Abstract
Appendicitis is the most common cause of acute abdominal pain that requires surgical intervention in the Western world.
Patients with appendicitis may present with a wide variety of symptoms that can lead to confusion and delay in diagnosis and treatment.
The delayed diagnosis of appendicitis has severe consequences.
The normal appendix is a blind-ended tubular structure (Fig. 10.1) with a diameter of less than 7 mm and a wall thickness of less than 2 mm.
There are a variety of other conditions in childhood that occur with abdominal pain that must be differentiated from acute appendicitis; furthermore one-third of children with acute appendicitis have atypical clinical findings so the clinical diagnosis is often not simple.
In these patients imaging plays a key role in the diagnosis of suspected appendicitis.
The principal imaging technique for evaluating children with suspected appendicitis is graded-compression US. The normal appendix measures 6 mm or less in maximal outer diameter, is compressible, and lacks adjacent inflammatory changes.
Although common, acute appendicitis can be a difficult diagnosis because a number of other common pathologic abdominal processes share a similar clinical presentation.
Computed tomography (CT) has become the predominant imaging method used to diagnose appendicitis in children in the United States.
The diagnosis of appendicitis with CT is made by identifying an abnormal appendix and periappendiceal signs of appendicitis.
CT is also more useful than US for evaluating complications of acute appendicitis, such as phlegmon and abscess.
Magnetic resonance (MR) imaging can be used to evaluate for abdominal disease without the use of ionizing radiation.
The criterion to define the abnormal appendix was the same one used for the detection of the abnormal appendix at CT and US.
In conclusion ultrasonography (US) remains the standard imaging technique to investigate acute appendicitis. MR imaging may be used as a complementary examination when US is inconclusive or when it is important to avoid exposure to CT radiation or contrast material in children with signs and symptoms of appendicitis.
This is a preview of subscription content, log in via an institution.
Buying options
Tax calculation will be finalised at checkout
Purchases are for personal use only
Learn about institutional subscriptionsReferences
Aspelund G, Fingeret A, Gross E, Kessler D, Keung C, Thirumoorthi A, Oh PS, Behr G, Chen S, Lampl B, Middlesworth W, Kandel J, Ruzal-Shapiro C (2014) Ultrasonography/MRI versus CT for diagnosing appendicitis. Pediatrics 133:586–593. doi:10.1542/peds.2013-2128, Epub 2014 Mar 3
Bachur RG, Levy JA, Callahan MJ, Rangel SJ, Monuteaux MC (2015) Effect of reduction in the use of computed tomography on clinical outcomes of appendicitis. JAMA Pediatr 169:755–760. doi:10.1001/jamapediatrics.2015.0479
Binkovitz LA, Unsdorfer KM, Thapa P, Kolbe AB, Hull NC, Zingula SN, Thomas KB, Homme JL (2015) Pediatric appendiceal ultrasound: accuracy, determinacy and clinical outcomes. Pediatr Radiol 45:1934–1944
Blumfield E, Nayak G, Srinivasan R, Muranaka MT, Blitman NM, Blumfield A, Levin TL (2013) Ultrasound for differentiation between perforated and nonperforated appendicitis in pediatric patients. AJR Am J Roentgenol 200(5):957–962
Brennan GD (2006) Pediatric appendicitis: pathophysiology and appropriate use of diagnostic imaging. CJEM 8:425–432
Butler M, Servaes S, Srinivasan A, Edgar JC, Del Pozo G, Darge K (2011) US depiction of the appendix: role of abdominal wall thickness and appendiceal location. Emerg Radiol 18:525–531
Catalano O, Lobianco R, Sandomenico F, Mattace Raso M, Siani A (2004) Real time contrast enhanced sonographic imaging in emergency radiology. Radiol Med 108:454–469
Chang PT, Yang E, Swenson DW, Lee EY (2016) Pediatric emergency magnetic resonance imaging: current indications, techniques, and clinical applications. Magn Reson Imaging Clin N Am 24:449–480. doi:10.1016/j.mric.2015.11.009, Epub 2016 Feb 22
Cogley JR, O’Connor SC, Houshyar R, Al Dulaimy K (2012) Emergent pediatric US: what every radiologist should know. Radiographics 32:651–665. doi:10.1148/rg.323115111
Cohen B, Bowling J, Midulla P, Shlasko E, Lester N, Rosenberg H, Lipskar A (2015) The non-diagnostic ultrasound in appendicitis: is a non-visualized appendix the same as a negative study? J Pediatr Surg 50:923–927
Di Giacomo V, Trinci M, Van der Byl G, Catania VD, Calisti A, Miele V (2015) Ultrasound in newborns and children suffering from nontraumatic acute abdominal pain: imaging with clinical and surgical correlation. J Ultrasound 18:385393. doi:10.1007/s4047701400874, Epub 2014 Apr 9
Ditkofsky NG, Singh A, Avery L, Novelline RA (2014) The role of emergency MRI in the setting of acute abdominal pain. Emerg Radiol 21:615–624. doi:10.1007/s10140-014-1232-2, Epub 2014 May 15
Doria AS (2011) Optimizing the role of imaging in appendicitis. Pediatr Radiol 41(8):993–999
Doria AS, Moineddin R, Kellenberger CJ et al (2006) US or CT for diagnosis of appendicitis in children and adults? A meta-analysis. Radiology 241:283–294
Epifanio M, Antonio de Medeiros Lima M, Epifanio M, Corrêa P, Baldisserotto M (2016) An imaging diagnostic protocol in children with clinically suspected acute appendicitis. Am Surg 82(5):390–396
Farina R, Catalano O, Stavolo C, Sandomenico F, Petrillo RL (2015) Emergency radiology. Radiol Med 120:73–84. doi:10.1007/s1154701404802121
Fonio P, Coppolino F, Russo A, D’Andrea A, Giannattasio A, Reginelli A, Grassi R, Genovese EA (2013) Ultrasonography (US) in the assessment of pediatric non traumatic gastrointestinal emergencies. Crit Ultrasound J 15(5 Suppl 1):S12
Gaitini D (2011) Imaging acute appendicitis: state of the art. J Clin Imaging Sci 1:49. doi:10.4103/2156-7514.85778, Epub 2011 Oct 7
Gendel I, Gutermacher M, Buklan G, Lazar L, Kidron D, Paran H, Erez I (2011) Relative value of clinical, laboratory and imaging tools in diagnosing pediatric acute appendicitis. Eur J Pediatr Surg 21:229–233
Goldin AB, Khanna P, Thapa M, McBroom JA, Garrison MM, Parisi MT (2009) Revised ultrasound criteria for appendicitis in children improve diagnostic accuracy. Pediatr Radiol 39(Suppl 2):S144–S148
Hagendorf BA, Clarke JR, Burd RS (2004) The optimal initial management of children with suspected appendicitis: a decision analysis. J Pediatr Surg 39:880–885
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 200:969–973. doi:10.2214/AJR.12.10078
Horrow MM, White DS, Horrow JC (2003) Differentiation of perforated from nonperforated appendicitis at CT. Radiology 227:46–51
Hryhorczuk AL, Mannix RC, Taylor GA (2012) Pediatric abdominal pain: use of imaging in the Emergency Department in the United States from 1999 to 2007. Radiology 263:778–785
Je BK, Kim SB, Lee SH, Lee KY, Cha SH (2009) Diagnostic value of maximal-outer-diameter and maximal-mural-thickness in use of ultrasound for acute appendicitis in children. World J Gastroenterol 15:2900–2903
Kaiser S, Jorulf H, Söderman E, Frenckner B (2004) Impact of radiologic imaging on the surgical decision-making process in suspected appendicitis in children. Acad Radiol 11:971–979
Kearl YL, Claudius I, Behar S, Cooper J, Dollbaum R, Hardasmalani M, Hardiman K, Rose E, Santillanes G, Berdahl C (2016) Accuracy of magnetic resonance imaging and ultrasound for appendicitis in diagnostic and nondiagnostic studies. Acad Emerg Med 23:179–185
Kim ME, Orth RC, Fallon SC, Lopez ME, Brandt ML, Zhang W, Bisset GS (2015) Performance of CT examinations in children with suspected acute appendicitis in the community setting: a need for more education. AJR Am J Roentgenol 204:857–860. doi:10.2214/AJR.14.12750
Klein MD (2007) Clinical approach to a child with abdominal pain who might have appendicitis. Pediatr Radiol 37:11–14, Epub 2006 Oct 17
Koike Y, Uchida K, Matsushita K, Otake K, Nakazawa M, Inoue M, Kusunoki M, Tsukamoto Y (2014) Intraluminal appendiceal fluid is a predictive factor for recurrent appendicitis after initial successful non-operative management of uncomplicated appendicitis in pediatric patients. J Pediatr Surg 49(7):1116–1121
Krishnamoorthi R, Ramarajan N, Wang NE, Newman B, Rubesova E, Mueller CM, Barth RA (2011) Effectiveness of a staged US and CT protocol for the diagnosis of pediatric appendicitis: reducing radiation exposure in the age of ALARA. Radiology 259:231–239
Leeson K, Leeson B (2013) Pediatric ultrasound: applications in the emergency department. Emerg Med Clin North Am 31:809–829
Levine CD, Aizenstein O, Wachsberg RH (2004) Pitfalls in the CT diagnosis of appendicitis. Br J Radiol 77:792–799
Lim HK, Lee WJ, Lee SJ, Namgung S et al (1996) Focal appendicitis confined to the tip: diagnosis at US. Radiology 200:799–801
Lovrenski J, Jokić R, Varga I (2016) Sonographically detected free appendicolith as a sign of retrocecal perforated appendicitis in a 2-year-old child. J Clin Ultrasound 44(6):395–398. doi:10.1002/jcu.22337
Marin JR, Kornblith AE, Doniger SJ (2016) Point-of-care ultrasonography for appendicitis uncovers two alternate diagnoses. Pediatr Emerg Care 32:262–265
Mazeh H, Epelboym I, Reinherz J, Greenstein AJ, Divino CM (2009) Tip appendicitis: clinical implications and management. Am J Surg 197:211–215
Menichini G, Sessa B, Trinci M, Galluzzo M, Miele V (2015) Accuracy of contrast enhanced ultrasound (CEUS) in the identification and characterization of traumatic solid organ lesions in children: a retrospective comparison with baseline US and CEMDCT. Radiol Med 120:9891001. doi:10.1007/s115470150535z, Epub 2015 Mar 31
Miele V, Di Giampietro I (2014) Diagnostic imaging in emergency. Salute Soc, (2EN):127–138. doi:10.3280/SES2014-002010EN
Miele V, De Cicco ML, Andreoli C, Buffa V, Adami L, David V (2001) US and CT findings in complicated Meckel diverticulum. Radiol Med 101:230–234
Miele V, Andreoli C, Cortese A, De Cicco ML, Luzietti M, Stasolla A, David V (2002) Hemoperitoneum following ovarian cyst rupture: CT usefulness in the diagnosis. Radiol Med 104:122–126
Miele V, Andreoli C, Grassi R (2006) The management of emergency radiology: key facts. Eur J Radiol 59:311–314, Epub2006 Jun27
Miele V, Di Giampietro I, Ianniello S, Pinto F, Trinci M (2015) Diagnostic imaging in pediatric polytrauma management. Radiol Med 120:3349. doi:10.1007/s115470140469x.Epub2014Nov7
Miele V, Piccolo CL, Sessa B, Trinci M, Galluzzo M (2016a) Comparison between MRI and CEUS in the follow up of patients with blunt abdominal trauma managed conservatively. Radiol Med 121:27–37. doi:10.1007/s1154701505781Epub2016Jan8
Miele V, Piccolo CL, Galluzzo M, Ianniello S, Sessa B, Trinci M (2016b) Contrast enhanced ultrasound (CEUS) in blunt abdominal trauma. Br J Radiol 89(1061):20150823. doi:10.1259/bjr.20150823Epub2016Jan8
Miele V, Piccolo CL, Trinci M, Galluzzo M, Ianniello S, Brunese L (2016c) Diagnostic imaging of blunt abdominal trauma in pediatric patients. Radiol Med 121:409–430. doi:10.1007/s11547-016-0637-2, Epub 2016 Apr 13
Orth RC, Guillerman RP, Zhang W, Masand P, Bisset GS III (2014) Prospective comparison of MR imaging and US for the diagnosis of pediatric appendicitis. Radiology 272:233–240
Ozturkmen Akay H, Akpinar E, Akgul Ozmen C, Ergun O, Haliloglu M (2007) Visualization of the normal appendix in children by non-contrast MDCT. Acta Chir Belg 107:531–534
Pastore V, Cocomazzi R, Basile A, Pastore M, Bartoli F (2014) Limits and advantages of abdominal ultrasonography in children with acute appendicitis syndrome. Afr J Paediatr Surg 11:293–296
Pinto F, Miele V, Scaglione M, Pinto A (2014) The use of contrast-enhanced ultrasound in blunt abdominal trauma: advantages and limitations. Acta Radiol 55:776784. doi:10.1177/0284185113505517.Epub2013Sep23
Pinto F, Valentino M, Romanini L, Basilico R, Miele V (2015) The role of CEUS in the assessment of haemodinamically stable patients with blunt abdominal trauma. Radiol Med 120:311. doi:10.1007/s1154701404553.Epub2014Aug21
Pinto A, Miele V, Schillirò ML, Nasuto M, Chianese V, Romano L, Guglielmi G (2016) Spectrum of signs of pneumoperitoneum. Semin US CT MRI 37:39. doi:10.1053/j.sult.2015.10.008Epub2015Oct28
Prendergast PM, Poonai N, Lynch T, McKillop S, Lim R (2014) Acute appendicitis: investigating an optimal outer appendiceal diameter cut-point in a pediatric population. J Emerg Med 46:157–164
Ripollès T, Martinez-Perez MJ, PAredes JM, Vizuete J, Garcìa-Martinez E, Jimènez-Restrepo DH (2013) Contrast-enhanced ultrasound in the differentiation between phlegmon and abscess in Crohn’s disease and other abdominal conditions. Eur J Radiol 82:e525–e531
Rosines LA, Chow DS, Lampl BS, Chen S, Gordon S, Mui LW, Aspelund G, Ruzal-Shapiro CB (2014) Value of gadolinium-enhanced MRI in detection of acute appendicitis in children and adolescents. AJR Am J Roentgenol 203:W543–W548. doi:10.2214/AJR.13.12093
Sessa B, Trinci M, Ianniello S, Menichini G, Galluzzo M, Miele V (2015) Blunt abdominal trauma: role of contrast enhanced ultrasound in the detection and staging of abdominal traumatic lesions compared with US and CEMDCT. Radiol Med 120:180189. doi:10.1007/s1154701404259, Epub 2014 Jun 25
Shah BR, Stewart J, Jeffrey RB, Olcott EW (2014) Value of short-interval computed tomography when sonography fails to visualize the appendix and shows otherwise normal findings. J Ultrasound Med 33:1589–1595
Simonovsky V (2002) Normal appendix: is there any significant difference in the maximal mural thickness at US between pediatric and adult populations? Radiology 224:333–337
Sivit CJ (2004) Imaging the child with right lower quadrant pain and suspected appendicitis: current concepts. Pediatr Radiol 34:447–453
Srinivasan A, Servaes S, Peña A, Darge K (2015) Utility of CT after sonography for suspected appendicitis in children: integration of a clinical scoring system with a staged imaging protocol. Emerg Radiol 22(1):31–42. doi:10.1007/s10140-014-1241-1, Epub 2014 Jun 12
Strouse PJ (2010) Pediatric appendicitis: an argument for US. Radiology 255:8–13
Sung T, Callahan MJ, Taylor GA (2006) Clinical and imaging mimickers of acute appendicitis in the pediatric population. AJR Am J Roentgenol 186:67–74
Swenson DW, Schooler GR, Stamoulis C, Lee EY (2016) MRI of the normal appendix in children: data toward a new reference standard. Pediatr Radiol 46:1003–1010
Taylor GA (2004) Suspected appendicitis in children: in search of the single best diagnostic test. Radiology 231:293–295
Trout AT, Sanchez R, Ladino-Torres MF (2012) Reevaluating the sonographic criteria for acute appendicitis in children: a review of the literature and a retrospective analysis of 246 cases. Acad Radiol 19:1382–1394
Tseng P, Berdahl C, Kearl YL, Behar S, Cooper J, Dollbaum R, Hardasmalani M, Hardiman K, Rose E, Santillanes G, Lam C, Claudius I (2016) Does right lower quadrant abdominal ultrasound accurately identify perforation in pediatric acute appendicitis? J Emerg Med 50(4):638–642
Wan MJ, Krahn M, Ungar WJ, Caku E, Sung L, Medina LS, Doria AS (2009) Acute appendicitis in young children: cost-effectiveness of US versus CT in diagnosis—a Markov decision analytic model. Radiology 250:378–386
Xu Y, Jeffrey RB, DiMaio MA, Olcott EW (2016) Lymphoid hyperplasia of the appendix: a potential pitfall in the sonographic diagnosis of appendicitis. AJR Am J Roentgenol 206(1):189–194. doi:10.2214/AJR.15.14846
Yiğiter M, Kantarci M, Yalçin O, Yalçin A, Salman AB (2011) Does obesity limit the sonographic diagnosis of appendicitis in children? J Clin Ultrasound 39:187–190. doi:10.1002/jcu.20782, Epub 2010 Dec 28
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2016 Springer International Publishing Switzerland
About this chapter
Cite this chapter
Buquicchio, G.L., Cuneo, G., Giannecchini, S., Pizzi, C., Rende, C., Trinci, M. (2016). Acute Appendicitis. In: Miele, V., Trinci, M. (eds) Imaging Non-traumatic Abdominal Emergencies in Pediatric Patients. Springer, Cham. https://doi.org/10.1007/978-3-319-41866-7_10
Download citation
DOI: https://doi.org/10.1007/978-3-319-41866-7_10
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-319-41865-0
Online ISBN: 978-3-319-41866-7
eBook Packages: MedicineMedicine (R0)