Imaging of Acute Appendicitis in Children: Computed Tomography Including Radiation Issues

  • Andrew J. Spencer
  • Megan R. Saettele
  • Lisa H. Lowe
Part of the Medical Radiology book series (MEDRAD)


Clinical presentation, along with careful diagnostic imaging, should be employed when appendicitis is suspected in a child. Because computed tomography (CT) is becoming increasingly utilized for the diagnosis of acute appendicitis in children, radiologists must carefully and responsibly consider the issue of radiation exposure.


Compute Tomography Imaging Acute Appendicitis Pelvic Inflammatory Disease Perforated Appendicitis Normal Appendix 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Computed tomography


As low as reasonably achievable


  1. Acosta R, Crain EF, Goldman HS (2005) CT can reduce hospitalization for observation in children with suspected appendicitis. Pediatr Radiol 35(5):495–500PubMedCrossRefGoogle Scholar
  2. Aldrich JE et al (2006) Radiation dose in abdominal computed tomography: the role of patient size and the selection of tube current. Can Assoc Radiol J 57(3):152–158PubMedGoogle Scholar
  3. Applegate KE et al (2001) Effect of cross-sectional imaging on negative appendectomy and perforation rates in children. Radiology 220(1):103–107PubMedGoogle Scholar
  4. Arch ME, Frush DP (2008) Pediatric body MDCT: a 5-year follow-up survey of scanning parameters used by pediatric radiologists. AJR Am J Roentgenol 191(2):611–617PubMedCrossRefGoogle Scholar
  5. Bennett GL, Slywotzky CM, Giovanniello G (2002) Gynecologic causes of acute pelvic pain: spectrum of CT findings. Radiographics 22(4):785–801PubMedGoogle Scholar
  6. Birnbaum BA, Wilson SR (2000) Appendicitis at the millennium. Radiology 215(2):337–348PubMedGoogle Scholar
  7. Brenner D et al (2001) Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol 176(2):289–296PubMedGoogle Scholar
  8. Brenner DJ et al (2003) Cancer risks attributable to low doses of ionizing radiation: assessing what we really know. Proc Natl Acad Sci USA 100(24):13761–13766PubMedCrossRefGoogle Scholar
  9. Brenner DJ (2002) Estimating cancer risks from pediatric CT: going from the qualitative to the quantitative. Pediatr Radiol 32(4):228–231 (discussion 242–244)Google Scholar
  10. Brenner DJ, Hall EJ (2007) Computed tomography—an increasing source of radiation exposure. N Engl J Med 357(22):2277–2284PubMedCrossRefGoogle Scholar
  11. Brown JJ (1991) Acute appendicitis: the radiologist’s role. Radiology 180(1):13–14PubMedGoogle Scholar
  12. Callahan MJ, Rodriguez DP, Taylor GA (2002) CT of appendicitis in children. Radiology 224(2):325–332PubMedCrossRefGoogle Scholar
  13. Carty HM (2002) Paediatric emergencies: non-traumatic abdominal emergencies. Eur Radiol 12(12):2835–2848PubMedGoogle Scholar
  14. Charles MW (2003) Studies of mortality of atomic bomb survivors. Report 13: solid cancer and noncancer disease mortality: 1950–1997. J Radiol Prot 23(4):457–459Google Scholar
  15. Choi D et al (2003) The most useful findings for diagnosing acute appendicitis on contrast-enhanced helical CT. Acta Radiol 44(6):574–582PubMedGoogle Scholar
  16. Cody DD (2002) AAPM/RSNA physics tutorial for residents: topics in CT. Image processing in CT. Radiographics 22(5):1255–1268PubMedGoogle Scholar
  17. Doria AS et al (2006) US or CT for diagnosis of appendicitis in children and adults? a meta-analysis. Radiology 241(1):83–94PubMedCrossRefGoogle Scholar
  18. Fisher JD, Reeves JJ (2004) Presentation variability of acute urolithiasis in school-aged children. Am J Emerg Med 22(2):108–110PubMedCrossRefGoogle Scholar
  19. Flum DR, Koepsell T (2002) The clinical and economic correlates of misdiagnosed appendicitis: nationwide analysis. Arch Surg 137(7):799–804 (discussion 804)Google Scholar
  20. Frei SP et al (2008) Appendicitis outcomes with increasing computed tomographic scanning. Am J Emerg Med 26(1):39–44PubMedCrossRefGoogle Scholar
  21. Frush DP, Applegate K (2004) Computed tomography and radiation: understanding the issues. J Am Coll Radiol 1(2):113–119PubMedCrossRefGoogle Scholar
  22. Frush DP, Donnelly LF (1998) Helical CT in children: technical considerations and body applications. Radiology 209(1):37–48PubMedGoogle Scholar
  23. Gaitini D et al (2008) Diagnosing acute appendicitis in adults: accuracy of color doppler sonography and MDCT compared with surgery and clinical follow-up. AJR Am J Roentgenol 190(5):1300–1306PubMedCrossRefGoogle Scholar
  24. Garcia Pena BM et al (1999) Ultrasonography and limited computed tomography in the diagnosis and management of appendicitis in children. JAMA 282(11):1041–1046PubMedCrossRefGoogle Scholar
  25. Goske MJ et al (2008) The Image Gently campaign: working together to change practice. AJR Am J Roentgenol 190(2):273–274PubMedCrossRefGoogle Scholar
  26. Goske MJ, Frush DP, Schauer DA (2009) Image Gently campaign promotes radiation protection for children. Radiat Prot Dosimetry 135(4):276PubMedCrossRefGoogle Scholar
  27. Grattan-Smith JD, Blews DE, Brand T (2002) Omental infarction in pediatric patients: sonographic and CT findings. AJR Am J Roentgenol 178(6):1537–1539PubMedGoogle Scholar
  28. Hall EJ (2002) Lessons we have learned from our children: cancer risks from diagnostic radiology. Pediatr Radiol 32(10):700–706PubMedCrossRefGoogle Scholar
  29. Helmrath MA et al (2001) Right lower quadrant pain in children caused by omental infarction. Am J Surg 182(6):729–732PubMedCrossRefGoogle Scholar
  30. Hernanz-Schulman M (2010) CT and US in the diagnosis of appendicitis: an argument for CT. Radiology 255(1):3–7PubMedCrossRefGoogle Scholar
  31. Horrow MM, White DS, Horrow JC (2003) Differentiation of perforated from nonperforated appendicitis at CT. Radiology 227(1):46–51PubMedCrossRefGoogle Scholar
  32. Huda W et al (1997) An approach for the estimation of effective radiation dose at CT in pediatric patients. Radiology 203(2):417–422PubMedGoogle Scholar
  33. IMV (2006) CT market Summary Report. Available from Cited 12 July 2010
  34. Johansson EP, Rydh A, Riklund KA (2007) Ultrasound computed tomography, and laboratory findings in the diagnosis of appendicitis. Acta Radiologica 48(3):267–273PubMedCrossRefGoogle Scholar
  35. Jones K et al (2004) Are negative appendectomies still acceptable? Am J Surg 188(6):748–754PubMedCrossRefGoogle Scholar
  36. Kaiser S et al (2004) Impact of radiologic imaging on the surgical decision-making process in suspected appendicitis in children. Acad Radiol 11(9):971–979PubMedCrossRefGoogle Scholar
  37. Kaiser S, Frenckner B, Jorulf HK (2002) Suspected appendicitis in children: US and CT—a prospective randomized study. Radiology 223(3):633–638PubMedCrossRefGoogle Scholar
  38. Kalra MK et al (2004) Techniques and applications of automatic tube current modulation for CT. Radiology 233(3):649–657PubMedCrossRefGoogle Scholar
  39. Kharbanda AB, Taylor GA, Bachur RG (2007) Suspected appendicitis in children: rectal and intravenous contrast-enhanced versus intravenous contrast-enhanced CT. Radiology 243(2):520–526PubMedCrossRefGoogle Scholar
  40. Koumanidou C et al (2002) Sonographic detection of lymph nodes in the intussusception of infants and young children: clinical evaluation and hydrostatic reduction. AJR Am J Roentgenol 178(2):445–450PubMedGoogle Scholar
  41. Lameris W et al (2009) Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: diagnostic accuracy study. BMJ 338:b2431PubMedCrossRefGoogle Scholar
  42. Lowe LH et al (2000) Appendicolith revealed on CT in children with suspected appendicitis: how specific is it in the diagnosis of appendicitis? AJR Am J Roentgenol 175(4):981–984PubMedGoogle Scholar
  43. Lowe LH et al (2001a) Unenhanced limited CT of the abdomen in the diagnosis of appendicitis in children: comparison with sonography. AJR Am J Roentgenol 176(1):31–35PubMedGoogle Scholar
  44. Lowe LH et al (2001b) Nonenhanced limited CT in children suspected of having appendicitis: prospective comparison of attending and resident interpretations. Radiology 221(3):755–759PubMedCrossRefGoogle Scholar
  45. Lowe LH et al (2001c) Appendicitis and alternate diagnoses in children: findings on unenhanced limited helical CT. Pediatr Radiol 31(8):569–577PubMedCrossRefGoogle Scholar
  46. Macari M et al (2002) Mesenteric adenitis: CT diagnosis of primary versus secondary causes, incidence, and clinical significance in pediatric and adult patients. AJR Am J Roentgenol 178(4):853–858PubMedGoogle Scholar
  47. Martin AE et al (2004) CT scans may not reduce the negative appendectomy rate in children. J Pediatr Surg 39(6) 886–890 (discussion 886–890)Google Scholar
  48. McCollough CH, Bruesewitz MR, Kofler JM Jr (2006) CT dose reduction and dose management tools: overview of available options. Radiographics 26(2):503–512PubMedCrossRefGoogle Scholar
  49. Menes TS et al (2006) Increased use of computed tomography does not harm patients with acute appendicitis. Am Surg 72(4):326–329PubMedGoogle Scholar
  50. Mettler FA Jr et al (2000) CT scanning: patterns of use and dose. J Radiol Prot 20(4):353–359PubMedCrossRefGoogle Scholar
  51. Mettler FA Jr et al (2009) Radiologic and nuclear medicine studies in the United States and worldwide: frequency, radiation dose, and comparison with other radiation sources—1950–2007. Radiology 253(2):520–531Google Scholar
  52. Moore C et al (2009) Prevalence of abnormal CT findings in patients with proven ovarian torsion and a proposed triage schema. Emerg Radiol 16(2):115–120PubMedCrossRefGoogle Scholar
  53. Mountford PJ, Temperton DH (1992) Recommendations of the international commission on radiological protection (ICRP) 1990. Eur J Nuc Med 19(2):77–79Google Scholar
  54. Nagar H et al (2003) Omental infarction: an unusual cause of acute abdomen in children. Pediatr Surg Int 19(9–10):677–679PubMedCrossRefGoogle Scholar
  55. Pena BM et al (2000) Costs and effectiveness of ultrasonography and limited computed tomography for diagnosing appendicitis in children. Pediatrics 106(4):672–676PubMedCrossRefGoogle Scholar
  56. Puig S et al (2008) Imaging of appendicitis in children and adolescents: useful or useless? A comparison of imaging techniques and a critical review of the current literature. Semin Roentgenol 43(1):22–28PubMedCrossRefGoogle Scholar
  57. Puylaert JB, van der Zant FM, Rijke AM (1997) Sonography and the acute abdomen: practical considerations. AJR Am J Roentgenol 168(1):179–186PubMedGoogle Scholar
  58. Raman SS et al (2008) Effect of CT on false positive diagnosis of appendicitis and perforation. N Engl J Med 358(9):972–973PubMedCrossRefGoogle Scholar
  59. Rao PM et al (1997) Appendicitis: use of arrowhead sign for diagnosis at CT. Radiology 202(2):363–366PubMedGoogle Scholar
  60. Rao PM et al (1999) Introduction of appendiceal CT: impact on negative appendectomy and appendiceal perforation rates. Ann Surg 229(3):344–349PubMedCrossRefGoogle Scholar
  61. Rao PM, Rhea JT, Novelline RA (1997) Sensitivity and specificity of the individual CT signs of appendicitis: experience with 200 helical appendiceal CT examinations. J Comput Assist Tomogr 21(5):686–692PubMedCrossRefGoogle Scholar
  62. Rettenbacher T et al (2000) Presence or absence of gas in the appendix: additional criteria to rule out or confirm acute appendicitis–evaluation with US. Radiology 214(1):183–187PubMedGoogle Scholar
  63. Rodriguez DP et al (2006) Appendicitis in young children: imaging experience and clinical outcomes. AJR Am J Roentgenol 186(4):1158–1164PubMedCrossRefGoogle Scholar
  64. Rosendahl K, Aukland SM, Fosse K (2004) Imaging strategies in children with suspected appendicitis. Eur Radiol 14(Suppl 4):L138–L145PubMedGoogle Scholar
  65. Ruess L et al (2000) Inflammatory bowel disease in children and young adults: correlation of sonographic and clinical parameters during treatment. AJR Am J Roentgenol 175(1):79–84PubMedGoogle Scholar
  66. Siegel MJ (1992) Acute appendicitis in childhood: the role of US. Radiology 185(2):341–342PubMedGoogle Scholar
  67. Sivit CJ et al (2000) Imaging evaluation of suspected appendicitis in a pediatric population: effectiveness of sonography versus CT. AJR Am J Roentgenol 175(4):977–980PubMedGoogle Scholar
  68. Sivit CJ (2004) Imaging the child with right lower quadrant pain and suspected appendicitis: current concepts. Pediatr Radiol 34(6):447–453PubMedCrossRefGoogle Scholar
  69. Sivit CJ, Applegate KE (2003) Imaging of acute appendicitis in children. Semin Ultrasound CT MR 24(2):74–82PubMedCrossRefGoogle Scholar
  70. Sivit CJ et al (2001) When appendicitis is suspected in children. Radiographics 21(1):247–262 (questionnaire 288–294)Google Scholar
  71. Stephen AE et al (2003) The diagnosis of acute appendicitis in a pediatric population: to CT or not to CT. J Pediatr Surg 38(3):367–371 (discsussion 367–371)Google Scholar
  72. Strauss KJ et al (2010) Image gently: Ten steps you can take to optimize image quality and lower CT dose for pediatric patients. AJR Am J Roentgenol 194(4):868–873PubMedCrossRefGoogle Scholar
  73. Sturm EJ et al (2004) Detection of ileocecal Crohn’s disease using ultrasound as the primary imaging modality. Eur Radiol 14(5):778–782PubMedCrossRefGoogle Scholar
  74. Taylor GA et al (2006) CT for suspected appendicitis in children: an analysis of diagnostic errors. Pediatr Radiol 36(4):331–337PubMedCrossRefGoogle Scholar
  75. Teo EL et al (2000) Ultrasonography and computed tomography in a clinical algorithm for the evaluation of suspected acute appendicitis in children. Singapore Med J 41(8):387–392PubMedGoogle Scholar
  76. Thomas KE, Wang B (2008) Age-specific effective doses for pediatric MSCT examinations at a large children’s hospital using DLP conversion coefficients: a simple estimation method. Pediatr Radiol 38(6):645–656PubMedCrossRefGoogle Scholar
  77. Townsend BA, Callahan MJ, Zuralowski D, Taylor GA (2010) Has the use of pediatric CT at children’s hospitals reached its peak? Am J Roentgenol 194:1194–31196CrossRefGoogle Scholar
  78. van Breda Vriesman AC, Puylaert JB (2006) Mimics of appendicitis: alternative nonsurgical diagnoses with sonography and CT. AJR Am J Roentgenol 186(4):1103–1112PubMedCrossRefGoogle Scholar
  79. van Randen A et al (2008) Acute appendicitis: meta-analysis of diagnostic performance of CT and graded compression US related to prevalence of disease. Radiology 249(1):97–106PubMedCrossRefGoogle Scholar
  80. Varjavandi V et al (2003) Omental infarction: risk factors in children. J Pediatr Surg 38(2):233–235PubMedCrossRefGoogle Scholar
  81. Vermeulen B et al (1999) Acute appendicitis: influence of early pain relief on the accuracy of clinical and US findings in the decision to operate—a randomized trial. Radiology 210(3):639–643PubMedGoogle Scholar
  82. Voss SD et al (2009) The ALARA concept in pediatric oncology. Pediatr Radiol 39(11):1142–1146PubMedCrossRefGoogle Scholar
  83. Weltman DI et al (2000) Diagnosis of acute appendicitis: comparison of 5- and 10-mm CT sections in the same patient. Radiology 216(1):172–177PubMedGoogle Scholar
  84. Yeung KW, Chang MS, Hsiao CP (2004) Evaluation of perforated and nonperforated appendicitis with CT. Clin Imaging 28(6):422–427PubMedCrossRefGoogle Scholar
  85. Yu J et al (2005a) Helical CT evaluation of acute right lower quadrant pain: part I, common mimics of appendicitis. AJR Am J Roentgenol 184(4):1136–1142PubMedGoogle Scholar
  86. Yu J et al (2005b) Helical CT evaluation of acute right lower quadrant pain: part II, uncommon mimics of appendicitis. AJR Am J Roentgenol 184(4):1143–1149PubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  • Andrew J. Spencer
    • 1
  • Megan R. Saettele
    • 1
    • 2
  • Lisa H. Lowe
    • 1
    • 3
  1. 1.School of MedicineUniversity of Missouri-Kansas CityKansas CityUSA
  2. 2.Department of RadiologySt. Luke’s Hospital, University of Missouri-Kansas CityKansas CityUSA
  3. 3.Department of RadiologyChildren’s Mercy Hospitals and Clinics, University of Missouri-Kansas CityKansas CityUSA

Personalised recommendations