis-in-children/ . Accessed August 16, 2016
    PubMed
  • 44 Mak GZ, Loeff DS. Paradigm shifts in the treatment of appendicitis. Pediatr Ann 2016; 45 (7) e235-e240
    CrossrefPubMedSearch in Google Scholar
  • 45 Armstrong J, Merritt N, Jones S, Scott L, Bütter A. Non-operative management of early, acute appendicitis in children: is it safe and effective?. J Pediatr Surg 2014; 49 (5) 782-785
    CrossrefPubMedSearch in Google Scholar
  • 46 Hartwich J, Luks FI, Watson-Smith D , et al. Nonoperative treatment of acute appendicitis in children: a feasibility study. J Pediatr Surg 2016; 51 (1) 111-116
    CrossrefPubMedSearch in Google Scholar
  • 47 Wray CJ, Kao LS, Millas SG, Tsao K, Ko TC. Acute appendicitis: controversies in diagnosis and management. Curr Probl Surg 2013; 50 (2) 54-86
    CrossrefPubMedSearch in Google Scholar
  • 48 Seif HMA, Reyad HA, Korany M, Metwally M, Ahmed AI. Immediate operation versus percutaneous drainage for treatment of appendicular abscess. Egypt J Radiol Nucl Med 2015; 46 (4) 999-1002
    PubMedSearch in Google Scholar
  • 49 Arani K, Nandalur K, Tucker CM, Bloom DA. Image-guided percutaneous drainage in the pediatric population: a primer for radiologists. J Clin Imaging Sci 2011; 1: 31
    CrossrefPubMedSearch in Google Scholar
  • 50 Brenner DJ, Hall EJ. Computed tomography--an increasing source of radiation exposure. N Engl J Med 2007; 357 (22) 2277-2284
    CrossrefPubMedSearch in Google Scholar
  • 51 Moore MM, Kulaylat AN, Hollenbeak CS, Engbrecht BW, Dillman JR, Methratta ST. Magnetic resonance imaging in pediatric appendicitis: a systematic review. Pediatr Radiol 2016; 46 (6) 928-939
    CrossrefPubMedSearch in Google Scholar
  • 52 Cobben L, Groot I, Kingma L, Coerkamp E, Puylaert J, Blickman J. A simple MRI protocol in patients with clinically suspected appendicitis: results in 138 patients and effect on outcome of appendectomy. Eur Radiol 2009; 19 (5) 1175-1183
    CrossrefPubMedSearch in Google Scholar
  • 53 Thieme ME, Leeuwenburgh MM, Valdehueza ZD , et al. Diagnostic accuracy and patient acceptance of MRI in children with suspected appendicitis. Eur Radiol 2014; 24 (3) 630-637
    CrossrefPubMedSearch in Google Scholar
  • 54 Bayraktutan Ü, Oral A, Kantarci M , et al. Diagnostic performance of diffusion-weighted MR imaging in detecting acute appendicitis in children: comparison with conventional MRI and surgical findings. J Magn Reson Imaging 2014; 39 (6) 1518-1524
    CrossrefPubMedSearch in Google Scholar
  • 55 Leeuwenburgh MM, Wiarda BM, Bipat S , et al. Acute appendicitis on abdominal MR images: training readers to improve diagnostic accuracy. Radiology 2012; 264 (2) 455-463
    CrossrefPubMedSearch in Google Scholar
  • 56 Leeuwenburgh MM, Jensch S, Gratama JW , et al; OPTIMAP study group. MRI features associated with acute appendicitis. Eur Radiol 2014; 24 (1) 214-222
    CrossrefPubMedSearch in Google Scholar
  • 57 Koning JL, Naheedy JH, Kruk PG. Diagnostic performance of contrast-enhanced MR for acute appendicitis and alternative causes of abdominal pain in children. Pediatr Radiol 2014; 44 (8) 948-955
    CrossrefPubMedSearch in Google Scholar
  • 58 Kulaylat AN, Moore MM, Engbrecht BW , et al. An implemented MRI program to eliminate radiation from the evaluation of pediatric appendicitis. J Pediatr Surg 2015; 50 (8) 1359-1363
    CrossrefPubMedSearch in Google Scholar
  • 59 Moore MM, Gustas CN, Choudhary AK , et al. MRI for clinically suspected pediatric appendicitis: an implemented program. Pediatr Radiol 2012; 42 (9) 1056-1063
    CrossrefPubMedSearch in Google Scholar
  • 60 Aspelund G, Fingeret A, Gross E , et al. Ultrasonography/MRI versus CT for diagnosing appendicitis. Pediatrics 2014; 133 (4) 586-593
    CrossrefPubMedSearch in Google Scholar
  • 61 Johnson AK, Filippi CG, Andrews T , et al. Ultrafast 3-T MRI in the evaluation of children with acute lower abdominal pain for the detection of appendicitis. AJR Am J Roentgenol 2012; 198 (6) 1424-1430
    CrossrefPubMedSearch in Google Scholar
  • 62 Dillman JR, Gadepalli S, Sroufe NS , et al. Equivocal pediatric appendicitis: unenhanced MR imaging protocol for nonsedated children—a clinical effectiveness study. Radiology 2016; 279 (1) 216-225
    CrossrefPubMedSearch in Google Scholar
  • 63 Nitta N, Takahashi M, Furukawa A, Murata K, Mori M, Fukushima M. MR imaging of the normal appendix and acute appendicitis. J Magn Reson Imaging 2005; 21 (2) 156-165
    CrossrefPubMedSearch in Google Scholar
  • 64 Swenson DW, Schooler GR, Stamoulis C, Lee EY. MRI of the normal appendix in children: data toward a new reference standard. Pediatr Radiol 2016; 46 (7) 1003-1010
    CrossrefPubMedSearch in Google Scholar
  • 65 Bachur RG, Levy JA, Callahan MJ, Rangel SJ, Monuteaux MC. Effect of reduction in the use of computed tomography on clinical outcomes of appendicitis. JAMA Pediatr 2015; 169 (8) 755-760
    CrossrefPubMedSearch in Google Scholar
  • 66 Rao PM, Rhea JT, Novelline RA, Mostafavi AA, McCabe CJ. Effect of computed tomography of the appendix on treatment of patients and use of hospital resources. N Engl J Med 1998; 338 (3) 141-146
    CrossrefPubMedSearch in Google Scholar
  • 67 Peña BM, Taylor GA, Fishman SJ, Mandl KD. Effect of an imaging protocol on clinical outcomes among pediatric patients with appendicitis. Pediatrics 2002; 110 (6) 1088-1093
    CrossrefPubMedSearch in Google Scholar
  • 68 Doria AS, Moineddin R, Kellenberger CJ , et al. US or CT for diagnosis of appendicitis in children and adults? A meta-analysis. Radiology 2006; 241 (1) 83-94
    CrossrefPubMedSearch in Google Scholar
  • 69 Pearce MS, Salotti JA, Little MP , et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet 2012; 380 (9840): 499-505
    CrossrefPubMedSearch in Google Scholar
  • 70 Miglioretti DL, Johnson E, Williams A , et al. The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. JAMA Pediatr 2013; 167 (8) 700-707
    CrossrefPubMedSearch in Google Scholar
  • 71 Sharp NE, Raghavan MU, Svetanoff WJ , et al. Radiation exposure - how do CT scans for appendicitis compare between a free standing children's hospital and non-dedicated pediatric facilities?. J Pediatr Surg 2014; 49 (6) 1016-1019 , discussion 1019
    CrossrefPubMedSearch in Google Scholar
  • 72 Goske MJ, Applegate KE, Boylan J , et al. The ‘Image Gently’ campaign: increasing CT radiation dose awareness through a national education and awareness program. Pediatr Radiol 2008; 38 (3) 265-269
    CrossrefPubMedSearch in Google Scholar
  • 73 Goske MJ, Applegate KE, Boylan J , et al. The Image Gently campaign: working together to change practice. AJR Am J Roentgenol 2008; 190 (2) 273-274
    CrossrefPubMedSearch in Google Scholar
  • 74 Binkovitz LA, Unsdorfer KM, Thapa P , et al. Pediatric appendiceal ultrasound: accuracy, determinacy and clinical outcomes. Pediatr Radiol 2015; 45 (13) 1934-1944
    CrossrefPubMedSearch in Google Scholar
  • 75 van Atta AJ, Baskin HJ, Maves CK , et al. Implementing an ultrasound-based protocol for diagnosing appendicitis while maintaining diagnostic accuracy. Pediatr Radiol 2015; 45 (5) 678-685
    CrossrefPubMedSearch in Google Scholar
  • 76 Blitman NM, Anwar M, Brady KB, Taragin BH, Freeman K. Value of focused appendicitis ultrasound and Alvarado score in predicting appendicitis in children: can we reduce the use of CT?. AJR Am J Roentgenol 2015; 204 (6) W707-12
    PubMedSearch in Google Scholar
  • 77 Athans BS, Depinet HE, Towbin AJ, Zhang Y, Zhang B, Trout AT. Use of clinical data to predict appendicitis in patients with equivocal US findings. Radiology 2016; 280 (2) 557-567
    CrossrefPubMedSearch in Google Scholar
  • 78 Srinivasan A, Servaes S, Peña A, Darge K. Utility of CT after sonography for suspected appendicitis in children: integration of a clinical scoring system with a staged imaging protocol. Emerg Radiol 2015; 22 (1) 31-42
    CrossrefPubMedSearch in Google Scholar
  • 79 Ramarajan N, Krishnamoorthi R, Barth R , et al. An interdisciplinary initiative to reduce radiation exposure: evaluation of appendicitis in a pediatric emergency department with clinical assessment supported by a staged ultrasound and computed tomography pathway. Acad Emerg Med 2009; 16 (11) 1258-1265
    CrossrefPubMedSearch in Google Scholar
  • 80 Krishnamoorthi R, Ramarajan N, Wang NE , et al. Effectiveness of a staged US and CT protocol for the diagnosis of pediatric appendicitis: reducing radiation exposure in the age of ALARA. Radiology 2011; 259 (1) 231-239
    CrossrefPubMedSearch in Google Scholar
  • 81 Le J, Kurian J, Cohen HW, Weinberg G, Scheinfeld MH. Do clinical outcomes suffer during transition to an ultrasound-first paradigm for the evaluation of acute appendicitis in children?. AJR Am J Roentgenol 2013; 201 (6) 1348-1352
    CrossrefPubMedSearch in Google Scholar
  • 82 Doniger SJ, Kornblith A. Point-of-care ultrasound integrated into a staged diagnostic algorithm for pediatric appendicitis. Pediatr Emerg Care 2016 (e-pub ahead of print)
    PubMedSearch in Google Scholar
  • 83 Wan MJ, Krahn M, Ungar WJ , et al. Acute appendicitis in young children: cost-effectiveness of US versus CT in diagnosis--a Markov decision analytic model. Radiology 2009; 250 (2) 378-386
    CrossrefPubMedSearch in Google Scholar
  • 84 Herliczek TW, Swenson DW, Mayo-Smith WW. Utility of MRI after inconclusive ultrasound in pediatric patients with suspected appendicitis: retrospective review of 60 consecutive patients. AJR Am J Roentgenol 2013; 200 (5) 969-973
    CrossrefPubMedSearch in Google Scholar
  • 85 Orth RC, Guillerman RP, Zhang W, Masand P, Bisset III GS. Prospective comparison of MR imaging and US for the diagnosis of pediatric appendicitis. Radiology 2014; 272 (1) 233-240
    CrossrefPubMedSearch in Google Scholar