Downloaded from www.ajronline.org by 39.210.239.29 on 12/15/13 from IP address 39.210.239.29. Copyright ARRS.

For personal use only; all rights reserved

763

Diagnosis
Value

J. Malone,
Jr.1
Clifford R. Wolf
Allan S. MaImed
Bradley
F. Melliere

of Acute

Appendicitis:

of Unenhanced

CT

OBJECTIVE.
Two hundred
eleven patients with
had CT without
oral or IV contrast
material.

Anthony

acute pain in the right lower quadThe CT examination

required
less

rant

than

5 mm

ination

to perform

arotomy.
SUBJECTS
in 211
from

the

two

to 30

L3

lower

Scans

level

per

assessed

acute

symphysis

patient

of this

who

of uncertain

by using
pubis

were

efficacy

without

obtained,

(130

IV or oral

the

and

at 10-mm

contrast

on

of the

81

men

intervals

material.

size

lap-

was performed

women

collimation

depending

CT exam-

emergency

abdomen

origin

10-mm

limited

required

CT of the lower

pain

obtained

the

appendicitis

Unenhanced

abdominal

were

to the

images

We

with

METHODS.

with

old).

interpret.

patients

AND

patients

years

4-91

and

in identifying

Twentypatient.

On

average,
the entire examination
took less than 5 mm to complete.
Prospective
diagnoses based on CT findings were compared
with surgical results and clinical follow-up.
RESULTS.
Unenhanced
CT was an accurate
imaging technique
for the initial examination

of

patients

accuracy

was

93%.

The

87%, the specificity

was 97%, the positive
predictive
and the negative
predictive
value was 93%.
CONCLUSION.
This study shows that unenhanced
CT is a useful

value

was

94%,

test to diagnose

appendicitis

quadrant.

sensitivity

AJR

with

suspected

acute

appendicitis.

The

was

in patients

1 993;i

Reginald

with

acute

abdominal

in the

right

lower

60:763-766

H. Fitz [1] first described

However,

pain

quick

and

accurate

acute

diagnosis

appendicitis

of this

more

common

than

100 years

condition

is still

ago.

a major

problem.
Ten percent of men undergoing
appendectomy
and up to 35% of women
undergoing
appendectomy
are found to have histologically
normal appendixes
[2,
3]. Laparotomy
could be avoided
in many patients
if a reliable diagnostic
method
were
available
to make,
or more
importantly
exclude,
the diagnosis
of acute
appendicitis.
Unnecessary
laparotomy
for removal
of a normal appendix
is not
without
morbidity
[4, 5].
Accordingly,
many diagnostic
techniques
including
plain abdominal
radiography, conventional
full-column
barium
enema,
and, more recently,
graded
compression
real-time
sonography
have been used to diagnose
acute appendicitis
in
patients
with acute
pain in the right lower
quadrant
[5-il].
CT with oral contrast
material
also has been used in these cases [5, 12-18].
All of these techniques,
however,
have limitations
[19, 20].
This report describes
the use and accuracy
of unenhanced,
rapidly performed
CT in diagnosing
acute appendicitis
in 211 patients
with pain in the right lower
quadrant.
Received
August 25, 1992; accepted
after revision November
6, 1992.
1All authors:
Department
of Radiology,
North-

Subjects

west Community
lington Heights,
to A. J. Malone,

gency

barium

Pace,

General

Hospital,
800 W. Central Rd., ArIL 60005. Address correspondence
Jr.

0361 -803X/93/1
604-0763
American
Roentgen
Ray Society

and Methods

Beginning

10-mm

intervals

in May
enema

1991,

Electric,
from

all patients

to exclude
Milwaukee,
the

L3 level

who

acute
WI).
to the

came

appendicitis
Scans
symphysis

to the
were

were

radiology
first

obtained
pubis

department

examined

without

by using

IV or

for

with

CT

10-mm
oral

(GE

an

emer9800

collimation

contrast

material.

or
at

764

MALONE

Twenty-two

to 30 images

the size of the patient.

than

5 mm

Downloaded from www.ajronline.org by 39.210.239.29 on 12/15/13 from IP address 39.210.239.29. Copyright ARRS. For personal use only; all rights reserved

patients

to complete.

seen

per patient were obtained,

On average,
No

record

in the emergency

the entire
was

kept

department

depending

examination
to determine

on

took less
how

many

had CT and how many

had an appendectomy
without any imaging procedure.
A total of 211 patients, 130 women and 81 men 4-91 years old,
had unenhanced CT. These were a select group of patients who had
lower, usually right-sided,
abdominal
pain and no history of appendectomy,
and in whom the diagnosis
was not obvious.
No attempt
was made to correlate
CT findings with clinical signs or symptoms.

A radiologist

immediately

reported

the CT findings

to the attending

surgeon,
who then decided
if surgery was warranted.
Unenhanced
CT findings
of acute appendicitis
included
a thickened
appendix
with

diameter

exceeding

mm

with

associated

inflammatory

changes
in the periappendiceal
fat and/or abnormal
thickening
of
the right lateroconal
fascia with or without a calcified
appendicolith.
These initial interpretations
were the ones used in the study. The
pathologic
findings from the specimens
of resected appendix
served

as the gold standard

did not have

surgery

for the diagnosis

were

contacted

of appendicitis.
to determine

Patients

who

if surgery

had

been performed elsewhere at a later date. if no surgery had been

done and the patients symptoms resolved, this was recorded as a
true-negative

finding

on unenhanced

CT.

Results
Seventy-five
(80%) of 94 patients
who had surgery
had
pathologically
proved acute appendicitis.
The remaining
19
patients
had various
other conditions,
and normal
appendixes were excised.
Acute appendicitis
was correctly
diagnosed
with rapid unenhanced
CT in 65 (87%) of the 75
proved
cases.
Of the remaining
1 0 cases
(false-negative
findings
on CT), two were diagnosed
as endoappendicitis
on
the basis of pathologic
examination
of surgically
resected
tissues.
In these cases the appendix
had a normal
gross
appearance
and the lesion consisted
entirely of early microscopic mucosal
changes
[21] that we discovered
are impossible to detect with CT. The other eight patients
who had
false-negative
findings
on CT scans
all had early acute
appendicitis
and were generally
slender
people
who had
very little peniappendiceal
or penicecal
fat, which is needed
to detect early inflammatory
changes.
Two cases of acute
diverticulitis,
two cases of hemorrhagic
ovarian
cyst, three
cases of pelvic inflammatory
disease,
three cases of torqued
ovarian
masses,
and one case of Crohns
disease
were
among diagnoses
made prospectively
on the basis of unenhanced CT scans.
One hundred
thirty-six
patients
did not have acute appendicitis.
Nineteen
normal
appendixes
were
surgically
removed (prospectively,
15 of these were diagnosed
as normal
on the basis of unenhanced
CT findings).
The remaining
117
patients who did not have lapanotomy
were followed
up clinically for up to 6 months and none had appendectomies.
In four patients,
findings
on unenhanced
CT scans were
false-positive.
At surgery, two patients had a markedly
edematous hyperemic
inflamed
appendix,
but by definition
they did
not have acute appendicitis
because
pathologic
examination
showed
that the acute
inflammatory
response
was most
intense
in the serosal
layer rather than within the wall and
mucosa
of the appendix.
No other pathologic
process
was
apparent
at surgery
in either
patient,
and both patients
improved
clinically
after appendectomy.
In the other two
patients
with false-positive
findings
on unenhanced
CT,

ET AL.

AJA:160,

April1993

pathologic
examination
showed
a normal
appendix
amidst
an inflammatory
process
of the mesentery
in one and a normal appendix
amidst free blood from a hemorrhagic
ovarian
cyst in the other. Thus, if the decision to remove the appendix
had been made solely on the basis of CT findings,
only two
histologically
normal appendixes
would have been excised,
giving a surgically
false-positive
rate of less than 1%.
Statistical
analysis
of the final diagnoses
based on unenhanced
CT findings
indicated
a sensitivity
of 87%, a specificity of 97%, and an accuracy
of 93% for unenhanced
CT in
the diagnosis
of acute appendicitis.
The positive
predictive
value was 94% and the negative
predictive
value was 93%.
These results compare
favorably
with those for high-resolution real-time
sonography
[7-9, 22] and with those of previous studies that used enhanced
CT [12].

Discussion
Several
investigators
[5, 12-1 8] have shown
that enhanced
CT is an accurate
imaging
technique
for detecting
acute appendicitis.
However,
because
of the high cost (more
than $700 per examination
in many institutions)
and the delay
before orally ingested
contrast
material
reaches
and opacifies the ileocecal
region, contrast-enhanced
CT has not been
widely used to examine
patients
with pain in the right lower
quadrant
who are suspected
of having
acute appendicitis.
Therefore,
we hypothesized
that rapidly
performed
unenhanced CT might be the best diagnostic
imaging
technique
for the diagnosis
of acute appendicitis.
The major advantages
of the technique
are its relatively
low cost ($300 total in our
institution)
and the minimal time required
(less than 5 mm).
The isolated
CT finding
of an appendix
with a diameter
exceeding
6 mm was an insufficient
basis for a diagnosis
of
acute appendicitis.
Our results
showed
that inflammatory
changes
involving
the thickened
appendix
had to be present
(i.e., streaking
and poorly defined
increased
attenuation)
in
the peniappendiceal
fat (Figs.
1 and 2). Thickening
and
prominence
of the right lateroconal
fascia immediately
adjacent to the edematous
inflamed
appendix
also was a common finding (Fig. 1). Detection
of a calcified
appendicolith
within the thickened
appendix
was a useful finding.
Forty of
our 211 patients
had a calcification
in the right lower quadrant; of these 40, 29 (73%) had acute appendicitis.
However,
a calcification
in the right lower quadrant
without
inflammatory changes
is an insufficient
basis for a diagnosis
of acute
appendicitis.
For a definitive
diagnosis,
a calcified
appendicolith must be associated
with inflammatory
changes
in and
around
the appendix
(Fig. 2). We think,
however,
that
patients who have a calcification
in the right lower quadrant
without definite inflammatory
changes
should be followed
up
closely within the 24 hr after the CT examination.
Another
common
finding was an acutely
inflamed
appendix extending
medially
from the cecum to drape across and
anterior
to the right psoas
muscle.
The peniappendiceal
inflammation
obliterates
the fat immediately
anterior
to the
psoas muscle (Fig. 3).
Inflammatory
infiltration
of the penicecal fat and fascia without definite visualization
of an abnormal
appendix
was also
often seen on unenhanced
CT. Balthazar
et al. [12] found
that lack of visualization
of an abnormal
appendix
on contrast-enhanced
CT scans, even in the presence
of obvious

AJA:160,

April

CT

1993

OF

ACUTE

765

APPENDICITIS

Fig. 1.-Early
acute
appendicitis.
Unenhanced
CT scan shows
inflamed
appendix
(white arrow) with thickened
lateroconal
fas-

cia extending

Downloaded from www.ajronline.org by 39.210.239.29 on 12/15/13 from IP address 39.210.239.29. Copyright ARRS. For personal use only; all rights reserved

it (arrowheads).
in fat anterior
arrows).

anteriorly

and posteriorly

from

Note inflammatory
changes
to right psoas
muscle
(black

Fig. 2.-Early
acute appendicitis
with calcified fecalith
in lumen of edematous
inflamed
appendix
(arrowhead).
Fecalith
was not visible on plain radiographs.

inflammatory
changes
in the right lower quadrant,
is a nonspecific
finding and is an insufficient
basis for the diagnosis
of acute appendicitis.
We found that determining
the origin or
epicenter
of the inflammatory
process
provided
information
that enabled
us to confidently
diagnose
acute appendicitis
with a high degree of accuracy
even when the appendix
itself
was lost in the inflammatory
changes
and could not be definitely visualized
(Fig. 4).
We encountered
several
pitfalls
in the interpretation
of
unenhanced
CT images.
Normal fluid-filled
small bowel must
not be taken
for a dilated
enlarged
appendix.
A careful
search
for inflammatory
changes
must be made.
Normal
small bowel will lack these changes.
Malposition
of the cecum or a low-lying
cecum in the anatomic pelvis can also cause misinterpretation.
Cecal position
should be ascertained
from plain radiographs
or the CT-generated scout image. Although
visualization
of a calcification
in the right lower quadrant
on unenhanced
CT scans is very

Fig. 3.-Unenhanced
CT scan shows obliteration of fat anterior
to right psoas muscle (arrowheads) by acutely inflamed
appendix.
Fat anterior
to left psoas muscle is normal (arrows).

important,

not

all

calcifications

seen

on

these

images

are

appendicoliths.
Orally ingested
radiopaque
pills and medications are frequently
visualized
on unenhanced
CT scans and
must not be mistaken
for calcified
appendicoliths.
Inflammatory
changes
in the penicecal
and peniappendiceal fat are the most important
findings
when basing the
diagnosis
of acute appendicitis
on unenhanced
CT. Therefore, slender
young patients
who have little retropenitoneal
and
mesentenic
fat present
a challenging
problem.
The
majority
of our false-negative
findings
were on unenhanced
CT scans of patients
who fit this description.
If no definite
inflammatory
changes
are detected,
our study results
indicate there remains approximately
a 5% chance of early acute
appendicitis.
Therefore,
on the basis of our experience
we
recommend
that in this instance
the patient be closely monitored for changes
in the clinical condition.
We think, however,
that

particular

diagnosis

even

attention

to our criteria

in children

Fig. 4.-Acute
appendicitis
without definite
visualization
of inflamed appendix. Unenhanced
CT scan shows diffuse
inflammatory
changes
involving
pericecal
region (arrowheads).
Anterior wall of cecum and small-bowel
loops are not
involved
by inflammatory
process,
suggesting
acute appendicitis
as cause. Note calcified fecalith in middle of inflammatory
response
(arrow).

and slender

will enable

patients

an accurate

(Fig. 5).

Fig. 5.-Acute
appendicitis
in slender
6year-old
boy with little retroperitoneal
fat. Unenhanced
CT scan shows edematous
appendix
(large
arrowhead)
and thickened
lateroconal
fascia (small arrowheads).
Note inflammatory
infiltration
of periappendiceal
fat (arrows).
Diagnosis
was based on these findings.

MALONE

Downloaded from www.ajronline.org by 39.210.239.29 on 12/15/13 from IP address 39.210.239.29. Copyright ARRS. For personal use only; all rights reserved

766

Abdominal
CT is nearly always
performed
with contrast
enhancement
from both oral and IV contrast
material.
However, our results
show that unenhanced
scans are efficacious when the diagnosis
of appendicitis
is suspected.
The
midportion
of the ascending
colon (usually
filled with stool
and air) provides
a landmark
because
this region is usually
cephalad
to the ileocecal
valve. By viewing
successive
caudal images,
the ileocecal
valve and terminal
ileum usually
can be detected.
A tubular soft-tissue
structure
caudal to the
cecum and not part of the cecum is often the appendix.
The
penicecal
fat in this area is frequently
involved
in early
inflammation
of the appendix.
We conclude
that unenhanced
CT is an accurate
examination in patients
with acute pain in the right lower quadrant.
The examination
is well tolerated
even by very sick patients,
is essentially
free of risk, is relatively
inexpensive,
and is not
operator
dependent.
The success of the examination
is unaffected by the presence
of increased
amounts
of bowel gas
or severe abdominal
pain. The prevalence
of surgical
excision of normal appendixes
can be reduced
without increasing the perforation
rate, and unenhanced
CT findings
can be
used
successfully
and
accurately
to determine
which
patients
have acute appendicitis
and which do not. Unenhanced
CT may also be helpful in detecting
diseases
other
than acute appendicitis
in patients
with acute pain in the
lower abdomen.

ACKNOWLEDGMENTS
We thank the entire CT staff, including
neau,

Arnie

Tydell,

Gloria

Grajdura,

John

Cindy Buffa, Patty ArseLivorsi,

Cindy

Rodstrom,

Julie Fisher, Desi Vargo, Cathy Koch, and Lois McKillop, for support
during the course of this study. We also thank Jill Trzeciak for preparing

the manuscript

for medical

assistance

and Daniel

G. Malone

and Terrance

Demos

in writing this article.

REFERENCES
1. Fitz RH. Perforating

inflammation

of the veriform

appendix

with special

ref-

erence to eariy diagnosis

and treatment.
Am J Med Sci 1886;92:321-346
2. Abu-Vousef
MM, Bleicher
JJ, Maher JW, Urdaneta
LF, Franken
EA Jr.

ET AL.

AJR:160,

April1993

Metcalf AM. High resolution

sonography
of acute appendicitis.
AJR 1987;
149:53-58
3. Lau W, Fran 5, Yiu 7, Chu K, Wong S. Negative
findings
at appendectomy. Am J Surg 1984;148:375-378
4. Bongard
F, Laners DV, Lewis F. Differential
diagnosis
of appendicitis
and
pelvic inflammatory
disease. Am Surg 1985;150:90-95
5. Balthazar
EJ, Gordon RB. CT of appendicitis.
Semin Ultrasound
CT MR
1989;10:326-340
6. Puylaert JBCM. Acute appendicitis:
US evaluation
using graded compression. Radiology
1986;1 58:355-360
7. Jeffrey RB, Laing FC, Townsend
RR. Acute appendicitis:
high resolution
real time US findings.
Radiology
1987;163:11-14
8. Jeffrey RB, Laing FC, Townsend
AR. Acute appendicitis:
sonographic
criteria based on 250 cases. Radiology
1988;167:327-329
9. Puylaert
JBCM,
Rutgers
PH, Lalisang
RI, et al. A prospective
study of
ultra-sonography
in the diagnosis
of appendicitis.
N EnglJ Med 1987;317:
666-669
10. El Ferzli G, Ozuner G, Davidson
PG. Isenberg JS, Redmond
P, Worth MH
Jr. Barium enema in the diagnosis
of acute appendicitis.
Surg Gynecol
Obstet 1990;1 71:40-47
11 . Garcia CJ, Rosenfeld
NS. The barium enema
in the diagncsis
of acute
appendicitis.
Semin Ultrasound
CT MR 1989; 10:314-320
12. Balthazar
E, Megibow A, Siegal SE, Birnbaum
BA. Appendicitis:
prospective evaluation
with high-resolution
CT. Radiology
1991180:21-24
13. Shapiro
MP, Gale ME, Gerzof
5G. CT of appendicitis:
diagnosis
and
treatment.
Radiol Clin North Am 1 989;27:735-762
14. Balthazar
EJ, Megibow
AJ, Halnick
D, Gordon
RB, Naidich
DP, Beranbaum ER. CT of appendicitis.
AJR 1986;147:705-710
15. Balthazar
EJ, Megibow
AS, Gordon
RB, Whelan
CA, Hulnick
D. Computed tomography
of the abdominal
appendix.
J Comput
Assist Tomogr
1988;12:595-601
16. Jones B, Fishman
EK, Siegelman
55. Computed
tomography
and appendiceal abscess:
special applicability
in the elderly. J ComputAssist
Tomogr
1983;3:434-438
17. Jeffrey
RB Jr, Federle
MP, Tolentino
CS. Periappendiceal
inflammatory
masses:
CT directed
management
and clinical outcome
in 70 patients.
Radiology
1988;167:1
3-16
18. Gale ME, Birnbaum
5, Gerzot SG, Sloan G, Johnson
WC, AobbinsAH.
CT
appearance
of appendicitis
and its local complications.
J Comput Assist
Tomogr 1985;9:34-37
19. Brown JJ. Acute appendicitis:
the radiologists
role. Radiology
1991;180:
13-14
20. Berry J Jr, Malt RA. Appendicitis
near its centenary.
Ann Surg 1984;200:
567-575
21. van Spreeuwel
JP, Lindeman
J. Campylobacter-associated
appendicitis.
PatholAnnu
1987;22:55-65
22. Adams DH, Fine C, Brooks DC. High resolution
real-time
ultra-sonography: a new tool in the diagnosis
of acute appendicitis.
Am J Surg 1988;
155:93-96