Skip to main content
SpringerLink
Log in
Book cover

Imaging Non-traumatic Abdominal Emergencies in Pediatric Patients pp 149–170Cite as

Acute Appendicitis

  • Chapter
  • First Online:

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.

Chapter
USD   29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD   109.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD   139.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD   139.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Learn about institutional subscriptions

References

  • 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

    Article  PubMed  Google Scholar 

  • 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

    Article  CAS  PubMed  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • Brennan GD (2006) Pediatric appendicitis: pathophysiology and appropriate use of diagnostic imaging. CJEM 8:425–432

    Article  PubMed  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • 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

    PubMed  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • 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

    Article  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • Doria AS (2011) Optimizing the role of imaging in appendicitis. Pediatr Radiol 41(8):993–999

    Article  Google Scholar 

  • 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

    Article  Google Scholar 

  • 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

    PubMed  Google Scholar 

  • Farina R, Catalano O, Stavolo C, Sandomenico F, Petrillo RL (2015) Emergency radiology. Radiol Med 120:73–84. doi:10.1007/s1154701404802121

    Article  PubMed  Google Scholar 

  • 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

    Google Scholar 

  • 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

    Article  PubMed  PubMed Central  Google Scholar 

  • 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

    Article  CAS  PubMed  Google Scholar 

  • 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

    Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • Horrow MM, White DS, Horrow JC (2003) Differentiation of perforated from nonperforated appendicitis at CT. Radiology 227:46–51

    Article  PubMed  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • 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

    Article  PubMed  PubMed Central  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • Klein MD (2007) Clinical approach to a child with abdominal pain who might have appendicitis. Pediatr Radiol 37:11–14, Epub 2006 Oct 17

    Article  PubMed  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • Leeson K, Leeson B (2013) Pediatric ultrasound: applications in the emergency department. Emerg Med Clin North Am 31:809–829

    Article  PubMed  Google Scholar 

  • Levine CD, Aizenstein O, Wachsberg RH (2004) Pitfalls in the CT diagnosis of appendicitis. Br J Radiol 77:792–799

    Article  CAS  PubMed  Google Scholar 

  • Lim HK, Lee WJ, Lee SJ, Namgung S et al (1996) Focal appendicitis confined to the tip: diagnosis at US. Radiology 200:799–801

    Article  CAS  PubMed  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • Marin JR, Kornblith AE, Doniger SJ (2016) Point-of-care ultrasonography for appendicitis uncovers two alternate diagnoses. Pediatr Emerg Care 32:262–265

    Article  Google Scholar 

  • Mazeh H, Epelboym I, Reinherz J, Greenstein AJ, Divino CM (2009) Tip appendicitis: clinical implications and management. Am J Surg 197:211–215

    Article  PubMed  Google Scholar 

  • 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

    Article  Google Scholar 

  • 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

    CAS  PubMed  Google Scholar 

  • 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

    Google Scholar 

  • Miele V, Andreoli C, Grassi R (2006) The management of emergency radiology: key facts. Eur J Radiol 59:311–314, Epub2006 Jun27

    Article  PubMed  Google Scholar 

  • 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

    Article  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • 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

    Article  CAS  PubMed  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • 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

    Article  Google Scholar 

  • 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

    Article  Google Scholar 

  • 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

    Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • 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

    Article  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • Sivit CJ (2004) Imaging the child with right lower quadrant pain and suspected appendicitis: current concepts. Pediatr Radiol 34:447–453

    Article  PubMed  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • Strouse PJ (2010) Pediatric appendicitis: an argument for US. Radiology 255:8–13

    Article  PubMed  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • Taylor GA (2004) Suspected appendicitis in children: in search of the single best diagnostic test. Radiology 231:293–295

    Article  PubMed  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

  • 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

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Emergency Radiology, S. Camillo Hospital, Rome, Italy

    Grazia Loretta Buquicchio, Gavina Cuneo, Stefano Giannecchini, Caterina Pizzi, Carmelo Rende & Margherita Trinci

Authors
  1. Grazia Loretta Buquicchio
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Gavina Cuneo
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Stefano Giannecchini
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Caterina Pizzi
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Carmelo Rende
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Margherita Trinci
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Grazia Loretta Buquicchio .

Editor information

Editors and Affiliations

  1. Department of Emergency Radiology, S. Camillo Hospital, Rome, Italy

    Vittorio Miele

  2. Department of Emergency Radiology, S. Camillo Hospital, Rome, Italy

    Margherita Trinci

Rights and permissions

Reprints 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)

Publish with us

Policies and ethics

Search

Navigation