Mimics of Appendicitis: Alternative Nonsurgical Diagnoses with Sonography and CT

OBJECTIVE
To

illustrate the imaging features of alternative nonsurgical disorders in patients presenting with clinical signs of appendicitis.

Normal and Inflamed Appendix

Normal appendix
Maximum outer diameter : 6mm Homogeneous noninflamed fat Compressible on US Often contains intraluminal gas

1. 2. 3. 4.

Inflamed appendix

1. Outer diameter : 6mm 2. Surrounded by hyperechoic inflamed fat on US 3. Extramural changes with fat stranding on CT 4. Presence of an appendicolith 5. Cecal apical thickening 6. Hypervascularity of the appendix wall on color Doppler sonography

Normal appendix

Inflamed Appendix

Nonsurgical Mimics of Appendicitis : Gastrointestinal Tract

1.
2. 3.

Gastrointestinal Tract
Mesenteric adenitis Infectious enterocolitis Epiploic appendages Omental infarction Right-sided colonic diverticulitis Crohns disease Ileocecal intussusception

4.
5. 6. 7.

Nonsurgical Mimics of Appendicitis : Gastrointestinal Tract

1.

Mesenteric adenitis
The second most common cause of RLQ pain after appendicitis US & CT : Cluster of enlarged mesenteric lymph nodes and no other abnormalities

Nonsurgical Mimics of Appendicitis : Gastrointestinal Tract

2. Infectious enterocolitis

Bacterial ileocecitis caused by Yersinia, Campylobacter, or Salmonella spp. US & CT : Mural thickening of the terminal ileum and cecum without inflammation of the surrounding fat and moderate mesenteric adenopathy

Nonsurgical Mimics of Appendicitis : Gastrointestinal Tract

3. Epiploic appendagitis

Epiploic appendage may undergo torsion and secondary inflammation. US & CT : An inflamed fatty mass adjacent to the colon containing a characteristic hyperattenuating ring of thickened visceral peritoneal lining Occasional dense central focus caused by a thrombosed vessel or hemorrhagic changes on CT.

Nonsurgical Mimics of Appendicitis : Gastrointestinal Tract

3. Omental infarction

Pathophysiology and clinical presentation similar to that of epiploic appendagitis Both have a similar benign natural history CT : A cakelike inflamed fatty mass larger than in epiploic appendagitis and lacking a hyperattenuating ring

Nonsurgical Mimics of Appendicitis : Gastrointestinal Tract

4. Right-sided colonic diverticulitis

In comparison with sigmoid diverticula, rightsided colonic diverticula are usually true diverticula Explain the essentially benign selflimiting character of right-sided diverticulitis US & CT : Inflammatory changes in pericolic fat Segmental thickening of the colonic wall at the level of an inflamed diverticulum

Nonsurgical Mimics of Appendicitis : Gastrointestinal Tract

5. Crohn's disease

Up to one-third of patients with ileocecal Crohn's disease present with initial symptoms so acute that they are misdiagnosed as appendicitis US & CT : Transmural bowel wall thickening, often predominantly of the submucosal layer, with frequent inflammatory changes of the surrounding fat in the acute active phase.

Nonsurgical Mimics of Appendicitis : Gastrointestinal Tract

6. Ileocecal intussusception

Peak age between 3 and 9 months Enlarged mesenteric lymph nodes or lymphoid hyperplasia of the distal ileum often acts as a lead point for intussusception US : A bowel-within-bowel configuration with a targetlike mass on sonography consisting of multiple concentric rings related to the invaginating layers of the bowel wall

Nonsurgical Mimics of Appendicitis : Genitourinary Tract

1.
2. 3.

Genitourinary Tract
Pelvic inflammatory disease Hemorrhagic functional ovarian cyst Urolithiasis

Nonsurgical Mimics of Appendicitis : Genitourinary Tract

1. Pelvic inflammatory disease

The imaging findings vary according to the severity of the disease and may be normal in early conditions. US & CT : Enlargement of the internal genital organs with indistinct contours and free pelvic fluid in more advanced stage.

Nonsurgical Mimics of Appendicitis : Genitourinary Tract

2. hemorrhagic ovarian cyst

Frequent cause of lower abdominal pain in the pubertal population

US & CT : A complicated cyst on sonography and a high-attenuation adnexal mass on unenhanced CT

Nonsurgical Mimics of Appendicitis : Genitourinary Tract

3. Urolithiasis

US & CT : Unenhanced CT is more accurate in detecting ureteral stones than sonography Hydronephrosis and a hydroureter as signs of obstruction

Nonsurgical Mimics of Appendicitis : Musculoskeletal Tract

1. Rectus sheath hematoma

Easy to diagnose in patients presenting with a painful palpable mass under anticoagulant therapy Small nonpalpable hematomas can clinically masquerade as appendicitis US & CT : Hemorrhagic mass within the sheath of the rectus abdominis muscle

CONCLUSION

A correct imaging diagnosis of these alternative disorders may have a major impact on patient management because it prevents an unnecessary operation or hospitalization.