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MRI Evaluation of the Pregnant Patient with Suspected Appendicitis: Imaging Considerations and Alternative Explanations for Abdominal and Pelvic Pain

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Emergency Imaging of Pregnant Patients

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Abstract

Learning Objectives: To review the indications for magnetic resonance imaging (MRI) in the pregnant patient with suspected appendicitis, discuss imaging protocols, demonstrate MRI findings of acute appendicitis, and illustrate alternative explanations for abdominal and pelvic pain in the pregnant patient.

Summary: Appendicitis is the most common condition necessitating emergency surgery in the pregnant patient. The clinical presentation is non-specific, and the diagnosis difficult to make, in part due to displacement of the appendix by the gravid uterus, and the range of symptomatology encountered during normal pregnancy. MRI is our first-line diagnostic test due to its lack of ionizing radiation and the high non-visualization rate of the appendix using ultrasound. At our institution, MRI is performed at 1.5 T without oral or intravenous contrast using a comprehensive multi-planar multi-weighted imaging protocol, which includes single-shot T2-weighted images, T2-weighted images with fat saturation, balanced steady-state free-precession gradient-echo images, and T1-weighted gradient-echo images with fat saturation. Magnetic resonance (MR) findings of appendicitis include a thick-walled and enlarged (size ≥8 mm) appendix, periappendiceal inflammation, and the presence of an appendicolith or appendicoliths. Non-visualization of the appendix on MRI, in contradistinction to ultrasound, has very high negative predictive value for acute appendicitis. MRI can be used to simultaneously evaluate for alternative obstetric and non-obstetric explanations for abdominal and pelvic pain.

Conclusion: MRI has a high diagnostic accuracy for acute appendicitis, and can be used to simultaneously evaluate for an alternative explanation for abdominal pain in the pregnant patient. MRI should be considered the first-line diagnostic test in the pregnant patient with suspected appendicitis.

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Acknowledgements

Disclosure of Conflicts of Interest: The authors have no relevant relationships to disclose.

Author information

Authors and Affiliations

  1. Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, MO, USA

    Daniel R. Ludwig, Demetrios A. Raptis & Vincent M. Mellnick

  2. Advanced Radiology Consultants, Leawood, KS, USA

    Richard Tsai

Authors
  1. Daniel R. Ludwig
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  2. Richard Tsai
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  3. Demetrios A. Raptis
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  4. Vincent M. Mellnick
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Correspondence to Daniel R. Ludwig .

Editor information

Editors and Affiliations

  1. Hamilton General Hospital, McMaster University, Hamilton, ON, Canada

    Michael N. Patlas

  2. Department of Radiology, NYU Winthrop Hospital, Mineola, NY, USA

    Douglas S. Katz

  3. Department of Radiology, Pineta Grande Hospital, Castel Volturno, Italy

    Mariano Scaglione

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Ludwig, D.R., Tsai, R., Raptis, D.A., Mellnick, V.M. (2020). MRI Evaluation of the Pregnant Patient with Suspected Appendicitis: Imaging Considerations and Alternative Explanations for Abdominal and Pelvic Pain. In: Patlas, M., Katz, D., Scaglione, M. (eds) Emergency Imaging of Pregnant Patients. Springer, Cham. https://doi.org/10.1007/978-3-030-42722-1_5

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  • DOI: https://doi.org/10.1007/978-3-030-42722-1_5

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-42721-4

  • Online ISBN: 978-3-030-42722-1

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