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Background: Discrimination between simple and perforated appendicitis in patients with suspected
appendicitis may help to determine the therapy, timing of surgery and risk of complications. The aim of
this study was to estimate the accuracy of magnetic resonance imaging (MRI) in distinguishing between
simple and perforated appendicitis, and to compare MRI against ultrasound imaging with selected
additional (conditional) use of computed tomography (CT).
Methods: Patients with clinically suspected appendicitis were identified prospectively at the emergency
department of six hospitals. Consenting patients underwent MRI, but were managed based on findings at
ultrasonography and conditional CT. Radiologists who evaluated the MRI were blinded to the results of
ultrasound imaging and CT. The presence of perforated appendicitis was recorded after each evaluation.
The final diagnosis was assigned by an expert panel based on perioperative data, histopathology and
clinical follow-up after 3 months.
Results: MRI was performed in 223 of 230 included patients. Acute appendicitis was the final diagnosis
in 118 of 230 patients, of whom 87 had simple and 31 perforated appendicitis. MRI correctly identified
17 of 30 patients with perforated appendicitis (sensitivity 57 (95 per cent confidence interval 39 to 73)
per cent), whereas ultrasound imaging with conditional CT identified 15 of 31 (sensitivity 48 (32 to 65)
per cent) (P = 0517). All missed diagnoses of perforated appendicitis were identified as simple acute
appendicitis with both imaging protocols. None of the MRI features for perforated appendicitis had a
positive predictive value higher than 53 per cent.
Conclusion: MRI is comparable to ultrasonography with conditional use of CT in identifying perforated
appendicitis. However, both strategies incorrectly classify up to half of all patients with perforated
appendicitis as having simple appendicitis. Triage of appendicitis based on imaging for conservative
treatment is inaccurate and may be considered unsafe for decision-making.
Presented to a scientic meeting of the Association of Surgeons of the Netherlands, Veldhoven, The Netherlands,
May 2012; published in abstract form as Br J Surg 2012; 99(Suppl 7): S6
Paper accepted 24 September 2013
Published online 22 November 2013 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9350
Introduction
Appendicectomy for acute appendicitis has been questioned recently as being the only correct treatment for
appendicitis. Antibiotic treatment has been shown to be
effective in the management of selected patients with acute
non-perforated (simple) appendicitis in randomized clinical
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mortality rate following perforation. An accurate preoperative diagnosis of perforation is therefore clinically relevant
in determining treatment and timing of surgery, and in
evaluating the risk of complications.
Diagnostic imaging with ultrasonography or computed
tomography (CT) has been proven accurately to detect
acute appendicitis8 . However, these imaging modalities do
not seem to be as effective in differentiating simple from
perforated appendicitis. For ultrasonography, the reported
sensitivities vary from 29 per cent9 to 84 per cent10 . More
recent studies11 13 evaluating the accuracy of CT in detecting perforated appendicitis have documented sensitivities
between 28 and 62 per cent, and specicities between 81
and 91 per cent. In a recent randomized trial1 the investigators selected patients with simple acute appendicitis by
systematic CT assessment before randomization to conservative or operative treatment. Despite the use of CT, complicated appendicitis with peritonitis was found at surgery
in 18 per cent of patients in the appendicectomy group.
Magnetic resonance imaging (MRI) is a promising
modality in the evaluation of suspected acute appendicitis
owing to its high diagnostic accuracy14,15 , and avoidance
of ionizing radiation and intravenous contrast medium.
Newer MRI techniques such as diffusion-weighted imaging
may further increase its accuracy16,17 . Because the use of
MRI in the evaluation of acute appendicitis is relatively
new, data on accuracy for perforated versus simple
appendicitis are not yet available in the literature.
The present study was designed to estimate the accuracy
of MRI for diagnosing perforated appendicitis in patients
with suspected acute appendicitis. The primary aim was
to compare the accuracy of MRI with the currently used
imaging strategy for evaluation of suspected appendicitis:
initial use of ultrasound imaging followed by CT if the
ultrasound results are negative or inconclusive18,19 . The
secondary aim was to identify MRI features associated with
perforated appendicitis.
Methods
MRI protocol
Included patients underwent MRI in a 15-T scanner
(MAGNETOM Avanto 15 T MRI, Siemens Medical
Systems; Intera 15 T MRI, Philips Medical Systems)
within 2 h of admission to the emergency department.
The MRI examination comprised breath-hold axial and
coronal T2-weighted sequences (half-Fourier-acquisition
single-shot turbo spin-echo (HASTE): repetition time
(TR) 1500 ms, echo time (TE) 90 ms, ip angle 170 , slice
thickness 6 mm, eld of view (FOV) 400 mm, 256 256
matrix; spectral selection attenuated inversion recovery
HASTE: TR 1400 ms, TE 93 ms, ip angle 160 , slice
thickness 6 mm, FOV 400 mm, 256 256 matrix), and freebreathing axial and coronal diffusion-weighted sequences
(diffusion-weighted imaging: TR 3900 ms, TE 75 ms, slice
thickness 6 mm, FOV 400 mm, 192 192 matrix, B-values
50400800 s/mm2 , 192 192 matrix). No intravenous or
oral contrast medium was administered.
Image interpretation
Two experienced radiologists (over 500 MRI readings of
the abdomen) read the MRI in a research setting on a
picture archiving and communication system workstation.
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Reference standard
All cases were assigned to one of two expert panels,
each consisting of two surgeons and one radiologist. The
panel assigned a nal diagnosis based on peroperative
observations, histopathological ndings and outcome at
3-month follow-up. If the patient had not returned to
the hospital within this period, their general practitioner
was contacted for information. The diagnosis was
classied as no appendicitis (any other diagnosis), simple
appendicitis or perforated appendicitis. Criteria for
perforated appendicitis were perioperative observation of
a perforation in the appendix, pus in the abdomen or
perforation at histopathological examination. Conicting
ndings at perioperative observation, histopathological
or clinical examination were resolved during consensus
meetings of the two expert panels.
Definitions
The diagnostic accuracy for perforated appendicitis was
evaluated for MRI and for ultrasound imaging with
conditional CT. Estimates of sensitivity, specicity and
predictive values were calculated with corresponding 95
per cent condence intervals (c.i.), by comparing the imaging results with the nal diagnosis assigned by the expert
panel. For these calculations only imaging results positive
for perforated or simple appendicitis were used. Cases
of perforated appendicitis in which imaging identied
perforated appendicitis were considered as true positives,
whereas cases of perforated appendicitis identied as simple appendicitis were false negatives. Cases of simple or no
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Statistical analysis
With an MRI sensitivity in detecting perforated appendicitis of around 60 per cent, and about one in seven patients
with suspected appendicitis having a nal diagnosis of perforated appendicitis, the inclusion of 230 patients would
produce a 95 per cent c.i. that extends 15 per cent from the
estimated sensitivity21 .
Differences in sensitivity, specicity and predictive values were tested for statistical signicance using the 2 test.
P < 0050 was considered to indicate statistical signicance.
The presence of individual MRI features, as specied
above, was compared between patients with perforated
and simple appendicitis as nal diagnosis using the 2 test.
Estimates of positive (PPV) and negative (NPV) predictive
values for perforated appendicitis were calculated per
MRI feature, with corresponding 95 per cent c.i. This
was also calculated for the combination of any two MRI
features. The association between each imaging feature
and a nal diagnosis of perforated acute appendicitis was
expressed as a diagnostic odds ratio with corresponding
95 per cent c.i. All statistical analyses were performed with
SPSS software version 18.0 (IBM, Armonk, New York,
USA).
Results
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Ultrasonography
n = 229
No appendicitis
Appendicitis
CT
n = 115
Perforated appendicitis n = 22
Final diagnosis
Perforated appendicitis n = 15
Simple appendicitis n = 6
Other n = 1
No appendicitis n = 105
Final diagnosis
Perforated appendicitis n = 0
Simple appendicitis n = 3
Other n = 102
Ultrasonography and CT
Clinically suspected appendicitis
n = 230
MRI
n = 223
Appendicitis
Perforated appendicitis n = 30
Final diagnosis
Perforated appendicitis n = 17
Simple appendicitis n = 12
Other n = 1
No appendicitis
Simple appendicitis n = 90
Final diagnosis
Perforated appendicitis n = 13
Simple appendicitis n = 71
Other n = 6
No appendicitis n = 103
Final diagnosis
Perforated appendicitis n = 0
Simple appendicitis n = 4
Other n = 99
MRI
Fig. 1 Flow chart showing imaging results: a ultrasound imaging with conditional computed tomography (CT) and b magnetic
resonance imaging (MRI)
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Table 1
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No appendicitis ( n =112)
15
16
0
6
78
3
1
9
102
17
13
0
1
12
71
4
0
1
6
99
6
230
223
*All patients underwent initial ultrasonography, then computed tomography (CT) if the ultrasound results were negative or inconclusive.
Table 2
125
MRI
120
Sensitivity (%)
Specificity (%)
PPV (%)
NPV (%)
48 (32, 65)
15 of 31
57 (39, 73)
17 of 30
93 (85, 96)
87 of 94
86 (77, 91)
77 of 90
68 (47, 84)
15 of 22
57 (39, 73)
17 of 30
84 (76, 90)
87 of 103
86 (77, 91)
77 of 90
0517
0127
0399
0833
Values in parentheses are 95 per cent condence intervals; proportions used to calculate diagnostic indices are also shown. Only imaging results positive
for perforated or simple appendicitis were used for these calculations. *All patients underwent initial ultrasonography, then computed tomography (CT) if
the ultrasound results were negative or inconclusive. PPV, positive predictive value; NPV, negative predictive value; MRI, magnetic resonance imaging.
2 test.
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Table 3
Prevalence and predictive values for perforated appendicitis according to features on MRI
Appendicitis group
Predictive values
No. of patients
(n = 223)
Perforated
(n = 30)
Simple
(n = 87)
No
(n = 106)
PPV (%)
NPV (%)
Diagnostic
odds ratio
210
210
210
210
210
210
223
223
207
207
207
30 of 30
29 of 30
27 of 30
26 of 30
16 of 30
14 of 30
10 of 30
1 of 30
27 of 29
24 of 29
15 of 29
84 of 86
81 of 86
61 of 86
80 of 86
36 of 86
13 of 86
8 of 87
0 of 87
72 of 85
62 of 85
12 of 85
13 of 94
8 of 94
13 of 94
29 of 94
4 of 94
2 of 94
1 of 106
1 of 106
5 of 93
8 of 93
4 of 93
24 (17, 32)
25 (18, 33)
27 (19, 36)
19 (14, 27)
29 (18, 41)
48 (31, 66)
53 (32, 73)
50 (9, 91)
26 (19, 35)
26 (18, 35)
48 (32, 65)
(5, )
30 (4, 222)
13 (4, 44)
4 (1, 13)
4 (2, 9)
10 (4, 23)
10 (4, 28)
7 (0, 109)
18 (4, 77)
7 (3, 20)
11 (4, 26)
Values in parentheses are 95 per cent condence intervals. Data were missing for some features. MRI, magnetic resonance imaging; PPV, positive
predictive value; NPV, negative predictive value.
Discussion
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Collaborators
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Acknowledgements
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Published by John Wiley & Sons Ltd
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Supporting information
Additional supporting information may be found in the online version of this article:
Appendix S1 Structured case record form (Word document)
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