Pediatric Radiology

, Volume 47, Issue 2, pp 186–196 | Cite as

Ultrasound, computed tomography or magnetic resonance imaging - which is preferred for acute appendicitis in children? A Meta-analysis

  • Hanfei Zhang
  • Meiyan Liao
  • Jie Chen
  • Dongyong Zhu
  • Sama Byanju
Original Article



There is no established consensus about the relative accuracies of US, CT and MRI in childhood appendicitis.


To compare, through meta-analysis, the accuracies of US, CT and MRI for clinically suspected acute appendicitis in children.

Materials and methods

PubMed, Embase, Web of Science and the Cochrane Library were searched. After study selection, data extraction and quality assessment, the sensitivity, specificity and the area under the curve of summary receiver operating characteristic were calculated and compared.


Twenty-seven articles including 29 studies met the inclusion criteria, including 19 studies (9,170 patients) of US, 6 studies (928 patients) of CT and 4 studies (990 patients) of MRI. The analysis showed that the area under the receiver operator characteristics curve of MRI (0.995) was a little higher than that of US (0.987) and CT (0.982; P > 0.05).


US, CT and MRI have high diagnostic accuracies of clinically suspected acute appendicitis in children overall with no significant difference.


Acute appendicitis Children Computed tomography Diagnostic accuracy Magnetic resonance imaging Meta-analysis Ultrasonography 


Compliance with ethical standards

Conflicts of interest



  1. 1.
    Henderson J, Goldacre MJ, Fairweather JM et al (1992) Conditions accounting for substantial time spent in hospital in children aged 1-14 years. Arch Dis Child 67:83–86CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Addiss DG, Shaffer N, Fowler BS et al (1990) The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 132:910–925PubMedGoogle Scholar
  3. 3.
    Körner H, Söndenaa K, Söreide JA et al (2000) The history is important in patients with suspected acute appendicitis. Dig Surg 17:364–368CrossRefPubMedGoogle Scholar
  4. 4.
    Grover CA, Sternbach G (2012) Charles McBurney: McBurney's point. J Emerg Med 42:578–581CrossRefPubMedGoogle Scholar
  5. 5.
    Puylaert JB (1986) Acute appendicitis: US evaluation using graded compression. Radiology 158:355–360CrossRefPubMedGoogle Scholar
  6. 6.
    Strouse PJ (2010) Pediatric appendicitis: an argument for US. Radiology 255:8–13CrossRefPubMedGoogle Scholar
  7. 7.
    Malone AJ Jr, Wolf CR, Malmed AS et al (1993) Diagnosis of acute appendicitis: value of unenhanced CT. AJR Am J Roentgenol 160:763–766CrossRefPubMedGoogle Scholar
  8. 8.
    Pinto Leite N, Pereira JM, Cunha R et al (2005) CT evaluation of appendicitis and its complications: imaging techniques and key diagnostic findings. AJR Am J Roentgenol 185:406–417CrossRefPubMedGoogle Scholar
  9. 9.
    Brenner D, Elliston C, Hall E et al (2001) Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol 176:289–296CrossRefPubMedGoogle Scholar
  10. 10.
    Orth RC, Guillerman RP, Zhang W et al (2015) Prospective comparison of MR imaging and US for the diagnosis of pediatric appendicitis. Radiology 272:233–240CrossRefGoogle Scholar
  11. 11.
    Thieme ME, Leeuwenburgh MM, Valdehueza ZD et al (2014) Diagnostic accuracy and patient acceptance of MRI in children with suspected appendicitis. Eur Radiol 24:630–637CrossRefPubMedGoogle Scholar
  12. 12.
    Michael R (2008) Potential of MR-imaging in the paediatric abdomen. Eur J Radiol 68:235–244CrossRefPubMedGoogle Scholar
  13. 13.
    Moore MM, Gustas CN, Choudhary AK et al (2012) MRI for clinically suspected pediatric appendicitis: an implemented program. Pediatr Radiol 42:1056–1063CrossRefPubMedGoogle Scholar
  14. 14.
    Moher D, Liberati A, Tetzlaff J et al (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 21:b2535CrossRefGoogle Scholar
  15. 15.
    Wiersma F, Toorenvliet BR, Bloem JL et al (2009) US examination of the appendix in children with suspected appendicitis: the additional value of secondary signs. Eur Radiol 19:455–461CrossRefPubMedGoogle Scholar
  16. 16.
    Dillman JR, Gadepalli S, Sroufe NS et al (2016) Equivocal pediatric appendicitis: unenhanced MR imaging protocol for nonsedated children-a clinical effectiveness study. Radiology 279:216–225Google Scholar
  17. 17.
    Rao PM, Rhea JT, Novelline RA et al (1997) Helical CT technique for the diagnosis of appendicitis: prospective evaluation of a focused appendix CT examination. Radiology 202:139–144CrossRefPubMedGoogle Scholar
  18. 18.
    Whiting PF, Rutjes AW, Westwood ME et al (2011) QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med 155:529–536CrossRefPubMedGoogle Scholar
  19. 19.
    Higgins JPT, Green S and editors (2011) Cochrane handbook for systematic reviews of interventions version 5.1.0 [updated March 2011]. The Cochrane collaboration. Available from
  20. 20.
    Deeks JJ, Macaskill P, Irwig L (2005) The performance of tests of publication bias and other sample size effects in systematic reviews of diagnostic test accuracy was assessed. J Clin Epidemiol 58:882–893CrossRefPubMedGoogle Scholar
  21. 21.
    Kaiser S, Frenckner B, Jorulf HK (2002) Suspected appendicitis in children: US and CT--a prospective randomized study. Radiology 233:633–638CrossRefGoogle Scholar
  22. 22.
    Baldisserotto M, Marchiori E (2000) Accuracy of noncompressive sonography of children with appendicitis according to the potential positions of the appendix. AJR Am J Roentgenol 175:1387–1392CrossRefPubMedGoogle Scholar
  23. 23.
    Baldisserotto M, Peletti AB (2007) Is colour Doppler sonography a good method to differentiate normal and abnormal appendices in children? Clin Radiol 62:365–369CrossRefPubMedGoogle Scholar
  24. 24.
    Binkovitz LA, Unsdorfer KM, Thapa P et al (2015) Pediatric appendiceal ultrasound: accuracy, determinacy and clinical outcomes. Pediatr Radiol 45:1934–1944CrossRefPubMedGoogle Scholar
  25. 25.
    Burford JM, Dassinger MS, Smith SD (2011) Surgeon-performed ultrasound as a diagnostic tool in appendicitis. J Pediatr Surg 46:1115–1120CrossRefPubMedGoogle Scholar
  26. 26.
    Chang YJ, Kong MS, Hsia SH et al (2007) Usefulness of ultrasonography in acute appendicitis in early childhood. J Pediatr Gastroenterol Nutr 44:592–595CrossRefPubMedGoogle Scholar
  27. 27.
    Hahn HB, Hoepner FU, Kalle T et al (1998) Sonography of acute appendicitis in children: 7 years experience. Pediatr Radiol 28:147–151CrossRefPubMedGoogle Scholar
  28. 28.
    Limchareon S, Wongsuttilert A, Boonyarit A (2014) Efficacy of ultrasonography in the evaluation of suspected appendicitis in a pediatric population. J Med Ultrasound 22:213–217CrossRefGoogle Scholar
  29. 29.
    Lowe LH, Penney MW, Stein SM et al (2001) Unenhanced limited CT of the abdomen in the diagnosis of appendicitis in children: comparison with sonography. AJR Am J Roentgenol 176:31–35CrossRefPubMedGoogle Scholar
  30. 30.
    Nosaka S, Miyasaka M, Miyazaki O et al (1997) Ultrasound in pediatric patients with suspected acute appendicitis: value in establishing alternative diagnoses. Emerg Radiol 4:207–211Google Scholar
  31. 31.
    Peña BM, Taylor GA (2000) Radiologists' confidence in interpretation of sonography and CT in suspected pediatric appendicitis. AJR Am J Roentgenol 175:71–74CrossRefPubMedGoogle Scholar
  32. 32.
    Scammell S, Lansdale N, Sprigg A et al (2011) Ultrasonography aids decision-making in children with abdominal pain. Ann R Coll Surg Engl 93:405–409CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Schulte B, Beyer D, Kaiser C et al (1998) Ultrasonography in suspected acute appendicitis in childhood-report of 1285 cases. Eur J Ultrasound 8:177–182CrossRefPubMedGoogle Scholar
  34. 34.
    Teo EL, Tan KP, Lam SL et al (2000) Ultrasonography and computed tomography in a clinical algorithm for the evaluation of suspected acute appendicitis in children. Singapore Med J 41:387–392PubMedGoogle Scholar
  35. 35.
    Tiu CM, Chou YH, Chen JD et al (2004) Ultrasound diagnosis of acute appendicitis: impact on cost and outcome in pediatric patients. J Med Ultrasound 12:69–74CrossRefGoogle Scholar
  36. 36.
    Toprak H, Kilincaslan H, Ahmad IC et al (2014) Integration of ultrasound findings with Alvarado score in children with suspected appendicitis. Pediatr Int 56:95–99CrossRefPubMedGoogle Scholar
  37. 37.
    van Atta AJ, Baskin HJ, Maves CK et al (2015) Implementing an ultrasound-based protocol for diagnosing appendicitis while maintaining diagnostic accuracy. Pediatr Radiol 45:678–685CrossRefPubMedGoogle Scholar
  38. 38.
    Akhtar W, Ali S, Arshad M et al (2011) Focused abdominal CT scan for acute appendicitis in children: can it help in need? J Pak Med Assoc 61:474–476PubMedGoogle Scholar
  39. 39.
    Didier RA, Vajtai PL, Hopkins KL (2015) Iterative reconstruction technique with reduced volume CT dose index: diagnostic accuracy in pediatric acute appendicitis. Pediatr Radiol 45:181–187CrossRefPubMedGoogle Scholar
  40. 40.
    Fefferman NR, Roche KJ, Pinkney LP et al (2001) Suspected appendicitis in children: focused CT technique for evaluation. Radiology 220:691–695CrossRefPubMedGoogle Scholar
  41. 41.
    Hoecker CC, Billman GF (2005) The utility of unenhanced computed tomography in appendicitis in children. J Emerg Med 28:415–421CrossRefPubMedGoogle Scholar
  42. 42.
    Sivit CJ, Applegate KE, Berlin SC et al (2000) Evaluation of suspected appendicitis in children and young adults: helical CT. Radiology 216:430–433CrossRefPubMedGoogle Scholar
  43. 43.
    Johnson AK, Filippi CG, Andrews T et al (2012) Ultrafast 3-T MRI in the evaluation of children with acute lower abdominal pain for the detection of appendicitis. AJR Am J Roentgenol 198:1424–1430CrossRefPubMedGoogle Scholar
  44. 44.
    Kulaylat AN, Moore MM, Engbrecht BW et al (2015) An implemented MRI program to eliminate radiation from the evaluation of pediatric appendicitis. J Pediatr Surg 50:1359–1363CrossRefPubMedGoogle Scholar
  45. 45.
    Nitta N, Takahashi M, Furukawa A et al (2005) MR imaging of the normal appendix and acute appendicitis. J Magn Reson Imaging 21:156–165CrossRefPubMedGoogle Scholar
  46. 46.
    Aspelund G, Fingeret A, Gross E et al (2014) Ultrasonography/MRI versus CT for diagnosing appendicitis. Pediatrics 133:586–593CrossRefPubMedGoogle Scholar
  47. 47.
    Herliczek TW, Swenson DW, Mayo-Smith WW (2013) Utility of MRI after inconclusive ultrasound in pediatric patients with suspected appendicitis: retrospective review of 60 consecutive patients. AJR Am J Roentgenol 200:969–973CrossRefPubMedGoogle Scholar
  48. 48.
    Doria AS, Moineddin R, Kellenberger CJ et al (2006) US or CT for diagnosis of appendicitis in children and adults? A meta-analysis. Radiology 241:83–94CrossRefPubMedGoogle Scholar
  49. 49.
    Callahan MJ, Rodriguez DP, Taylor GA (2002) CT of appendicitis in children. Radiology 224:325–332CrossRefPubMedGoogle Scholar
  50. 50.
    Hernandez JA, Swischuk LE, Angel CA et al (2005) Imaging of acute appendicitis: US as the primary imaging modality. Pediatr Radiol 35:392–395CrossRefPubMedGoogle Scholar
  51. 51.
    Rosendahl K, Aukland SM, Fosse K (2004) Imaging strategies in children with suspected appendicitis. Eur Radiol 14:L138–L145CrossRefPubMedGoogle Scholar
  52. 52.
    Irish MS, Pearl RH, Caty MG et al (1998) The approach to common abdominal diagnosis in infants and children. Pediatr Clin N Am 45:729–772CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • Hanfei Zhang
    • 1
  • Meiyan Liao
    • 1
  • Jie Chen
    • 1
  • Dongyong Zhu
    • 1
  • Sama Byanju
    • 1
  1. 1.Department of RadiologyZhongNan Hospital of Wuhan UniversityWuhanChina

Personalised recommendations