IndianJRadiolImaging164523-8683965 022443

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Imaging In Acute Appendicitis: A Review
RK JAIN, M JAIN, CL RAJAK, S MUKHERJEE, PP BHATTACHARYYA, MR SHAH
Ind J Radiol Imag 2006 16:4:523-532
Key words : Acute appendicitis, Xray, USG, CT
INTRODUCTION
Acute appendicitis is the most common cause of
emergencyabdominalsurgery(1).Whilethediagnosis
ofacuteappendicitisisstilllargelythoughttobeaclinical
one,ameaningfulnumberofpatientsarefoundtohave
normalappendicesatsurgery.Theerroneousdiagnosis
ofthisacuteconditionhasledtoahighrate(8-30%)of
inappropriateremovalofthenormalappendix.Thishigh
rateneedstobebalancedwiththeproblemofbeingover
restrictiveinthediagnosisofacuteappendicitis,which
may allow uncomplicated appendices to progress to
perforationandperitonitis(2).
However the incidence of acute appendicitis requiring
appendectomyhassignificantlydecreasedoverthepast
threeorfourdecade,andthetrendappearstocontinue.
Someofthedecreaseinthenumberofappendectomies
isattributabletobetterdiagnosis(3).Withtheavailability
ofhigh-resolutionsonographyandspiralCTitispossible
to bring down these high rates of false positivity
significantly.
Fig.1: Different positions of the appendix
ANATOMY
Thevermiformappendix,ablind-endingtubularstructure,
arisesfromtheposteromedialaspectthececuminferior
totheileocecaljunction.Itvariesconsiderablyinlength
andcircumference,theaveragelengthbeingbetween7.5
and10cms.Thepositionofthebaseoftheappendixis
essentially constant, being found at the confluence of
thethreetaeniaecoliofthececum,whichliesdeepto
theMcBurney'spoint.Thefreeendoftheappendixis
howeverfoundinvarietyoflocations.(Fig.1).Thedifference
in appendiceal position influences clinical findings
considerably(4).Inunusualcasesofmalrotationofthe
gut,orfailureofdecentofcecum,theappendixisnotin
therightlowerquadrant(5).
Theappendixhasitsownmesentry,themesoappendix,
arisingfromtheinferiorpartofthemesentryoftheterminal
ileum,whichattachestothececumandproximalpartof
the appendix. The mesoappendix contains the
appendicular artery, a branch of the ileocolic artery.
Venousdrainageoftheappendixisviatheileocolicveins
and the right colic vein into the portal system. The
lymphaticdrainageoccurstotheileocolicnodesalong
thecourseofthesuperiormesentericarterytotheceliac
nodesandcisternachyli.Theafferentnervefibersfrom
theappendixaccompanythesympatheticnervestothe
T10segmentofthespinalcord,whichexplainswhyin
appendicitis is sometimes referred to the periumbilical
area.
On histology, the submucosa contains numerous
lymphatic aggregations or follicles. There is a rough
parallel between the amount of lymphoid tissue in the
appendix and the incidence of acute appendicitis, the
peakforbothoccurringthemidteens(3).
PATHOPHYSIOLOGY
Appendicitisiscommonlyassociatedwithobstructionof
theappendiceallumenduetofecalith.Obstructionmay
also be secondary to hypertrophy of lymphoid tissue,
From the Department of Radiology, Quadra Medical Services Pvt. Ltd. Kolkata. India.
Request for Reprints: Ranjit Kumar Jain, Quadra Medical Services Pvt. Ltd. 41, Hazra Road, Kolkata 700019. India.
Received 21 May 2006;Accepted 10August 2006
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inspissatedbarium,gallstones,worms(ascaris),foreign
bodies,ortumor.
Followingobstructionoftheappendiceallumen,continued
mucus secretion and inflammatory exudation leads to
distension,mucosaledemaandmucosalulcerationalong
with translocation of bacteria to the submucosa. The
swelling of appendix stimulates the nerve endings of
visceralafferentfibersandthepatientperceivesvisceral
periumbilicalorepigastricpain.
Withincreasingintraluminalpressures,furtherdistension
resultsinobstructedlymphaticandvenousdrainageand
allows vascular congestion of the appendix. The
inflammatoryprocesssooninvolvestheserosa.When
the inflamed serosa of the appendix comes in contact
withtheparietalperitoneum,patientstypicallyexperience
the classic shift of pain to the right lower quadrant.
Intramuralvenousandarterialthrombosesensue,resulting
ingangrenousappendicitis.
Fig. 2. Mucocele of the appendix. (a) Sonogram of the right
lowerquadrantobtainedwithalinear10-6-MHzprobe,shows
well defined tubular cystic structure with some low- level
luminal echogenicity. (b) Transverse CT scan in another
patient obtained with oral contrast material reveals cystic
lesion in relation to the cecum suggestive of mucocele.
IJRI, 16:4, November 2006
Unrelenting tissue ischemia results in appendiceal
infarctionandperforation.Ruptureoftheappendixwith
spillageofpusintotheperitonealcavityresultsinlocalized
orgeneralizedperitonitis.Morecommonly,inflamedor
perforatedappendixcanbewalledoffbytheadjacent
greateromentumandloopsofsmallbowelresultingin
phlegmonousmassorparacecalabscess.
Thissequenceisnotinevitableandsomeepisodesof
acute appendicitis may resolve spontaneously if the
obstructionisrelieved.Rarely,appendicealinflammation
resolvesleavingadistendedmucus-filledorgantermed
mucoceleoftheappendix.(Fig.2.)
CLINICAL MANIFESTATIONS
Appendicitisoccursinallagegroups.Itisrareininfants
but becomes increasingly common in childhood and
reachespeakincidenceinthelateteenageyearsand
earlytwenties.Sexratioisequalbeforepubertyandmale-
to-femaleratiois3:2inteenagersandyoungadults.The
ratio again equalizes by the time patients reach their
midthirties.Noracialpredilectionexistsforappendicitis.
Adiagnosisofappendicitisusuallycanbemadeonthe
basisofhistoryandphysicalexamination.
Symptoms:
Painistheprimesymptomofappendicitisandinitiallyis
located in the lower epigastrium or periumbilical area.
Thepainsubsequentlylocalizestotherightlowerquadrant,
whereitbecomesprogressivelymoresevere.Thisclassic
painsequenceisusualbutnotinvariable.Thedifference
inappendicealposition,ageofthepatient,anddegreeof
inflammation, accounts for variations in the clinical
presentation.
Anorexia nearly always accompanies appendicitis.
Nausea, vomiting, and low-grade fever are common.
Uncommonly,diarrheaorconstipationmaybeseen.The
sequence of appearance of symptom that is anorexia
followedbypainandthenvomitinghasgreatdifferential
diagnosticsignificance3.Ifvomitingprecedestheonset
ofpain,thediagnosisshouldbequestioned.
Signs:
Thecardinalfeaturesofacuteappendicitisarelocalized
abdominaltenderness,rigidity,muscleguarding,painon
percussion,andreboundtenderness.Paininrightlower
quadrantwithpalpationoftheleftlowerquadrant(Rovsing
sign)ishelpfulinsupportingaclinicaldiagnosis.Asking
thepatienttocoughwillelicitasharppainintheright
lowerquadrant(positivecoughsign).
Witharetrocecalappendixtheanteriorabdominalfindings
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arelessstrikingandtendernessmaybemoremarkedin
theflank.Paininrightlowerquadrantwithhyperextension
of the right hip (psoas sign) demonstrates nearby
inflammationwhenstretchingtheileopsoas.Paininthe
rightlowerquadrantwithpassiveinternalrotationofthe
flexedrighthip(obturatorsign)indicatesthataninflamed
appendixiscontactwiththeobturatorinternus.
Laboratory findings:
High level of C-reactive protein (>0.8 mg/dL) with
leukocytosis and neutrophilia are the most important
laboratoryfindings6.
IMAGING
Theclinicalpresentationofappendicitisisvariable.While
theclinicaldiagnosismaybestraightforwardinpatients
whopresentwithclassicsignsandsymptoms,atypical
presentationsmayresultindiagnosticconfusionanddelay
in treatment 4. Clinical diagnosis is more confusing in
youngandelderlypatients.Inaddition,manyotherclinical
disorders present with symptoms similar to those of
appendicitisandthedifferentialdiagnosis3includesthe
following:
AcuteMesentericAdenitis
Acutegastroenteritis
Meckel'sDiverticulitis
Intussusception
Crohn'sdisease
Perforatedpepticulcer
Diverticulitis
Epiploicappendagitis
Urinarytractinfection
Uretericstone
Primaryperitonitis
Henoch-Schonleinpurpura
Yersiniosis
DiseasesoftheMale:Testiculartorsion
Epididymitis
Seminalvesciculitis
Gynecologicdisorders:Pelvicinflammatorydisease(PID)
Ovariancystortorsion
Endometriosis
Rupturedectopicpregnancy
Rectussheathhematoma
Cholecystitis
Sinceaccurateclinicaldiagnosisofappendicitisisdifficult,
negativeappendectomyrate7canbeashighas20%.
Unnecessarysurgeryforsuspectedappendicitisexposes
patients to increased risks, morbidity, and expense 8.
Radiological examination can reduce the number of
misdiagnoses and negative laparotomies and help in
treatmentofappendicealabscessesandinpostoperative
complications.JudicioususeofgradedcompressionUS
Imaging in Acute Appendicitis 525
&CTinpatientswithequivocalclinicalfindingsresultsin
lowerfalse-negativeappendectomyrates(4).
Conventional Radiography
Thoughplainfilmsarereportedtorevealabnormalitiesin
50%ofpatientswithappendicitis(9),theyarenotspecific,
notcosteffective,andcanbemisleading(8).Plainfilms
areindicatedfortheevaluationofapatientwithsuspected
appendicitisonlywhenotherdiagnosticprobabilities(e.g.,
perforation,intestinalobstruction,ureteralcalculus)are
alsoconsidered(8,10).
Thevariousplainfilmfindingsthathavebeendescribed
inappendicitisareasfollows:(8-11)
" Appendicolith.
" Rightlowerquadrantgas
" Increased soft tissue density of the right lower
quadrant
" Separationofthececumfromrightextraperitoneal
fatplanes
" Deformity of the cecal and ascending colon gas
shadowoccurringduetoadjacentinflammatorymass
" Localized ileus with gas in the cecum, ascending
colonandterminalileum
" Effacementoftherightextraperitonealfatline
" Gasinperitoneumandretroperitoneum
" Gasfilledappendix
Bariumenemaexaminationmaybehelpfulinselected
patients.Bariumenemaisperformedonanunprepared
bowel gently without any external pressure. Complete
filling of a normal appendix effectively excludes the
diagnosisofappendicitis.Nonfillingorincompletefilling
of the appendix along with mass effect on the cecum
suggestsappendicitis(8),themasseffectbeingdueto
abscess/inflammatoryreactionssurroundingtheinflamed
appendix. The terminal ileum may be displaced or
narrowedbytheadjacentinflammatorymassandthere
maybethickeningofthemucosalfoldsoftheterminal
ileum.However,non-fillingofappendixmaybeseeninas
manyas10-20%ofnormalpatients.
IthasbeenshownbySeheythatappendixfillsin92%of
normalchildrenandhencefailureoftheappendixtofillin
symptomaticchildrenisasignificantfinding.
Barium enema examination may also be useful in
evaluatingcomplexcolonicabnormalitiesdetectedwith
cross-sectionalimaging(4).
Ultrasonography
Ultrasonography (US) is valuable in the diagnosis of
doubtful cases of appendicitis and is a cost-efficient
adjuncttotheclinicalevaluation(12).USisinexpensive,
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safe, and widely available. Because US involves no
ionizing radiation and excels in the depiction of acute
gynecologicconditions,itisrecommendedastheinitial
imagingstudyinchildren,inyoungwomen,andduring
pregnancy8. It has reported sensitivities of 75%-90%,
specificities of 86%-100%, accuracies of 87%-96%,
positive predictive values of 91%-94%, and negative
predictivevaluesof89%-97%forthediagnosisofacute
appendicitis(4).Useofpreoperativeultrasonographyis
alsoassociatedwithoveralllowernegativeappendectomy
rate(12).
Fig.3.Acuteappendicitisina37-year-oldmanwithright-lower-
quadrant pain. (a) Long axis and (b) cross sectional US
images show inflamed appendix as a blind-ended,
noncompressible tubular structure filled with fluid and
surrounded by a hypoechoic mass representing phlegmon.
GradedcompressiontechniquedescribedbyPuylaert
(13)isthestandardmethodforsonographicevaluation
ofacuteappendicitis.GradedcompressionUS,withslow
andgentlemaintainedpressure,allowsforalengthyand
successfulevaluationoftheareaofinterestandshows
obstructedappendixasanoncompressibleloopofgut
(4).
RecentlyBaldisserottoetal(14)hasdescribedtheuse
of the noncompressive technique before the graded
compressionstudy.Thismaysuccessfullyestablishthe
diagnosisinsomecases,therebyavoidingcompression
inpatientswithabdominalpain.Changeofthepatient's
position to displace the bowel gas may also help in
visualizationoftheappendixdeeplysetintheabdominal
cavity without compression. Compression study is
however,usefulinidentifyingthecasesofappendicitis
notvisualizedatthenoncompressiveexamination.
Fig. 4.Appendicitis with appendicolith. (a) Long-axis and (b)
cross sectional US image of the right lower quadrant,
obtainedwithalinear10-6-MHzprobeina35yearoldwoman,
shows the inflamed appendix with an echogenic luminal
focus (between the calipers) with distal shadowing.
It is very important to standardize the examination
technique for identification of appendix and thereby
avoiding false negative diagnosis. Baldisserotto has
suggested an excellent routine for the actual US
examinationoftherightlowerquadrant,whichwehave
foundveryusefulinourdailypractice.TheUSexamination
oftherightlowerquadrantshouldstartinthetransverse
planefromthetipoftheliverandproceedtowardsthe
pelvicbrim.Theascendingcolonusuallyisappreciated
byitsgascontentandhaustralpattern.Intheregionof
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thececum,carefulattentionshouldbepaidtoinflammatory
changes in the perienteric fat and the appendix itself.
Sagittalandobliqueimagesshouldthenbeobtaineduntil
theentireregionofinteresthasbeenscanned.Detailed
imagesareobtainedoftheappendix,ifitisseen.The
examination is generally begun with a curvilinear
transducer appropriate for the patient: a 3.5-MHz
transducerforlargepatientsanda5-MHztransducerfor
thinpatients.Thelineartransducerisusedlatterformore
detailedstudy. Theretrocecalappendicitisisbeststudied
bytheexaminationthroughtherightflank(14).
The inflamed appendix is seen as a blind-ended,
aperistaltic,noncompressible,tubularstructurethatarises
fromthebaseofthececumhavingadiametergreater
than6mms.(Fig.3.)Presenceofafecalith(Fig.4)may
aidinarrivingatapositivediagnosis.
Fig.5. Classic features of acute appendicitis at US in a 26-
year-old man with right lower quadrant pain. (a) Long-axis
and (b) cross-sectional US images of the right lower
quadrant obtained with a linear 10-6 MHz transducer show
an 8-mm-diameter, blind-ended, tubular structure with a
laminated wall. The appendix was not compressible and
showed no peristalsis.
Theovoidshape15ofappendixintransversesectionon
USovertheentireappendiceallengthreliablyrulesout
acute appendicitis while in acute inflammation the
appendicealwallthickeningcausesanincreaseofthe
outerappendicealdiameterandaroundingoftheshape.
Inearlyacuteappendicitis(catarrhalstage)fivelayers
canbeidentified-(Fig.5.)
1. central, thin hyperechoic line representing the
collapsedlumenandsuperficialliningofthemucosa
oftheappendix,
2. hypoechoiclayer(2-3mms)representingedematous
laminapropriaandmuscularismucosa.
3. hyperechoicsubmucosa(2-3mms).
4. hypoechoicmuscularlayer(2-3-mms).
5. outerthinhyperechoiclinerepresentingtheserosa.
Inlate(suppurative)stagethelumenoftheappendixis
distendedwithpus/fluidandthereisincreasedthickening
ofthesubmucosaandmuscularwallintherangeof3-6
mms.
Circumferentialcolorinthewalloftheinflamedappendix
on color Doppler US images is strongly supportive
evidenceofactiveinflammation(4).(Fig6.)
Fig.6. Cross-sectional Color Doppler US image obtained
through the base of thick walled appendix in a 74 year old
male presenting with right lower quadrant abdominal pain
showsvirtuallycircumferentialflowinthewalloftheinflamed
appendix.
Loculated pericecal fluid, phlegmon or abscess,
prominentpericecalfatandcircumferentiallossofthe
submucosal layer of appendix are associated with
appendicealperforation16.(Fig7.)
A significant disadvantage of sonography is that it is
operatordependent.Difficultieswithultrasonographyalso
includethefactthatanormalappendixmustbeidentified
toruleoutacuteappendicitis.Visualizationofanormal
appendixismoredifficultinpatientswithalargebody
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habitus and when there is an associated ileus, which
produces shadowing secondary to overlying gas-filled
loops of bowel. It may also be not possible on US to
differentiate between appendiceal phlegmon from an
abscessandCTmaybehelpfulinthissetting.
Computed Tomography
Fig. 7. Acute appendicitis with perforation in a 17-year-old
boy presenting with right lower quadrant pain and
tenderness. (a) Long-axis and (b) cross sectional US
image, obtained through the right lower quadrant with a
linear 10-6-MHz probe, shows the perforated appendix, with
discontinuity of its wall and surrounded by an abscess.
CThasbecomeincreasinglypopularasaneffectivecross-
sectionalimagingtechniquefordiagnosingandstaging
acuteappendicitis.Itisaquickandaccurateexamination
thatisoperator-independent,isrelativelyeasytoperform
and provides images that are easy to interpret.(4, 17)
Helical CT has reported sensitivities of 90%-100%,
specificitiesof91%-99%,accuraciesof94%-98%,positive
predictivevaluesof92%-98%,andnegativepredictive
values of 95%-100% for the diagnosis of acute
appendicitis.(4)Itsusehasdecreasedtherateofnegative
appendectomiesandhasdecreasedthenumberofcases
ofappendicealperforation.(17,18)
DisadvantagesofCTincludepossibleiodinated-contrast-
mediaallergy,patientdiscomfortfromadministrationof
contrast media (especially if rectal contrast media is
used),exposuretoionizingradiation,andcost.However,
thecostisconsiderablylessthanthatofremovinganormal
appendixorhospitalobservation.(8)
Technique- there is no consensus on the ideal CT
techniqueforstudyingappendix.TherearedifferentCT
protocolsdependinguponthegenerationofCTscanners
used as well as varying from center to center. While
nonfocusedCTperformedforentireabdomenandpelvis
withintravenousandoralcontrastmaterialisthemost
popular approach(4,17), CT evaluation of appendicitis
withouttheuseofintravenouslyadministeredcontrast
materialisalsoagrowingtrend(2,19,21).Opacification
oftheterminalileumandcecumwithoraland/orrectal
contrast material alone or in combination has been
advocated4.Howeverlaneetal19donotrecommendthe
useofanycontrastmaterial.Weltmanetal20hasshown
that the use of thin-section (5mms) CT significantly
improvesthediagnosisofacuteappendicitiscompared
to10mmsections.Weatourclinicprefertoopacifythe
bowelusingoraland/orrectalcontrastalongwithIV
contrast,andusethinnersections.
Image interpretation- the evaluation starts with the
identificationofappendix.Sincethepositionofthececum
andascendingcolonishighlyvariable,identificationof
the fatty lips of the ileocecal valve is helpful. Careful
scrutiny of the entire cecum then frequently allows
identification of the appendix as it arises from the
posteromedialborder.Theappendixisfrequentlyseen
drapedovertherightexternaliliacarteryandvein.The
right common and external iliac artery and vein are
therefore carefully evaluated from their origins at the
bifurcationoftheaortaintothefemoralcanaltoidentify
theoverlyingappendix.Thisusuallyhelpstoavoidthe
pitfallofnotseeingapelvicappendix.
Oncetheappendixisidentified,itisevaluatedforsignof
acute appendicitis as described to confirm or exclude
thediagnosisofacuteappendicitis.Oncetheappendiceal
regioniscleared,thececumandascendingcolonare
carefully examined for potential involvement by cecal
neoplasm (Fig.8), cecal diverticulitis, typhlitis, or
segmental colitis. Diseases that involve primarily the
pericolonicfat,suchasprimaryepiploicappendagitisand
omentalinfarction,arethenexcluded.
Focus is then turned to the terminal ileum and its
subtended mesentery. Gastrointestinal diseases to
considerinthisanatomiclocationincludeacuteterminal
ileitis, mesenteric lymphadenitis, Crohn's disease and
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tuberculosis. Genitourinary disease then should be
excluded, including acute pyelonephritis, ureteral
obstruction,complicationsofovariancystsandmasses,
andacutepostpartumovarianveinthrombosis.Inadult
patients, one must also consider acute cholecystitis
(which may mimic acute appendicitis if the enlarged
gallbladder extends into the right-lower quadrant),
pancreatitis,sigmoiddiverticulitis,bowelischemia,and
bowelobstruction.
Fig. 8. Cecal mass with appendicitis. Coronal reformatted
CT scan shows lobulated heterogenous mass of cecum
with involvement of the base of the appendix.
Imaging findings- the normal appendix appears as a
tubularorringlikepericecalstructurethatiseithertotally
collapsedorpartiallyfilledwithfluid,contrastmaterial,or
air.Thenormalappendixhasathicknessof3mmsor
less and a diameter of 6mms or less(14,21). The
periappendicealfatshouldappearhomogeneous,although
athinmesoappendixmaybepresent.Thefindingofa
normal appendix with no fluid in its lumen, normal
periappendiceal fat, and no calcified appendicolith
indicatesthattheappendixisnotinflamed.
ThemainCTcriteriaforthediagnosisofacuteappendicitis
includeidentificationofathickenedappendixwithatwo-
walldiametergreaterthan6.0-7.0mm,periappendiceal
inflammatory changes, and a calcified
appendicolith(21).(Fig. 9 a). Alobaidi et al(22) has
recommended the use of bone window settings for
detectingappendicolithswhenevaluatingpatientsforacute
appendicitis,particularlypatientsinwhomevidenceof
appendicitisisequivocal.
Fig. 9. Classic CT findings of acute appendicitis in a 48-
year-old woman who presented with right lower quadrant
pain and tenderness. (a) Transverse CT scan obtained with
oral contrast material and with 5-mm collimation reveals
an obstructing appendicolith within the distended appendix.
(b) Caudal helical CT image reveals periappendiceal
inflammation
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Thesizecriteriontodiagnoseappendicitisisespecially
importantintheabsenceofperiappendicealinflammation.
Benjaminovetal(21)observedthatanupperlimitof6.0
mmfornormalappendicealthicknesscanbeusedreliably
atCTonlyiftheluminalcontentisvisualizedbecausein
theabsenceofperiappendicealinflammatorychanges,it
isnotpossibletodifferentiateanoncollapsedappendix
filledwithfluidofthesameattenuationasthewallfroma
thickinflamedappendixifthecontentisnotvisualized.
Theysuggested10.0mmastheupperlimitofnormalif
theluminalcontentisnotvisualizedandextraappendiceal
inflammatorychangesarenotpresent.Patientswithan
appendicealthicknessof6.0-10.0mmshouldtherefore
undergofurtherexaminationwithrectallyorintravenously
administered contrast material or with US to visualize
thewallandthuspreventafalse-positivediagnosisof
appendicitis.
InearlyormildappendicitistheCTfindingsareverysubtle.
Theappendixmayappearminimallydistendedassociated
withahazy,ill-definedincreaseinCTattenuationinthe
fatimmediatelysurroundingtheappendix.Howevermost
patientswhoundergoCTdemonstrategreaterdegreesof
luminal distention and evidence of transmural
inflammation. Circumferential and symmetric wall
thickening is nearly always present and is best
demonstrated on images obtained with intravenous
contrast material enhancement. Periappendiceal
inflammation(Fig.9b)ispresentin98%ofpatientswith
acuteappendicitis.
Fig. 10. Transverse CT scan obtained with oral contrast
material and with 5-mm collimation in a 13 year old child
with acute appendicitis demonstrates the arrow head sign
consisting of a triangle-shaped contrast collection between
the thickened cecal apical walls. Surgical exploration
revealed perforated appendicitis.
Other important findings include focal cecal apical
thickeningandthearrowheadsign,(Fig.10)whichisseen
asanarrowhead-shapedcollectionofcontrastmedium
localizedtotheupperpartofthececumneartheorifice
oftheappendix(23,24).Inflammatorychangesassociated
with acute appendicitis can cause focal cecal apical
thickening,whichallowscontrastmaterialtoassumethe
configurationofanarrowheadasitfunnelsatthececal
apextothepointoftheobstructedappendicealorifice.
Because the sign is formed by the extension of
inflammation from the appendix to the cecum, the
arrowheadsignmayallowforplacementofpatientswith
appendicitisintotwosurgicalgroups(24):thosewholikely
will do well with standard ligation (arrowhead sign not
present)andthosewhomayrequirepartialcecectomy
(arrowheadsignpresent).
Complications- Perforated appendicitis is usually
accompanied by pericecal phlegmon or abscess
formation.Associatedfindingsincludeextraluminalair,
(Fig. 11) marked ileocecal thickening, localized
lymphadenopathy, peritonitis, and small-bowel
obstruction.
Fig. 11a and b. Transverse CT scan obtained with oral
contrast material and with 5-mm collimation in a 32 year old
woman with acute appendicitis demonstrates an enlarged
thick-walled appendix with an associated cecal apical
thickening and infiltration of surrounding fat. Extraluminal air
pocket suggests perforation.
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Iftheabnormalappendixisnotseen,aspecificdiagnosis
of appendicitis can be made by identifying an
appendicolith within a periappendiceal abscess or
phlegmon
Although a pericecal phlegmon or abscess is strongly
suggestiveofappendicitis,thesearenonspecificfindings
thatmaybeseenwithotherdiseaseentities.Ifsubstantial
inflammationispresentwithintherightlowerquadrant,it
maybedifficulttodifferentiateprimaryappendicitiswith
secondaryinflammationofthececumandterminalileum
from ileocolitis with secondary inflammation of the
appendix.
CTisofconsiderablevalueinthetreatmentofpatients
who present with a periappendiceal mass and can be
usedtoaccuratelystagetheextentofperiappendiceal
inflammationandtoreliablydifferentiateperiappendiceal
abscessfromphlegmon,whichisofcriticalimportance
tothesurgeon.Manysurgeonsbelievethatthereislittle
valueinattemptingtodrainanonliquefiedphlegmonand
preferinitialnonsurgicaltreatmentwithantibiotictherapy
in such cases. Patients with well-defined and well-
localizedperiappendicealabscessestypicallybenefitfrom
CT-directed percutaneous catheter drainage.(4,17)
Patients with extensive and poorly defined collections
usually require immediate surgical exploration and
abscessdrainage.
Magnetic Resonance Imaging
MRImayalsobeusedinthediagnosisofappendicitisin
caseswhereeitherCTiscontraindicatedlikeinpregnancy
orinchildrenwhereitisadvisabletoavoidradiation. T1-
weightedandT2-weightedturbospin-echosequencesand
fat-suppressed inversion recovery turbo spin-echo
sequences as well as post contrast T1 weighted
sequences can be used. On T2-weighted images,
inflamedappendixshowmarkedlyhyperintensecenter
andaslightlyhyperintensethickenedwallwithmarkedly
hyperintense periappendiceal tissue.(Fig. 12) On post
contrast study, intense contrast enhancement of the
inflamed appendiceal wall indicates the presence of
appendicitis. There is also significant enhancement of
surroundingfatongadolinium-enhancedT1-weightedfat-
suppressedspin-echoimages.Mildenhancementcan
howeverbeseeninthenormalappendixandgut.Using
fat-saturationtechnique,contrastdifferences between
theinflamedappendixandthesurroundingfatisbetter
appreciated. However, MRI has inherent limitation in
detectingappendicolith.
Inflammatorydiseasesofthegut,suchasilealdiverticulitis
andCrohn'sdiseasemaymimicappendicitisandmay
becauseforfalse-positivediagnosisofacuteappendicitis.
False-negative results usually depend on technique-
related limitations, such as inefficient fat saturation
causingappendicealwallenhancementtobeobscured
bymesentericfat.
Fig.12.AxialT2(a)andT1(b)weightedimagesthroughright
lower quadrant in a 23 year old man presenting with acute
abdomen shows enlarged thick walled inflamed appendix
with periappendiceal inflammation
Fat-suppressedgadoliniumenhancedMRIimagesare
sensitive(97%)andaccurate(95%)inthedetectionof
acuteappendicitis25.
Incesu, et al (25) found MR imaging superior to
sonography in revealing appendicitis. Despite some
disadvantage, MR imaging can also be used after
suboptimal or nondiagnostic sonography in cases of
suspectedacuteappendicitis.
CONCLUSION
Althoughrareininfants,appendicitisiscommoninhuman
population.Itisoneofthemostcommoncauseofacute
rightlowerquadrantabdominalpainandinmajorityof
cases diagnosis of acute appendicitis can largely be
532
532 RK Jain et al
madeonthebasisofhistoryandphysicalexamination.
Thoughdecreasing,stillalargenumberofappendicesat
surgeryarefoundtobenormal,leadingtoahighrateof
negativeappendectomies(8-30%).Thisisbecauseof
similar signs and symptoms of a wide range of acute
abdominalclinicaldisordersandnonspecificlaboratory
andconventionalradiographicfindings.Inrecentyears
howeverwiththeavailabilityofvariouscross-sectional
imagingtechniquesviz.Ultrasonography,SpiralCTand
MRI,falsepositivediagnosisofacuteappendicitishas
reduced therefore also reducing rate of negative
appendectomies.Theoverallaccuracyofcross-sectional
imagingtechniquesindiagnosingacuteappendicitisvaries
from87%-98%.
Highresolutionsonographyisanmostcommonimaging
techniqueusedindiagnosingappendicitisasitisless
expensive, easily available and free from radiation,
howeveritisoperatorandsubjectdependentandrequires
lotofexperience.MRIcanalsobeusedinthesettingof
pregnancy,otherwiseitexpensive,timeconsumingand
cumbersome. Spiral and recently multislice CT has
thereforeemergedasthemosteffectivetoolfordiagnosing
appendicitisanditscomplicationsbecauseofitsexcellent
resolution.Itprovidesexquisitedetailedanatomicalimages
forreview,andisalsofastandoperatorindependent.
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