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Gastrointestinal Imaging Original Research

Bennett et al.
CT of Mucocele of Appendix
Gastrointestinal Imaging
Original Research

CT Diagnosis of Mucocele of
the Appendix in Patients with
Acute Appendicitis
Genevieve L. Bennett 1
Teerath P. Tanpitukpongse
Michael Macari
Kyunghee C. Cho
James S. Babb
Bennett GL, Tanpitukpongse TP, Macari M, Cho
KC, Babb JS

OBJECTIVE. The purpose of this study was to identify the CT features of mucocele of
the appendix coexisting with acute appendicitis and to determine whether this entity can be
differentiated from acute appendicitis without mucocele.
MATERIALS AND METHODS. CT scans of 70 patients (12 with acute appendicitis
with mucocele, 29 with acute appendicitis without mucocele, 29 with a normal appendix)
were retrospectively interpreted by two readers. The appendix was evaluated for maximal
luminal diameter, cystic dilatation, luminal attenuation, appendicolith, mural calcification
and enhancement, periappendiceal fat stranding, fluid, and lymphadenopathy. CT findings
were compared by use of Mann-Whitney U and Fishers exact tests. Receiver operating
characteristics analysis was performed to assess the diagnostic utility of appendiceal luminal
diameter in differentiating acute appendicitis with from that without coexisting mucocele.
RESULTS. Cystic dilatation of the appendix and maximal luminal diameter achieved
statistical significance (p < 0.05) for the diagnosis of acute appendicitis with mucocele. Mural
calcification achieved statistical significance for one reader (p = 0.0049) and a statistical trend
for the other (p < 0.1). A maximal luminal diameter greater than 1.3 cm had a sensitivity of
71.4%, specificity of 94.6%, and overall diagnostic accuracy of 88.2% for the diagnosis of
acute appendicitis with mucocele.
CONCLUSION. Although there is overlap with acute appendicitis without mucocele, CT
features suggestive of coexisting mucocele in patients with acute appendicitis include cystic
dilatation of the appendix, mural calcification, and a luminal diameter greater than 1.3 cm.

Keywords: acute appendicitis, appendix, CT, mucocele


DOI:10.2214/AJR.08.1572
Received July 22, 2008; accepted after revision
September 23, 2008.
1

All authors: Department of Radiology, New York


University Medical Center, 560 First Ave., Ste. HW 202,
New York, NY 10016. Address correspondence to
G. L. Bennett (genevieve.bennett@med.nyu.edu).

WEB
This is a Web exclusive article.
AJR 2009; 192:W103W110
0361803X/09/1923W103
American Roentgen Ray Society

AJR:192, March 2009

ucocele is a descriptive term refer


ring to a dilated appendix with
abnormal intraluminal accumu
lation of mucus [1, 2]. Appendi
ceal mucocele can be caused by chronic ob
struction of the appendix (simple mucocele)
or result from mucosal hyperplasia and be
nign or malignant neoplasms of the appendix
[3, 4]. A mucocele can be an incidental find
ing at surgery or imaging or come to clinical
attention because of symptoms such as right
lower quadrant pain and a palpable mass.
In association with acute appendicitis, a
mucocele can become inflamed, and the
clinical and CT findings can mimic those of
acute appendicitis without mucocele [57]. It
is important to identify mucocele preopera
tively because the surgical approach may have
to be altered to avoid rupture of the mucocele
and resultant pseudomyxoma peritonei [8, 9].
In addition, more extensive surgical resection
may be needed if a neoplastic cause of a

mucocele is identified. The objective of this


study was to identify the CT features of
mucocele of the appendix in association with
acute appendicitis and to determine whether
this entity can be differentiated from acute
appendicitis without mucocele.
Materials and Methods
The institutional review board at our hospital
approved the study protocol with waiver of informed
consent. The study was HIPAA compliant.

Subjects
Patients with acute appendicitis and coexisting
mucoceleA search of the pathology database
at our medical center from January 1, 1996, to
December 30, 2006, was performed to identify all
patients who had undergone appendectomy with
the pathologic findings of both acute appendicitis
and mucocele of the appendix. This search
yielded 18 patients. The radiology database was
then searched to identify which of these patients

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Bennett et al.
had undergone preoperative abdominopelvic
CT. This search yielded 12 patients (seven men,
five women; mean age, 46 years; range, 2773
years). According to the radiology reports, all
of these patients presented with right lower
quadrant pain, and CT was performed to rule
out acute appendicitis. The initial preoperative
interpretations of these CT scans were as follows:
acute appendicitis without perforation in four
cases, perforated acute appendicitis in three cases,
inflamed mucocele in two cases, and appendicitis
versus mucocele in three cases.
Operative reports were obtained for 10 of the 12
patients. Both of the patients with a prospective CT
diagnosis of inflamed mucocele underwent open
appendectomy, one with interval right hemi
colectomy. Two of the patients with the diagnosis of
appendicitis versus mucocele underwent open
appendectomy, one with partial cecectomy. Two of
the patients with the diagnosis of perforated
appendicitis underwent laparoscopic appendecto
my, and one underwent abscess drainage and
interval appendectomy. Two of the three patients
with the diagnosis of acute appendicitis who had
operative reports available underwent laparoscopic
appendectomy; the third underwent open appen
dectomy. In addition to acute appendicitis, findings
at pathologic examination were mucinous cyst
adenoma of the appendix and mucocele in six cases,
mucinous cystadenocarcinoma of the appendix and
mucocele in one case, simple mucocele in four
cases, and mucocele resulting from endometriotic
implant in one case. In three of the 12 patients, the
mucocele was perforated.
Patients with acute appendicitis without muco
cele or with a normal appendixThe radiology
database in 2007 was searched to identify 30
consecutively registered patients who underwent
preoperative CT and had pathologically proven
acute appendicitis without mucocele and 30
patients with a normal appendix. The sample
size for each of these two groups of patients
was determined on the basis of statistical power
considerations. The number of patients without
mucocele was determined so that the accuracy
for discrimination of appendicitis with from
appendicitis without mucocele could be estimated
with a precision of 12.5 percentage points and
overall accuracy for the diagnosis of acute
appendicitis with mucocele could be estimated
with a precision of 10 percentage points. This
requirement dictated the accrual of 30 patients
who had appendicitis without mucocele and 30
patients with a normal appendix. At the time of
data analysis, one subject in each group was found
to have been inadvertently included in the sample
twice, leaving a final sample size of 29 patients in
each group.

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For the group of patients with a normal


appendix, only patients with a well-visualized
normal appendix according to previously estab
lished CT criteria were included. These patients
were selected by the authors. The pathology data
base was reviewed to ensure that none of these
patients subsequently underwent appendectomy at
our institution. The group of patients with acute
appendicitis without mucocele consisted of 16 men
and 13 women (mean age, 41 years; range, 2569
years). The group of patients with a normal
appendix consisted of nine men and 20 women
(mean age, 45 years; range, 2473 years). In the
patients with acute appendicitis, findings at
pathologic examination were as follows: acute
appendicitis without perforation in 14 cases,
perforated acute appendicitis in nine cases, necro
tizing or gangrenous appendicitis in three cases,
and early or mild appendicitis in three cases.

CT Technique
For the patients with acute appendicitis without
mucocele or with a normal appendix, CT data
were acquired with a 16-MDCT system (Sensation,
Siemens Medical Solutions). CT was performed
8090 seconds after IV administration of 1.5 mL/
kg of nonionic iodinated contrast material (iopro
mide, 300 mg I/mL, Ultravist, Bayer HealthCare)
injected at a rate of 23 mL/s. All patients ingested
5001,000 mL of 2% water-soluble iodinated oral
contrast material (diatrizoate meglumine and
diatrizoate sodium solution, Gastrografin, Bracco
Diagnostics) beginning at least 60 minutes before
imaging. CT images were sent to the PACS system
(SIENET PACs version VF50, Siemens Medical
Solutions) as 4-mm-thick sections.
CT parameters for the group of patients with
appendicitis and mucocele were variable owing to
the longer time over which the studies were
performed. Ten of these patients received both
IV and oral contrast material, and two patients
received oral contrast material only. The contrast
dosage was similar to that for the group of patients
with acute appendicitis without mucocele. Four of
these patients were evaluated with a single-detector
helical scanner (CTi, GE Healthcare), five patients
with a 4-MDCT system (MX 8,000, Philips
Healthcare), and three patients with a 16-MDCT
system (Sensation, Siemens Medical Solutions).
Slice thickness varied from 4 to 7 mm.

Image Interpretation
CT images of the three groups of patients were
randomized and retrospectively reviewed indi
vidually by two experienced abdominal
radiologists, each with more than 10 years of
experience. The readers were unaware of the
radiologic and pathologic diagnoses but were

informed that the subjects included patients who


had acute appendicitis with mucocele, acute
appendicitis without mucocele, or a normal
appendix. For all except one patient with a
mucocele, who had only hard-copy images,
images were evaluated at a PACs workstation.
The reviewers evaluated the appendix for the
following findings: maximal luminal diameter,
presence of cystic dilatation (defined as tubular or
spheric dilatation of the appendix with lowattenuation intraluminal contents), attenuation of
luminal contents, maximal wall thickness, wall
contour (smooth or irregular), presence of an
appendicolith, intraluminal gas, mural calci
fication (curvilinear in configuration and not
intraluminal), mural enhancement (present or
absent on the basis of subjective assessment
relative to adjacent bowel loops), target sign
(mural stratification pattern), and focal mass.
Additional findings evaluated were presence of an
arrowhead sign [10], periappendiceal fat stranding
(mild, moderate, severe), and intraperitoneal free
fluid (small, moderate, large amount). Reviewers
also evaluated each image for the following
findings: abscess, extraluminal gas, right lower
quadrant mesenteric lymphadenopathy (largest
lymph node measured in short axis), and smallbowel mural thickening.

Statistical Methods
The following statistical methods were used to
evaluate findings for the three groups of patients.
For each of the binary assessments, reader agree
ment was evaluated with Cohens kappa, kappa
values less than 0.4 indicating poor agreement,
values between 0.4 and 0.6 moderate agreement,
and values greater than 0.6 substantial agreement.
For each of the binary assessments, Fishers exact
test was used to compare each pair of patient groups
in terms of percentage of times a given reader
reported a positive finding. Exact p values from a
Mann-Whitney U test were used to assess the
difference between pairs of patient groups in terms
of each numeric and ordinal measure. Receiver
operating characteristics analysis was performed to
assess the diagnostic utility of maximal appendiceal
luminal diameter in differentiating acute appen
dicitis without mucocele from acute appendicitis
with mucocele. All reported p values were twosided without correction for multiple comparisons,
and p < 0.05 was declared significant. SAS software
(version 9.0, SAS Institute) was used for all
statistical computations.

Results
For each of the binary measures evaluated,
reader agreement, in terms of Cohens kappa
coefficient, and the percentage of cases for

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CT of Mucocele of Appendix
which the reader opinions were concordant
are listed in Table 1. Denominators less than
70 (the total number of patients) were due to
missing data from one or both readers,
indicating that the reader was unable to
assess the finding for a given subject. Most of
the CT features evaluated achieved good
agreement between the readers, with kappa
scores of 0.6 and 0.8. The most interobserver
variability occurred for lymphadenopathy,
small-bowel mural thickening, target sign,
focal mass, and irregular wall contour.
The frequency of each CT finding in each
of the three patient groups is listed in Table 2.
A comparison of findings between the patients
with acute appendicitis without mucocele and
patients with acute appendicitis with mucocele
also is shown in Table 2 with p values from
Fishers exact test. Cystic dilatation of the
appendix was observed in 6.9% of patients
with acute appendicitis without mucocele and
66.7% of patients with appendicitis and
mucocele (Figs. 13). This finding achieved
statistical significance for both readers (p =
0.0066, p = < 0.0001) for differentiation of
acute appendicitis without mucocele from
appendicitis with mucocele. Mural calci
fication was observed in no patient with acute
appendicitis without mucocele and in 25% of
patients with appendicitis and mucocele
(Figs. 1 and 2). This finding achieved
statistical significance for reader 2 (p =
0.0049) and was compatible with a trend for
reader 1 (p = 0.0846). Mural enhancement
was statistically significant for reader 1 (p =
0.0020) but not for reader 2 (p = 1.0000).
None of the other CT findings had a
statistically significant difference between
patients with and those without mucocele.
However, an appendicolith was found in
22.8% of patients with acute appendicitis
without mucocele and in no patient with a
mucocele (p = 0.1529, p = 0.0850).
Table 3 summarizes CT measurements
evaluated for each patient group, and signif
icance in differentiating acute appendicitis
without mucocele from acute appendicitis
with mucocele is indicated. The mean
maximal luminal diameters of the appendix
in patients with mucocele were 2.10 1.08
and 2.02 1.07 cm (range, 0.84.7 cm) for
each of the two readers. For the patients with
acute appendicitis without mucocele, the
mean luminal diameters were 0.71 0.38
and 0.98 0.36 cm (range, 0.41.6 cm).
Maximal luminal diameter achieved sta
tistical significance for both readers (p =
0.0003, p = 0.0004).

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Differences in maximal lymph node size,


luminal attenuation, and wall thickness did
not achieve statistical significance, although
there was a trend toward lower luminal

attenuation in the mucocele patients for


reader 2 (p = 0.0891). No statistical difference
was found between the patients with acute
appendicitis without mucocele and those

TABLE 1: Interobserver Agreement for CT Findings: Kappa Coefficient and


Percentage of Concordant Readings

Finding

Percentage Concordant

Cystic dilatation of the appendix

0.650

91.3 (63/69)

Intraperitoneal fluid

0.676

88.6 (62/70)

Lymphadenopathy

0.432

70.0 (49/70)

Mural calcification of the appendix

0.653

97.1 (66/68)

Mural enhancement of the appendix

0.607

80.3 (53/66)

Small bowel mural thickening

0.377

85.1 (57/67)

Periappendiceal fat stranding

0.720

85.7 (60/70)

Extraluminal gas

0.850

98.6 (68/69)

Intraluminal gas

0.625

82.6 (57/69)
88.4 (61/69)

Arrowhead sign

0.720

Target sign

0.215

75.0 (51/68)

Appendicolith

0.745

95.7 (66/69)

Abscess

0.746

95.7 (67/70)

Focal appendiceal mass

0.000a

95.7 (66/69)

Irregular appendiceal wall contour

0.402

84.1 (58/69)

NoteValues in parentheses are raw numbers.


aKappa value was zero because one reader provided the same value for all subjects (no mass present).

TABLE 2: Percentage of Patients with Each CT Finding and Significance in


Differentiating Acute Appendicitis With and Without Mucocele

CT Finding

Normal
Appendix

Appendicitis
without
Mucocele

Appendicitis
with Mucocele

pa
Reader 1

Reader 2

Cystic dilatation

0 (0/57)

6.9 (4/58)

66.7 (16/24)

0.0066

< 0.0001

Mural calcification

0 (0/57)

0 (0/57)

25 (6/24)

0.0846

0.0049

66.7 (16/24)

0.0020

1.0000

0.1529

0.0850

Mural enhancement

8.6 (5/58)

92.6 (50/54)

Appendicolith

0 (0/58)

22.8 (13/57)

Intraperitoneal fluid

6.9 (4/58)

34.5 (20/58)

33.3 (8/24)

1.0000

1.0000

Lymphadenopathy

17.2 (10/58)

75.9 (44/58)

54.2 (13/24)

0.1654

0.3069

Small bowel mural thickening

1.7 (1/58)

23.6 (13/55)

20.8 (5/24)

1.0000

1.0000

Periappendiceal fat stranding

3.5 (2/58)

86.2 (50/58)

83.3 (20/24)

0.4410

1.0000

Extraluminal gas

0 (0/58)

0 (0/24)

5.2 (3/58)

17.4 (4/23)

0.5670

0.1781

Intraluminal gas

56.9 (33/58)

26.3 (15/57)

8.3 (2/24)

0.2332

0.3984

Arrowhead sign

1.7 (1/58)

52.6 (30/57)

41.7 (10/24)

1.0000

0.3246

Target sign

0 (0/58)

37.5 (21/56)

20.8 (5/24)

1.0000

0.0855

Abscess

0 (0/58)

15.5 (9/58)

16.7 (4/24)

1.0000

1.0000

Focal mass

0 (0/58)

1.8 (1/57)

8.3 (2/24)

1.0000

0.2002

Irregular wall contour

0 (0/58)

29.8 (17/57)

25.0 (6/24)

0.4507

0.7211

NoteValues in parentheses are raw numbers. Magnitude and variation of the denominators reflect missing
data and the fact that data were provided by each of two readers (denominator = 2 number of subjects
number missing).
aFishers exact test.

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Bennett et al.

Fig. 135-year-old woman with acute appendicitis, mucinous cystadenoma of appendix, and mucocele manifesting as right lower quadrant pain and fever.
A, CT scan obtained with oral and IV contrast enhancement shows oval, thick-walled, low-attenuation mass (white arrow) contiguous with base of cecum in right lower
quadrant. Inflammatory changes are present in surrounding fat (black arrow).
B, CT scan slightly more caudal than A shows foci of calcification (arrow) in wall of mass.

with mucocele with respect to presence and


degree of periappendiceal fat stranding or
periappendiceal fluid (data not shown).
Receiver operating characteristics analysis
was performed to assess the utility of maximal
appendiceal luminal diameter in differen
tiating appendicitis with mucocele from acute
appendicitis without mucocele. A maximal
luminal diameter of the appendix greater than
1.3 cm achieved a sensitivity of 71.4%
(15/21), specificity of 94.6% (52/55), positive

predictive value of 83.3% (15/18), and neg


ative predictive value of 89.7% (52/58) for
the diagnosis of acute appendicitis with
mucocele. The overall diagnostic accuracy
was 88.2% (67/76). When the maximal
luminal diameter was increased to greater
than 1.7 cm, specificity increased to 98.2%,
and sensitivity decreased to 61.9% (Table 4).
Three mucoceles were found to be per
forated at surgery, and there were nine cases
of acute appendicitis with perforation. Given

the theoretic possibility of decrease in ap


pendiceal luminal diameter when the
appendix is perforated as a potential con
founding factor in our results, a separate
analysis excluding these perforated cases
from both of the appendicitis groups was
performed. As shown in Table 3, excluding
the perforated cases, the mean luminal dia
meter of acute appendicitis without mucocele
cases actually decreased for both readers. In
fact, the acute appendicitis case in our series

Fig. 261-year-old man with acute appendicitis, mucinous cystadenocarcinoma of appendix, and mucocele manifesting as right lower quadrant pain and fever.
A, CT scan obtained with oral and IV contrast enhancement shows low-attenuation mass (open arrow) containing air bubbles in right lower quadrant. Curvilinear
calcification (solid arrow) with adjacent inflammatory changes is present in wall of mass.
B, CT scan more caudal than A shows tubular nature of mass and mural calcification (arrow).

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CT of Mucocele of Appendix

Fig. 348-year-old woman with acute appendicitis, mucinous cystadenoma of appendix, and mucocele manifesting as right lower quadrant pain and fever.
A, CT scan obtained with oral contrast enhancement shows low-attenuation tubular mass (arrow) contiguous with base of cecum.
B, CT scan more caudal than A shows tip of mass (solid arrow) and surrounding inflammatory changes in mesenteric fat (open arrow).

TABLE 3: Summary of CT Measurements (Mean Values) and Significance in Differentiating Acute Appendicitis
with and without Mucocele
Normal Appendix
Finding
Luminal diameter (cm)

Appendicitis with
Mucocele

Reader 1

Reader 2

Reader 1

Reader 2

Reader 1

Reader 2

Reader 1

Reader 2

0.25 0.13

0.42 0.11

0.71 0.38

0.98 0.36

2.10 1.08

2.02 1.07

0.0003

0.0004

0.68 0.37

0.88 0.33

1.94 1.09

2.07 1.18

0.0049

0.00036

8.83 12.58

0.3576

0.0891

Luminal diameter (cm) with perforated cases excluded


Luminal attenuation (HU)

Appendicitis without
Mucocele

20.00 0.00 81.61 65.16 27.21 14.97 13.10 10.73 21.67 7.14

Wall thickness (mm)

1.63 0.56

1.07 0.38

3.58 1.24

2.05 0.98

3.86 2.81

1.92 1.00

0.2387

0.3579

Maximum lymph node size (mm)

5.25 1.28 10.00 0.00

6.46 2.02

9.67 2.79

6.38 1.06

8.20 2.05

0.9470

0.2804

NoteExact p values from Mann-Whitney U test for comparisons between acute appendicitis without mucocele and appendicitis with mucocele.

with the greatest luminal diameter was per


forated (Fig. 4). Likewise, the mean luminal
diameter in the mucocele cases decreased for
reader 1 with only a slight increase for reader
2. In a separate receiver operating char
acteristics analysis, 1.2 cm was identified as
the diagnostic threshold for luminal diameter
that maximized observed overall accuracy
with 75% sensitivity, 86.4% specificity, and
88.9% diagnostic accuracy.
Discussion
Mucocele of the appendix is a descriptive
term referring to a dilated appendix with
abnormal accumulation of mucus resulting
from obstruction of the appendiceal lumen [1,
2]. The reported prevalence at appendectomy
is 0.20.3%, and four types of mucocele have
been described [3, 4]. A simple mucocele or
retention cyst results from nonneoplastic
chronic obstruction of the appendix with
normal appendiceal mucosa. Mucoceles also

AJR:192, March 2009

may be associated with mucosal hyperplasia,


mucinous cystadenoma, and cystadenocarci
noma of the appendix. The CT appearance of
a mucocele has been well-described [7, 11
16]. In general, a mucocele appears as a wellcircumscribed, low-attenuation, spheric or

tubular mass contiguous with the base of the


cecum. The finding of curvilinear mural
calcification suggests the diagnosis but is
seen in less than 50% of cases [7, 13].
Intraluminal gas bubbles or an airfluid level
within a mucocele suggest the presence of

TABLE 4: Maximal Luminal Diameter of the Appendix for Identifying


Mucocele in the Setting of Acute Appendicitis: Summary of
Receiver Operating Characteristics Analysis
Maximal Luminal Diameter (cm)

Sensitivity (%)

Specificity (%)

> 0.4

100.00

12.73

> 0.5

95.24

27.27

> 0.8

90.48

52.73

> 0.9

85.71

56.36

> 1.2

76.19

85.45

> 1.3

71.43

94.55

> 1.6

66.67

96.36

> 1.7

61.90

98.18

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Bennett et al.

Fig. 450-year-old man with right lower quadrant pain and fever with surgically confirmed perforated acute appendicitis without mucocele.
A, CT scan obtained with oral and IV contrast enhancement shows fluid and air-containing inflamed appendix (black arrow) containing appendicolith (white arrow).
Marked inflammatory changes and fluid are present in periappendiceal fat.
B, CT scan more caudal than A shows markedly dilated fluid-filled distal appendix (arrow) that measured up to 1.6 cm in maximal luminal diameter.

superinfection, which can occur in both


benign and malignant mucoceles [6, 7].
In patients with right lower quadrant pain,
acute appendicitis with an associated muco
cele can be clinically indistinguishable from
acute appendicitis without mucocele [5, 6]. It
is reported [17] that as many as 50% of
patients with mucocele may have symptoms
compatible with typical acute appendicitis.
Although a mucocele is encountered in less
than 1% of patients undergoing appendectomy,
preoperative detection is important because
of treatment implications. Although surgical

management of mucocele of the appendix is


not uniformly agreed on, many surgeons
believe that laparoscopic appendectomy is
contraindicated because rupture of the
mucocele can lead to free spillage of mucus
into the peritoneal cavity and resultant pseu
domyxoma peritonei, which has a poor
prognosis [8, 9]. In addition, if there is a
neoplastic cause of the mucocele, more
extensive surgical resection, including right
hemicolectomy, may be performed [16]. In
our study, both patients with the prospective
CT diagnosis of inflamed mucocele under

went open appendectomy, one with interval


right hemicolectomy. Furthermore, the larger
the luminal diameter of the appendix in
patients with acute appendicitis, the higher is
the rate of laparoscopic failure in removal of
an intact appendix [18].
CT findings of acute appendicitis with
associated mucocele can overlap with those
of acute appendicitis without mucocele; in
both conditions, the appendix is dilated with
low-attenuation intraluminal content and
there are periappendiceal inflammatory
changes [6, 7]. To our knowledge, there has

Fig. 555-year-old man with acute appendicitis, periappendicitis, and mucocele manifesting as right lower quadrant pain.
A, CT scan obtained with oral and IV contrast enhancement shows distended fluid-filled appendix (arrow) measuring 8 mm in diameter.
B, CT scan more caudal than A shows thickened enhancing wall and surrounding inflammatory change in periappendiceal fat (arrow). Prospective CT interpretation was
acute appendicitis.

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CT of Mucocele of Appendix
Fig. 651-year-old man
with acute appendicitis
and perforated
mucocele manifesting
as right lower quadrant
pain and fever. CT scan
obtained with oral and IV
contrast material shows
fluid and gas-containing
collection (white arrow)
in right lower quadrant.
Tubular enhancing
structure (black arrow)
contained within this
collection represents
appendix. Finding
was prospectively
interpreted as acute
appendicitis with
perforation.

been no literature describing successful use


of CT to differentiate acute appendicitis with
mucocele from acute appendicitis without
mucocele. Pickhardt and colleagues [6]
reviewed the CT scans of 22 patients
(including nine with mucocele) with primary
appendiceal neoplasms manifesting as acute
appendicitis and found that cystic dilatation
of the appendix, a focal mass, or both were
CT findings of associated neoplasm in
patients with acute appendicitis. In addition,
an appendiceal diameter greater than 15 mm
was suggestive of a neoplasm. However, a
comparison was not made between CT
findings in these patients and the findings in
patients with acute appendicitis without
mucocele to determine diagnostic sensitivity
and specificity. Lien and colleagues [19]
investigated appendiceal outer diameter
determined at sonography as a means of
differentiating mucocele of the appendix
from acute appendicitis. An appendiceal
outer diameter greater than 16 mm was most
diagnostic, with a sensitivity of 83% and
specificity of 92%.
In differentiating acute appendicitis with
mucocele from acute appendicitis without
mucocele, our results show that the most
discriminating CT features are maximal
luminal diameter of the appendix and the
presence of cystic dilatation and mural
calcification. The mean appendiceal luminal
diameter of approximately 2 cm in patients
with mucocele in our series is in agreement
with findings in other studies that an overall
appendiceal diameter of 15 mm or greater is
suggestive of appendiceal neoplasm [6]. In
our study, when the maximal luminal diameter
of the appendix was greater than 1.3 cm, the
sensitivity was 71.4% and the specificity was
94.6% in the diagnosis of mucocele. At a

AJR:192, March 2009

higher threshold value of 1.7 cm, the specificity


increased to 98.2%, allowing exclusion of
cases of acute appendicitis with more sig
nificant luminal distention (Fig. 4) but with a
decrease in sensitivity to 61.9%. Lowering the
threshold to less than 1.3 cm increases
sensitivity for detection of mucoceles with
smaller luminal diameters, which are pre
sumably imaged earlier in the process of
mucocele formation (Fig. 5) but with decreased
specificity caused by overlap with acute
appendicitis without mucocele. The thresholds
of 15 mm found by Pickhardt et al. [6] and of
16 mm found by Lien et al. [19] were for ap
pendiceal diameter, whereas in our analysis,
we looked at luminal diameter with a separate
evaluation of wall thickness. However, the
mean wall thickness for acute appendicitis
for reader 1 was 3.58 mm and for reader 2
was 2.05 mm and for cases of appendicitis
with mucocele was 3.86 for reader 1 and 1.92
for reader 2. If this value is added to the 13mm threshold luminal diameter, on average,
the total diameter would be 1517 mm,
which is not dissimilar to the results of
Pickhardt, Lien, and their colleagues.
Cystic dilatation was a statistically signif
icant finding for both readers, as it has been
in other studies [6]. Mural calcification was
observed exclusively in patients with
mucocele. This finding achieved statistical
significance for one reader and a statistical
trend for the other. Because the readers were
97.1% concordant in this finding, statistical
significance was likely limited by the small
number of patients with mucocele. These
results suggest, however, that the presence of
appendiceal mural calcification is an addi
tional CT finding of mucocele. Unfortunately,
less than 50% of mucoceles are associated
with mural calcification; therefore, this find

ing cannot be exclusively relied on to


establish this diagnosis. Appendiceal mural
enhancement was found in a greater number
of patients with acute appendicitis without
mucocele than in patients with mucocele.
Given the greater degree of distention of the
appendix in the setting of mucocele, it might
be expected that mural enhancement would
be more difficult to appreciate. This feature
was statistically significant for only one
reader with only 80% concordance for the
two readers, limiting diagnostic utility.
The presence of an appendicolith was
observed in 22.8% of cases of acute appen
dicitis without mucocele and in no cases of
appendicitis with mucocele. However, this
finding did not achieve statistical signifi
cance, again probably because of the small
number of patients with mucocele. However,
the data suggest that in the presence of an
appendicolith, a coexisting mucocele can be
considered less likely. This observation may
be related to the fact that mucoceles result
from chronic appendiceal obstruction,
whereas acute appendicitis without mucocele
results from acute obstruction, such as that
caused by an impacted appendicolith. Given
the presence of intraluminal mucus, intra
luminal attenuation would be expected to be
low in the presence of a mucocele. In our
series, however, there was not a statistically
significant difference in intraluminal atten
uation between the two patient groups. The
inflamed appendix is generally fluid-filled,
resulting in decreased intraluminal atten
uation and probably accounting for the ob
served overlap in luminal attenuation.
Unlike previous studies [6], in our study
the findings of appendiceal wall thickening
and focal appendiceal mass were not helpful
in differentiating appendicitis with mucocele
from appendicitis without mucocele. A
focal mass in the appendix was found in
1.8% of patients with appendicitis without
mucocele and 8.3% of patients with mucocele.
These results again might have been limited
by the small sample size. In addition, a
variety of CT features of acute appendicitis
also were nonspecific, including intra
peritoneal fluid, periappendiceal fat strand
ing, lymphadenopathy, small-bowel mural
thickening, extraluminal and intraluminal
gas, the arrowhead sign, the target sign,
irregular wall contour, and abscess. All three
cases of appendicitis with perforated
mucocele in which CT showed periap
pendiceal fluid and gas-containing collection
were prospectively interpreted as perforated

W109

Bennett et al.
appendicitis (Fig. 6). Because of overlap in
imaging features, mucocele with perforation
is difficult to differentiate from perforated
acute appendicitis without mucocele.
The most important limitation of our
study was the small number of patients
with mucocele, which limited the statistical
power of comparisons between patients with
mucocele and those without. However, acute
appendicitis with associated mucocele is a
rare condition, and a multicenter study would
be needed to collect a large number of cases.
Because of the small sample size, Bonferroni
correction was not made as part of the
statistical analyses. Bonferroni correction
is a mechanism for reducing the number of
false-positive declarations in a study that has
multiple comparisons and, hence, a greater
probability of one or more false declarations.
Additional studies, therefore, with larger
sample sizes may be helpful to further clarify
these findings.
There also were unavoidable limitations
due to the retrospective nature of the study
and selection of cases. The cases reviewed by
the readers were artificially selected in that
only cases of appendicitis with mucocele,
appendicitis without mucocele, and normal
appendix were included. That the readers
were aware of this selection resulted in in
herent review bias. This bias was reduced,
however, because the readers were blinded to
patient group. In addition, many other causes
of right lower quadrant pain can be diagnosed
at CT that were not included in the study. The
aim of the study was to identify CT features
that allow differentiation of acute appendicitis
with mucocele from that without mucocele,
not to determine the overall accuracy of CT in
the diagnosis of inflamed mucocele in patients
with right lower quadrant pain. Furthermore,
the cases of acute appendicitis used for com
parison were randomly selected, possibly with
selection bias, which may have influenced the
observed differences between the patients
with acute appendicitis without mucocele and
those with appendicitis and mucocele. How
ever, there was a spectrum of CT findings in
the group of patients with acute appendicitis
without mucocele; cases of early appendicitis
were mixed with more advanced cases with
necrosis and perforation as determined at
pathologic examination.
Because of the concern that perforation
might have been a confounding factor result
ing from a decrease in appendiceal luminal
diameter, a separate analysis excluding per

W110

forated cases showed that the luminal diameter


that best differentiated acute appendicitis
from appendicitis with mucocele actually
decreased to 1.2 cm from 1.3 cm. Other
investigators [20, 21] have found that luminal
diameter does not necessarily decrease with
perforation and may actually be larger in
patients with perforation.
The retrospective nature of the study
resulted in variable CT technique. Not all
patients with mucocele underwent imaging
with a state-of-the-art MDCT scanner, and
two patients did not receive IV contrast
material, which might have limited the
readers ability to visualize certain features,
such as a focal mass and mural irregularity.
The lack of availability of multiplanar
reformatted images may have further limited
the ability to identify certain findings.
Although there is some overlap with acute
appendicitis without a mucocele, particularly
with respect to appendiceal luminal diameter,
we conclude that CT features suggestive of a
mucocele coexisting with acute appendicitis
include cystic dilatation of the appendix,
mural calcification, and a luminal diameter
greater than 1.3 cm. If these features are
visualized in a patient with acute appen
dicitis, the surgeon should be alerted to the
possibility of coexisting mucocele because
surgical management may have to be altered.
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