Pediatric Surgery International

, Volume 34, Issue 12, pp 1287–1292 | Cite as

The non-visualized appendix and secondary signs on ultrasound for pediatric appendicitis in the community hospital setting

  • Jenny M. HeldEmail author
  • Christian S. McEvoy
  • Jonathan D. Auten
  • Stephen L. Foster
  • Robert L. Ricca
Original Article



Secondary signs of appendicitis on ultrasound may aid with diagnosis in the setting of a non-visualized appendix (NVA). This role has not been shown in the community hospital setting.

Materials and methods

All right lower quadrant ultrasounds performed in children for clinical suspicion of appendicitis over a 5-year period in a single community hospital were evaluated. Secondary signs of inflammation including free fluid, ileus, fat stranding, abscess, and lymphadenopathy were documented. Patients were followed for 1 year for the primary outcome of appendicitis. These data were analyzed to determine the utility of secondary signs in the diagnosis of acute appendicitis when an NVA is reported.


Six hundred and seventeen ultrasounds were reviewed; 470 of these had an NVA. Of NVAs, 47 (10%) of patients were diagnosed with appendicitis. Sensitivity and specificity of having at least one secondary were 38.3% and 80%, respectively. The positive and negative predictive values of having at least one secondary sign were 17.3% and 92%, respectively.


These data suggest that the absence of secondary signs has a strong negative predictive value for appendicitis in the community hospital setting; however, the full utility of secondary signs may be limited in this setting.


Appendicitis Right lower quadrant ultrasound Non-visualized appendix Secondary signs of inflammation 


Author contributions

Study design was completed by JH and RR. The data collection and manuscript preparation were performed by JH, JA, and CM. Data analysis was performed by CM. Critical revisions were performed by all the authors.

Compliance with ethical standards

Conflict of interest

The authors have no financial conflicts of interest to disclose.


The views expressed are those of the authors and do not necessarily reflect the official policy of the Department of the Navy, Department of Defense, or the United States Government. In addition, the authors are military service members. This work was prepared as part of official duties. Title 17, USC, Section 105 provides that Copyright protection under this title is not available for any work of the US Government. Title 17, USC, Section 101 defines a US Government work as a work prepared by a military service member or employee of the US Government as part of that person’s official duties. Research data derived from an approved Naval Medical Center, Portsmouth, Virginia IRB, protocol; number NMCP.2015.0037.


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Copyright information

© This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply 2018

Authors and Affiliations

  • Jenny M. Held
    • 1
    Email author
  • Christian S. McEvoy
    • 1
  • Jonathan D. Auten
    • 2
  • Stephen L. Foster
    • 3
  • Robert L. Ricca
    • 4
  1. 1.Department of General SurgeryNaval Medical Center PortsmouthPortsmouthUSA
  2. 2.Department of Emergency MedicineNaval Medical Center PortsmouthPortsmouthUSA
  3. 3.Department of RadiologyNaval Medical Center PortsmouthPortsmouthUSA
  4. 4.Department of Pediatric SurgeryNaval Medical Center PortsmouthPortsmouthUSA

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