GASTROENTEROLOGY 1989;97:630-9

Ultrasonography in the Diagnosis of

Acute Appendicitis: A Prospective Study
WOLF B. SCHWERK, BRITTA WICHTRUP, MATTHIAS ROTHMUND,
and JOSEPH RUSCHOFF
Departments of Internal Medicine, Surgery, and Pathology, Philipps-University of Marburg,
M&burg, Federal Republic of Germany

The diagnostic accuracy and practical impact of surgical intervention also cause an outstandingly
high-resolution sonography were prospectively high rate of appendiceal rupture in children Cl8 yr
studied in 523 consecutive patients admitted to the of age and in adults >5O yr old. Reported values for
hospital with suspected appendicitis. The criteria these groups range from 40% to 93% and 37% to
for ultrasound diagnosis of acute appendicitis in- 67%, respectively (1,3-6).
cluded visualization of a noncompressible aperi- Prospective controlled studies have shown that
staltic appendix, with a targetlike appearance in the overall accuracy of preoperative clinical diagno-
transverse view and a diameter ~7 mm. In 115 of sis is in the range of 70%78% for patients with
130 patients with proven appendicitis the inflamed suspected appendicitis and thus the rate of unnec-
appendix or appendiceal abscess could be visual- essary laparotomies is correspondingly high at ZO%-
ized, giving a sensitivity of 88.5%.The mean diam- 25% (7-10).
eter of ultrasonically visible appendices was 11.4 +- According to some reports, computer-aided anal-
3.2 mm. The overall accuracy and specificity of ysis and decision-making have reduced the inci-
sonography in the diagnosis of acute appendicitis dence of negative surgical exploration (7). Other
were 95.7% and 98% respectively. The predictive studies, however, have concluded that this method
value of a positive test was 94.5% and that of a offers no advantage over unaided clinical diagnosis
negative result 96.3%. In a separate analysis of the (11).
results in 121 women of childbearing age, who have There are two major reasons for the diagnostic
a high risk of preoperative misdiagnosis, the overall dilemma in acute appendicitis. First, the “typical”
accuracy was found to be 96.7%, with 82.6% sensi- clinical signs and symptoms are nonspecific and
tivity and 100% specificity. Twenty-four (89%) of may also be caused by a broad spectrum of other
the 27 patients with appendiceal rupture (incidence abdominal or pelvic disorders. Second, prior to high
20.8%) were correctly diagnosed with ultrasound. resolution sonography, no noninvasive imaging
The other 3 cases (11%) were missed. Routine use of technique was available to enable direct visualiza-
ultrasonography has significantly improved the di- tion of the inflamed vermiform appendix.
agnostic accuracy in patients with suspected appen- Following the initial case report on ultrasonic
dicitis and has reduced the negative laparotomy demonstration of the inflamed appendix (12), a re-
rate from 22.9% to 13.2%. cent study has taken a retrospective look at the role
of ultrasonography in the evaluation of patients with
suspected appendicitis (13) and there have been
A cute appendicitis is one of the most frequent
causes of abdominal emergency in nearly all age
groups. Primary appendectomy is considered to be
prospective trials on selected patients (14-16)as
well as on unselected populations (17,18). We have
now conducted a prospective evaluation of the rou-
the most appropriate treatment. It carries a low
tine use of high-resolution sonography in a larger
overall mortality rate of 0.2%0.8% that is attributed
group of unselected patients thought to be suffering
to complications during disease progression rather
from acute appendicitis. In this trial special atten-
than to the surgical intervention itself (1,~).
However, an increased mortality rate of up to 15%
has been observed in patients >70 yr of age and is
mainly attributed to diagnostic and thus therapeutic 0 1989 by the American Gastroenterological Association
delay (1).The more difficult diagnosis and delayed 0016-5065/69/$3.50
September 1989 ULTRASOUND IN ACUTE APPENDICITIS 631

tion was focused on two questions. (a) Can sonogra- The original intention of the study was to decide thera-
phy improve the preoperative diagnostic accuracy peutic measures without consideration of ultrasound find-
when compared with the results of the initial phys- ings and to analyze the diagnostic accuracy at a later date
ical examination? (b) Can this relatively new diag- to avoid the possible risk of sonographic results delaying
surgery. However, after examining the first 30 patients, the
nostic application reduce the rate of unnecessary
planned study design was revised and established as
laparotomies, particularly in equivocal cases and in
shown in Figure 1. For ethical reasons the ultrasound
patients who have a high risk of misdiagnoses?
findings could not be ignored when making definitive
decisions.
Materials and Methods This procedure of preliminary therapeutic decision
based on preultrasound diagnoses followed by definitive
Patients decisions taking ultrasound findings into account, enabled
The study comprises 532 unselected patients ad- us to determine both the calculated and real negative
mitted to the hospital with suspected acute appendicitis. laparotomy rate. Thus, the calculated negative laparotomy
These included 323 female and 209 male patients with a rate indicates the number of unnecessary laparotomies
mean age of 23.8 * 7.6 yr (age range 3-88 yr). that would have been performed if the results from the
sonographic investigations had not been considered.

Study Design
Subsequent to hospital admission all patients un- Equipment and Procedures
derwent thorough physical examination. A working diag-
nosis was performed by senior surgeons and took into Ultrasound scanning was performed using com-
account medical history, findings on physical examina- mercially available electronic real-time equipment with a
tion, and body temperature as well as laboratory findings. S-MHz curved-array transducer (LSC 7000; Picker, F.R.G.).
Based on preultrasound diagnoses, all patients were then During examination gradual compression was applied to
placed within clinically defined categories that also served the area of interest via the transducer. Thus, it was possi-
to assess the need for surgical intervention. ble to localize and simultaneously visualize the area of
greatest abdominal tenderness and to improve sound
1. Acute appendicitis with high grade of suspicion- transmission and imaging by displacement of obscuring
urgent surgery indicated. bowel gas. Gradual compression was generally well toler-
2. Acute appendicitis equivocal-in-hospital observation. ated by the patient.
3. Acute appendicitis very unlikely. Sonographic visualization of the cecal tip, the psoas
muscle, and the iliac vessels were considered landmarks
Ultrasound examination was performed immediately in the exploration of the appendix area.
after clinical categorization of the patients. The definitive To visualize retrocecal or subhepatic appendix posi-
decision regarding therapy was made including sono- tions, ultrasound scanning was performed both in the
graphic findings. sagittal plane through the anterior abdominal wall, and in
the horizontal plane from the right lateral.
In general not only the right lower quadrant but also the
entire abdomen and pelvis were examined to provide
Patients with suspected alternative diagnoses, particularly in those patients with-
acute appendicitis out evidence of acute appendicitis.

History, physical examination,

Criteria for Evaluation and Definitions
vital signs, laboratory values

1 Sonographic
dix or the identification
visualization of the inflamed
of a periappendiceal
appen-
abscess was
Initial clinical classification: considered a positive diagnosis of appendicitis. Nonvisu-
categories l-3 (preliminary alization of the appendix was recorded as a negative result.
If the inflamed appendix could be identified, the largest
decision regarding therapy) outer diameter was measured using electronic calipers. A

J detailed
surgically
histologic
removed
examination
appendices,
was performed
which formed the basis
on all

Real-time sonography (5 MHz) for definitive judgment. Diagnoses in patients not under-
going surgery were verified by evaluating all examinations,

3 including follow-up
To determine
observations.
and compare the diagnostic accuracy of
Definitive decision regarding therapy initial physical examination and sonography in acute
Figure I. Study design. appendicitis, the following criteria were considered:
632 SCHWERK ET AL. GASTROENTEROLOGY Vol. 97, No. 3

Figure 2. Early acute appendicitis (category 1). a. Longitudinal sonogram of the fluid-distended appendix (A, white arrow) in an unusual
subhepatic position with an outer diameter of 8 mm (measured by caliper]. Black arrow indicates hyperechoic appendicolith
with acoustic shadow (S). b. Transverse view of the appendix (arrow). c. Corresponding histologic section.

Sensitivity (TP results] = TP x lOO%i(TP + FN), of patients in category 1, and PC,,, = number of patients in
Specificity (TN results) = TN x lOO%i(TN + FP),
category 2 and 3 who required surgery.

Predictive value of positive results = TP x lOO%/(TP + FP).

Predictive value of negative results = TN x lOO%/(TN + FN),

Results
Overall accuracy = (TP + TN] X lOO%i(TP+TN+FP+FN).
Prevalence of Appendicitis
where FN = false-negative, FP = false-positive, TN =
true-negative, and TP = true-positive. Negative laparot- Of the 532 patients included in this study, 130
omy rate (NLR) and calculated NLR based on preultra- had proven acute appendicitis, i.e., there was a
sound diagnoses (NLR,), respectively, were based on the 24.4% prevalence of appendicitis. These 130 com-
following formulas: prised 64 women and 66 men with a mean age of
29.6 k 10.5 yr. The age distribution of appendicitis
NLR = NL x loos/LAP, (11
patients was as follows: <lo yr, 10%; 11-20 yr, 34%;
NLR, = NL, x lOO%/(PC, + PC,,,), (2) 21-30 yr, 23%; 31-40 yr, 7.5%; 41-50 yr, 7.5%; 51 yr
where NL = real negative Iaparotomies, LAP = total and over, 18%. In the subgroup of 121 women aged
number of laparotomies, NL, = calculated NL in category 20-40 yr the prevalence of acute appendicitis was
1 if all patients had been operated on, PC, = total number clearly lower at 19%.

Figure 3. Acute appendicitis (category 2). o. Longitudinal sonogram shows mural thickening of the appendix (A]. COE = cecum. b. The
target pattern (arrow] on transverse view. Arrowheads point to the surrounding hyperechoic halo indicating periappkndicitis.
c. Corresponding histologic section.
September 1989 ULTRASOUND IN ACUTE APPENDICITIS 633

Figure 4. Acute gangrenous appendicitis (category 1). a. Longitudinal scan showing the markedly thickened inflamed appendix (A) with
an outer diameter of 22 mm (measured by caliper). b. Transverse view. Arrow points to the focal wall destruction. c.
Corresponding histologic section.

Surgical Management and Negative operations including 41 negative laparotomies. Con-

Laparotomy Rate
Negative laparotomies were those operations
performed because of suspected appendicitis but
where a noninflamed appendix was removed and no
other surgical indications found.
A total of 159 patients in the present study under-
went surgery. Based on histologic examination of the
removed appendices, acute appendicitis was con-
firmed in 130 of these. Eight of the 29 operated
patients, who were found to have a normal appen-
dix, had other disorders indicating urgent surgery.
Consequently, there were 21 negative laparotomies,
for a real negative laparotomy rate of 13.2%.
If the decision for surgical intervention had been
based on preultrasound diagnoses (categorization)
alone, and with the optimistic assumption that no
patient in category 2 or 3 would have had a negative
appendectomy, there would have been a total of 179
sequently, the calculated negative laparotomy rate,
based on preultrasound diagnoses, would have been
22.9%.
In the subgroup of 20--4%yr-old women, a total of
34 operations were performed, including six nega-
tive laparotomies, giving a real negative laparotomy
rate of 17.6%. In contrast, the calculated negative
laparotomy rate, based on preultrasound diagnoses,
would have been 30%.
Sonographic Features of Appendicitis
The ultrasound pattern of acute appendicitis
is characterized by the so-called “targetlike” aspect
of the appendix in transverse view. This consists of
a hypoechoic fluid-distended lumen, a hyperechoic
inner ring representing mainly the mucosa and sub-
mucosa, and an outer hypoechoic ring representing

Figure 5. Acute appendicitis (category 1). a. Longitudinal view of the inflamed appendix (A) showing marked thickening of wall. Arrow
points to an echogenic fecalith with sound shadow (S) proximal to the bulbous dilated, pus-filled tip. b. Transverse scan.
Arrowheads point to the surrounding hyperechoic halo indicating inflammatory reaction. c. Corresponding histologic section.
September 1989 ULTRASOUND IN ACUTE APPENDICITIS 635

Table 2. Results of Initial Physical Examination and Sonography With Reference to the Diagnosis of Appendicitis in
the Subgroup of 121 Women Admitted With Suspected Appendicitis
Sonography
Initial Proven
Clinical physical acute True- True- False- False-
category examination appendicitis positive negative positive negative

1 29 15 12 14 0 3
2 26 5 5 21 0 0
3 66 3 2 63 0 1

Total 121 23 19 98 0 4

Patients are aged 20-40 yr. Data indicate number of patients.

itive in 8 (1.5%) cases overall. Four patients in this false-negative ultrasound examinations. False-posi-
group underwent appendectomy and histologic tive sonographic results did not occur in this sub-
studies failed to provide any evidence of appen- group.
diceal inflammation. The exact reasons for false-
positive sonographic diagnoses in these patients
Appendicitis During Pregnancy
remain speculative. The other 4 patients underwent
conservative treatment. It is not clear whether the A total of 7 women admitted to hospital with
sonographic findings in these 4 patients represent suspected acute appendicitis were pregnant. Two
misdiagnoses or are actually cases of early appendi- pregnancies were first diagnosed on ultrasound ex-
citis with spontaneous resolution of inflammation. amination. Two of these women had intraperitoneal
bleeding confirmed with ultrasound-guided needle
Appendicitis in Women of Childbearing Age aspiration. In one, an ectopic pregnancy was diag-
nosed (Figure 7) and in the other a ruptured corpus
Of the total 532 patients, 121 were women luteum cyst with intact pregnancy.
between 20 and 40 yr of age. In Tables 2 and 3, the Based on symptoms and the initial physical exam-
results of initial physical examination in this popu- ination 1 pregnant woman was placed in category 1,
lation, with a high risk of misdiagnoses, are listed 4 in category 2, and 2 in category 3. On sonographic
and compared with those of sonography. examination the only case of acute appendicitis in
Only 15 (65.2%) of the 23 women with appendi- this population was correctly diagnosed for a patient
citis were placed in the urgent category 1 based on in category 2. The remaining results were true-
physical examination on admission, 8 (34.8%) were negative.
placed in categories 2 and 3.
Sonography, however, enabled the visualization of
the inflamed appendix in 19 (82.6%) of the 23 Appendiceal Rupture
women with proven acute appendicitis. In 4 (17.4%) On the basis of intraoperative findings appen-
the appendix could not be identified, a total of 3.3%
diceal rupture was diagnosed in 27 (20.8%) of 130
patients with verified acute appendicitis (Table 4).
Table 3. Diagnostic Accuracy of Ultrasound With The mean age of these patients was 32.7 ? 11 yr (age
Reference to the Diagnosis of Appendicitis in range 5-68 yr). Nineteen (70%) of the patients with a
532 Patients Admitted With Suspected Acute perforated appendix were placed in category 1 on
Appendicitis and in the Subgroup of 121 the basis of physical examination. However, in the
Women”
remaining 30% with perforations the initial clinical
All Women aged presentation was found to be equivocal or even
patients 20-40 yr
improbable with regard to the diagnosis of appendi-
(%I (%I
citis (category 2 and 3).
Sensitivity 88.5 82.6 On ultrasound examination either a periappen-
Specificity 98.0 100.0
diceal abscess or an inflamed appendix could be
pv,,, 94.5 100.0
PV",, 96.3 96.1
identified in 24 (89%) of the 27 perforated appendi-
Overall accuracy 95.7 96.7 ces. In 3 patients (11%) the ruptured appendix was
Number/prevalence of 532124.4 121/19 probably obscured by overlaying intestinal gas. Two
acute appendicitis of these 3 patients with nondiagnostic sonographies
PV,,, and PV,,, are the positive and negative predictive values, presented with severe right lower quadrant peritoni-
respectively. DWomen in the subgroup aged 20-40 yr. tis and underwent surgery under the clinical diag-
636 SCHWERK ET AL. GASTROENTEROLOGY Vol. 97, No. 3

Figure 7. Ruptured ectopic pregnancy in a young woman with clinically suspected acute appendicitis (category 2). a. Transverse scan
through the urinary bladder (LJB) demonstrates ectopic pregnancy (arrow) and uterine pseudogestational sac [arrowhead). b.
Longitudinal scan of the right liver lobe shows intraperitoneal blood (B). ascertained by ultrasound-guided fine-needle
aspiration.

nosis of perforating appendicitis. The third patient diagnosed as having gastroenteritis. In 14 (13%) of
was operated on within 24 h because of a progres- these, sonography only showed an abnormal fluid
sion of the symptoms. accumulation in segments of the small intestine with
hyperperistalsis.
The category “other gastroenterologic disorders”
Other Diagnoses
included patients with cholecystitis, infarction of
Table 5 lists the final diagnoses for the 532 the greater omentum, duodenal ulcer, perforated
patients with suspected appendicitis included in Meckel’s diverticulum, perforated cecal diverticu-
this study. Ultrasound examination that provided lum, cecal carcinoma, intestinal strangulation, and
diagnostically relevant morphologic information invagination. Positive sonographic findings were ob-
was regarded as positive. Nonspecific mesenteric tained in 15 (58%) of the 26 patients. Diagnostically
lymphadenitis or acute terminal ileitis, or both, relevant echomorphologic findings could be estab-
mimicking symptoms of acute appendicitis could lished in 37 (79%) of 47 patients with gynecologic
often be diagnosed with ultrasonography. Given ap- diagnoses mimicking acute appendicitis. Among
propriate clinical symptoms, the final diagnosis of these were adnexitis; salpingitis; abscess; ruptured,
lymphadenitis relied largely on the characteristic torted, or bleeding ovarian cysts; and ectopic preg-
ultrasound findings (Figure 8). The typical location nancy (Figure 7). Ten patients with pain in the lower
of the generally multiple sonolucent lymph nodes right quadrant had urologic disorders, which could
was in the mesenterium of the ileocecal region be sonographically diagnosed in 8 cases. These in-
anterior and lateral to the inferior vena cava and the
iliac vessels.
One hundred and ten patients were clinically Table 5. Final Diagnoses in 532 Patients Admitted With
Suspected Acute Appendicitis

Sonography
Table 4. Appendiceal Perforation and Ultrasound
Detection Rate in 130 Patients With Proven Positive Negative
Acute Appendicitis of a Total of 532 Patients Final diagnoses n % findings findings
Admitted With Suspected Appendicitis Appendicitis 130 24.4 115 15
Perforated US Lymphadenitis, acute 149 28 148 1
Clinical appendicitis true-positive ileitis
category Gastroenteritis 110 20.7 14 96
(n) (n)
Other gastroenterologic 26 4.9 15 11
1 19 17 disorders
2 5 5 Gynecologic diagnoses 47 8.8 37 10
3 3 2 Urinary tract disorders 10 1.9 8 2
Pain of unknown cause 60 11.3 - 60
Total 27 (20.8%) 24 (89%)
Total 532 337 195
US, ultrasound.
September 1989 ULTRASOUND IN ACUTE APPENDICITIS 637

Figure 8. Mesenteric lymphadenitis in a patient with clinically suspected acute appendicitis (category 1). a. Grossly enlarged,
well-demarcated mesenteric lymph nodes (L) are seen anterior to the psoas muscle. b. Follow-up sonogram 6 wk later
demonstrates distinctly smaller but still visible lymph nodes (L).

eluded urinary tract obstruction, renal tumor, uri- and morbidity. Savrin and Clatworthy (3) reported a
noma, and pyelonephritis. disturbingly high overall incidence of 41.8% for
In 60 (11.3%) patients the reasons for the abdom- appendiceal rupture in children <18 yr of age. They
inal complaints remained unknown even after exten- found a strong inverse correlation between the inci-
sive diagnostic investigation, and no definite diag- dence of rupture and age, ranging from 93% in
nosis could be made. These cases are listed as “pain children 52 yr old to 33% in those >lO yr old,
of unknown cause.” presumably due to a lack of early recognition and
treatment. Moreover, 45% of their patients with
appendiceal rupture had been seen by physicians
Discussion
who failed to diagnose appendiceal disease. These
Acute appendicitis generally is considered to figures support the empirical knowledge that the
provide no major diagnostic problem. However, as diagnosis of acute appendicitis before perforation is
there are many abdominal and pelvic disorders that more difficult to make in young children, particu-
may mimic signs and symptoms of appendicitis, larly in those of preschool age.
prospective studies have demonstrated that the ac- With high-resolution real-time sonography a non-
curacy of preoperative clinical diagnosis lies in the invasive diagnostic modality is now readily avail-
range of a mere 700%,-780$,.Thus the rate of unnec- able, which enables a direct visualization of the
essary appendectomies is correspondingly high. Ac- inflamed appendix or periappendiceal abscess. Fur-
cording to various studies it is between 14% and thermore, sonography is also of value in patients
75%, around 20%25% on average (y-10).A partic- without evidence of acute appendicitis. It can pro-
ularly high negative laparotomy rate of 25%-48% vide echomorphologic findings that may suggest
has been reported in women of childbearing age alternative diagnoses such as terminal ileitis, mes-
(20-40 yr) (1,lO). In this group pelvic inflammatory enteric adenitis, gynecologic disorders, and urologic
disease and the complications of pregnancy are also disease (18,20).
prevalent, symptoms of which may closely simulate In healthy individuals the appendix usually can-
the clinical findings in acute appendicitis. not be visualized with ultrasound, or may only
In questionable cases of acute appendicitis, the rarely be identified. In a series of 250 patients, Jeffrey
possibility of a negative appendectomy, which in- et al. (21) observed only 5 adult patients with sono-
volves a substantial risk of complications, always graphically visible normal appendices that were <6
has to be weighted against the potential hazard of an mm in outer diameter, whereas 84 out of a total 86
inflamed appendix progressing to perforation before visualized acutely inflamed appendices had a max-
appendectomy is performed. Indeed, prospective imum diameter of r7 mm.
follow-up studies on patients with negative findings These findings are consistent with the results of
at appendectomy have revealed a total early and late ultrasound measurements obtained in the present
complication rate of at least 14% (19). On the other study. Corresponding to the different extents of in-
hand, delay in treatment of acute appendicitis re- flammatory wall-thickening and fluid distention of
sults in a significant increase of appendiceal rupture lumen, the outer appendiceal diameters ranged from
638 SCHWERK ET AL. GASTROENTEROLOGY Vol. 97, No. 3

Table 6. Diagnostic Value of High-Resolution Real-Time Sonography in Suspected Acute Appendicitis

Sonography
Prevalence Negative
Number of of acute Rate of laparotomy Overall Sensi- Speci-
patients appendicitis perforation rate accuracy tivity ficity PV,,, PV,,,
References (%I (%I (%I (%I Method (%I (%I (%I (%I (%I
Kastrup et al. (14) 46” 63 15.2 - ~-MHZ curved 87 83 94 96 76
array
Abu-Yousef et al. (15) 68” 37 40 - ~-MHZ linear 90 80 95 91 89
array
Jeffrey et al. (16) 9o” 33.3 - - ~-MHZ linear 9lb 83 95 89 92
array
Puylaert et al. (17) 111 46.8 16.3 8.5 5/7.5-MHz - 75 100 - -
linear array
Present study 532 24.4 20.8 13.2 ~-MHZ curved 95.7 88.5 98 94.5 96.3
array

PV,,, and PV,,, indicate predictive value of positive and negative results, respectively. ” Selected patients. b Nondiagnostic sonograms
included.

7 to 22 mm, giving a mean diameter of 11.4 k 3.2
mm. The overall accuracy of ultrasonography in the
diagnosis of acute appendicitis was found to be
95.7% with a 98% specificity, and a somewhat lower
sensitivity of 88.5%. Sonography enabled a signifi-
cantly higher level of preoperative diagnostic accuracy
when compared with the physical examination on
admission. Despite the low incidence of acute ap-
pendicitis in our study group (24.4%), the predictive
values of positive and negative ultrasonic diagnoses
of appendicitis were high (94.5% and 96.3%, respec-
tively).
A comparably high level of accuracy for diagnostic
ultrasound could be achieved in the group of ovu-
lating women between the ages of 20 and 40 yr,
where there is a high risk of misdiagnosis.
However, even if sonography can visualize the
inflamed appendix in a high percentage of patients
and may suggest alternative diagnoses in a signifi-
cant number of cases, ultrasonic nonvisualization
the appendix alone does not reliably serve to exclude
acute appendicitis. False-negative sonographic diag-
noses of acute appendicitis were observed at a rate of
2.8% in a total of 532 examinations. Thus the deci-
sion for either surgical intervention or conservative
treatment in patients with suspected appendicitis
must finally rest on a combined evaluation of clini-
cal and sonographic findings. Using this approach to
the diagnosis of acute appendicitis, the preoperative
diagnostic accuracy in our study rose markedly and
the negative laparotomy rate fell from a calculated
figure of 22.9%, when based on physical examina-
tion alone, to 13.2% with ultrasound feedback.
Table 6 summarizes further results of the present
study compared with those reported in the literature.
The rate of perforation for the 130 patients with
appendicitis was 20.8% overall, which is similar to
reported rates of 17%-39% (1,4). In 89% of the
patients with a ruptured appendix either the in-
flamed appendix or a periappendiceal abscess, or
both, could be identified with ultrasound. In con-
trast, on initial physical examination only 70% of the
cases could be attributed to category 1, whereas 30%
presented with equivocal or uncharacteristic symp-
toms. These findings differ from those of Puylaert et
al. (171, who reported a sensitivity of merely 28.5%
for ultrasonography in perforating appendicitis.
As, with only one exception, all perforated cases
were diagnosed or subjected to surgery on the day of
admission, it is evident that the principal cause of
our high rate of appendiceal rupture (20.8%) was not
a delay in in-hospital diagnosis or treatment but
rather a delay before admission to hospital.
Acute appendicitis during pregnancy is known to
create a further diagnostic problem. Clinical findings
such as nausea, vomiting, abdominal pain, and even
leukocytosis as high as 15,000 cells/mm3 frequently
of accompany a normal pregnancy, and this lessens
their value as diagnostic aids (22). Early recognition
and treatment of acute appendicitis are, however,
important, not least in view of the growing frequency
of spontaneous abortion. Fetal loss has been esti-
mated to rise from 8.5% in uncomplicated appendi-
citis to an extreme of 35.7% in individuals with
complicating peritonitis (23).
The only proven acute appendicitis in a total of 7
pregnant women with suspected appendicitis in our
series was associated with category 2 on physical
examination, and was correctly identified by means
of sonography.
In conclusion, high-resolution real-time sonogra-
phy has proven to be a sensitive and specific imaging
method for the diagnosis of acute appendicitis and
its complications. Furthermore, a variety of gastro-
intestinal, gynecologic, and urologic conditions
mimicking the symptoms and signs of acute appen-
September 1989 ULTRASOUND IN ACUTE APPENDICITIS 639

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akuten Appendizitis: wieviele “Irrtiimer” sind unvermeid- Received August I, 1988. Accepted April 4, 1989.
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