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Imaging In Acute Appendicitis: A Review

RK JAIN, M JAIN, CL RAJAK, S MUKHERJEE, PP BHATTACHARYYA, MR SHAH
Ind J Radiol Imag 2006 16:4:523-532
Key words : Acute appendicitis, Xray, USG, CT
INTRODUCTION

ANATOMY

Acute appendicitis is the most common cause of

emergency abdominal surgery (1). While the diagnosis
of acute appendicitis is still largely thought to be a clinical
one, a meaningful number of patients are found to have
normal appendices at surgery. The erroneous diagnosis
of this acute condition has led to a high rate (8-30%) of
inappropriate removal of the normal appendix. This high
rate needs to be balanced with the problem of being over
restrictive in the diagnosis of acute appendicitis, which
may allow uncomplicated appendices to progress to
perforation and peritonitis (2).

The vermiform appendix, a blind-ending tubular structure,

arises from the posteromedial aspect the cecum inferior
to the ileocecal junction. It varies considerably in length
and circumference, the average length being between 7.5
and 10 cms. The position of the base of the appendix is
essentially constant, being found at the confluence of
the three taeniae coli of the cecum, which lies deep to
the Mc Burney's point. The free end of the appendix is
however found in variety of locations. (Fig.1). The difference
in appendiceal position influences clinical findings
considerably (4). In unusual cases of malrotation of the
gut, or failure of decent of cecum, the appendix is not in
the right lower quadrant (5).

However the incidence of acute appendicitis requiring

appendectomy has significantly decreased over the past
three or four decade, and the trend appears to continue.
Some of the decrease in the number of appendectomies
is attributable to better diagnosis (3). With the availability
of high-resolution sonography and spiral CT it is possible
to bring down these high rates of false positivity
significantly.

The appendix has its own mesentry, the mesoappendix,

arising from the inferior part of the mesentry of the terminal
ileum, which attaches to the cecum and proximal part of
the appendix. The mesoappendix contains the
appendicular artery, a branch of the ileocolic artery.
Venous drainage of the appendix is via the ileocolic veins
and the right colic vein into the portal system. The
lymphatic drainage occurs to the ileocolic nodes along
the course of the superior mesenteric artery to the celiac
nodes and cisterna chyli. The afferent nerve fibers from
the appendix accompany the sympathetic nerves to the
T10 segment of the spinal cord, which explains why in
appendicitis is sometimes referred to the periumbilical
area.
On histology, the submucosa contains numerous
lymphatic aggregations or follicles. There is a rough
parallel between the amount of lymphoid tissue in the
appendix and the incidence of acute appendicitis, the
peak for both occurring the mid teens (3).
PATHOPHYSIOLOGY

Fig.1: Different positions of the appendix

Appendicitis is commonly associated with obstruction of

the appendiceal lumen due to fecalith. Obstruction may
also be secondary to hypertrophy of lymphoid tissue,

From the Department of Radiology, Quadra Medical Services Pvt. Ltd. Kolkata. India.
Request for Reprints: Ranjit Kumar Jain, Quadra Medical Services Pvt. Ltd. 41, Hazra Road, Kolkata 700019. India.
Received 21 May 2006; Accepted 10 August 2006

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524 RK Jain et al
inspissated barium, gallstones, worms (ascaris), foreign
bodies, or tumor.
Following obstruction of the appendiceal lumen, continued
mucus secretion and inflammatory exudation leads to
distension, mucosal edema and mucosal ulceration along
with translocation of bacteria to the submucosa. The
swelling of appendix stimulates the nerve endings of
visceral afferent fibers and the patient perceives visceral
periumbilical or epigastric pain.
With increasing intraluminal pressures, further distension
results in obstructed lymphatic and venous drainage and
allows vascular congestion of the appendix. The
inflammatory process soon involves the serosa. When
the inflamed serosa of the appendix comes in contact
with the parietal peritoneum, patients typically experience
the classic shift of pain to the right lower quadrant.
Intramural venous and arterial thromboses ensue, resulting
in gangrenous appendicitis.

IJRI, 16:4, November 2006

Unrelenting tissue ischemia results in appendiceal
infarction and perforation. Rupture of the appendix with
spillage of pus into the peritoneal cavity results in localized
or generalized peritonitis. More commonly, inflamed or
perforated appendix can be walled off by the adjacent
greater omentum and loops of small bowel resulting in
phlegmonous mass or paracecal abscess.
This sequence is not inevitable and some episodes of
acute appendicitis may resolve spontaneously if the
obstruction is relieved. Rarely, appendiceal inflammation
resolves leaving a distended mucus-filled organ termed
mucocele of the appendix.(Fig.2.)
CLINICAL MANIFESTATIONS
Appendicitis occurs in all age groups. It is rare in infants
but becomes increasingly common in childhood and
reaches peak incidence in the late teenage years and
early twenties. Sex ratio is equal before puberty and maleto-female ratio is 3:2 in teenagers and young adults. The
ratio again equalizes by the time patients reach their
midthirties. No racial predilection exists for appendicitis.
A diagnosis of appendicitis usually can be made on the
basis of history and physical examination.
Symptoms:
Pain is the prime symptom of appendicitis and initially is
located in the lower epigastrium or periumbilical area.
The pain subsequently localizes to the right lower quadrant,
where it becomes progressively more severe. This classic
pain sequence is usual but not invariable. The difference
in appendiceal position, age of the patient, and degree of
inflammation, accounts for variations in the clinical
presentation.
Anorexia nearly always accompanies appendicitis.
Nausea, vomiting, and low-grade fever are common.
Uncommonly, diarrhea or constipation may be seen. The
sequence of appearance of symptom that is anorexia
followed by pain and then vomiting has great differential
diagnostic significance 3. If vomiting precedes the onset
of pain, the diagnosis should be questioned.
Signs:

Fig. 2. Mucocele of the appendix. (a) Sonogram of the right

lower quadrant obtained with a linear 10-6-MHz probe, shows
well defined tubular cystic structure with some low- level
luminal echogenicity. (b) Transverse CT scan in another
patient obtained with oral contrast material reveals cystic
lesion in relation to the cecum suggestive of mucocele.

The cardinal features of acute appendicitis are localized

abdominal tenderness, rigidity, muscle guarding, pain on
percussion, and rebound tenderness. Pain in right lower
quadrant with palpation of the left lower quadrant (Rovsing
sign) is helpful in supporting a clinical diagnosis. Asking
the patient to cough will elicit a sharp pain in the right
lower quadrant (positive cough sign).
With a retrocecal appendix the anterior abdominal findings

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IJRI, 16:4, November 2006
are less striking and tenderness may be more marked in
the flank. Pain in right lower quadrant with hyperextension
of the right hip (psoas sign) demonstrates nearby
inflammation when stretching the ileopsoas. Pain in the
right lower quadrant with passive internal rotation of the
flexed right hip (obturator sign) indicates that an inflamed
appendix is contact with the obturator internus.
Laboratory findings:
High level of C-reactive protein (>0.8 mg/dL) with
leukocytosis and neutrophilia are the most important
laboratory findings 6.
IMAGING
The clinical presentation of appendicitis is variable. While
the clinical diagnosis may be straightforward in patients
who present with classic signs and symptoms, atypical
presentations may result in diagnostic confusion and delay
in treatment 4. Clinical diagnosis is more confusing in
young and elderly patients. In addition, many other clinical
disorders present with symptoms similar to those of
appendicitis and the differential diagnosis 3includes the
following:
Acute Mesenteric Adenitis
Acute gastroenteritis
Meckel's Diverticulitis
Intussusception
Crohn's disease
Perforated peptic ulcer
Diverticulitis
Epiploic appendagitis
Urinary tract infection
Ureteric stone
Primary peritonitis
Henoch-Schonlein purpura
Yersiniosis
Diseases of the Male: Testicular torsion
Epididymitis
Seminal vesciculitis
Gynecologic disorders: Pelvic inflammatory disease (PID)
Ovarian cyst or torsion
Endometriosis
Ruptured ectopic pregnancy
Rectus sheath hematoma
Cholecystitis
Since accurate clinical diagnosis of appendicitis is difficult,
negative appendectomy rate7 can be as high as 20%.
Unnecessary surgery for suspected appendicitis exposes
patients to increased risks, morbidity, and expense 8.
Radiological examination can reduce the number of
misdiagnoses and negative laparotomies and help in
treatment of appendiceal abscesses and in postoperative
complications. Judicious use of graded compression US

Imaging in Acute Appendicitis 525

& CT in patients with equivocal clinical findings results in
lower false-negative appendectomy rates (4).
Conventional Radiography
Though plain films are reported to reveal abnormalities in
50% of patients with appendicitis (9), they are not specific,
not cost effective, and can be misleading (8). Plain films
are indicated for the evaluation of a patient with suspected
appendicitis only when other diagnostic probabilities (e.g.,
perforation, intestinal obstruction, ureteral calculus) are
also considered (8,10).
The various plain film findings that have been described
in appendicitis are as follows: (8-11)
" Appendicolith.
" Right lower quadrant gas
" Increased soft tissue density of the right lower
quadrant
" Separation of the cecum from right extraperitoneal
fat planes
" Deformity of the cecal and ascending colon gas
shadow occurring due to adjacent inflammatory mass
" Localized ileus with gas in the cecum, ascending
colon and terminal ileum
" Effacement of the right extraperitoneal fat line
" Gas in peritoneum and retroperitoneum
" Gas filled appendix
Barium enema examination may be helpful in selected
patients. Barium enema is performed on an unprepared
bowel gently without any external pressure. Complete
filling of a normal appendix effectively excludes the
diagnosis of appendicitis. Nonfilling or incomplete filling
of the appendix along with mass effect on the cecum
suggests appendicitis(8), the mass effect being due to
abscess/ inflammatory reactions surrounding the inflamed
appendix. The terminal ileum may be displaced or
narrowed by the adjacent inflammatory mass and there
may be thickening of the mucosal folds of the terminal
ileum. However, non-filling of appendix may be seen in as
many as 10-20% of normal patients.
It has been shown by Sehey that appendix fills in 92% of
normal children and hence failure of the appendix to fill in
symptomatic children is a significant finding.
Barium enema examination may also be useful in
evaluating complex colonic abnormalities detected with
cross-sectional imaging (4).
Ultrasonography
Ultrasonography (US) is valuable in the diagnosis of
doubtful cases of appendicitis and is a cost-efficient
adjunct to the clinical evaluation(12). US is inexpensive,

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526 RK Jain et al
safe, and widely available. Because US involves no
ionizing radiation and excels in the depiction of acute
gynecologic conditions, it is recommended as the initial
imaging study in children, in young women, and during
pregnancy8. It has reported sensitivities of 75%-90%,
specificities of 86%-100%, accuracies of 87%-96%,
positive predictive values of 91%-94%, and negative
predictive values of 89%-97% for the diagnosis of acute
appendicitis (4). Use of preoperative ultrasonography is
also associated with overall lower negative appendectomy
rate (12).

Fig.3.Acute appendicitis in a 37-year-old man with right-lowerquadrant pain. (a) Long axis and (b) cross sectional US
images show inflamed appendix as a blind-ended,
noncompressible tubular structure filled with fluid and
surrounded by a hypoechoic mass representing phlegmon.

Graded compression technique described by Puylaert

(13) is the standard method for sonographic evaluation
of acute appendicitis. Graded compression US, with slow
and gentle maintained pressure, allows for a lengthy and
successful evaluation of the area of interest and shows
obstructed appendix as a noncompressible loop of gut
(4).

IJRI, 16:4, November 2006

Recently Baldisserotto et al (14) has described the use
of the noncompressive technique before the graded
compression study. This may successfully establish the
diagnosis in some cases, thereby avoiding compression
in patients with abdominal pain. Change of the patient's
position to displace the bowel gas may also help in
visualization of the appendix deeply set in the abdominal
cavity without compression. Compression study is
however, useful in identifying the cases of appendicitis
not visualized at the noncompressive examination.

Fig. 4. Appendicitis with appendicolith. (a) Long-axis and (b)

cross sectional US image of the right lower quadrant,
obtained with a linear 10-6-MHz probe in a 35 year old woman,
shows the inflamed appendix with an echogenic luminal
focus (between the calipers) with distal shadowing.

It is very important to standardize the examination

technique for identification of appendix and thereby
avoiding false negative diagnosis. Baldisserotto has
suggested an excellent routine for the actual US
examination of the right lower quadrant, which we have
found very useful in our daily practice. The US examination
of the right lower quadrant should start in the transverse
plane from the tip of the liver and proceed towards the
pelvic brim. The ascending colon usually is appreciated
by its gas content and haustral pattern. In the region of

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IJRI, 16:4, November 2006
the cecum, careful attention should be paid to inflammatory
changes in the perienteric fat and the appendix itself.
Sagittal and oblique images should then be obtained until
the entire region of interest has been scanned. Detailed
images are obtained of the appendix, if it is seen. The
examination is generally begun with a curvilinear
transducer appropriate for the patient: a 3.5-MHz
transducer for large patients and a 5-MHz transducer for
thin patients. The linear transducer is used latter for more
detailed study. The retrocecal appendicitis is best studied
by the examination through the right flank (14).
The inflamed appendix is seen as a blind-ended,
aperistaltic, noncompressible, tubular structure that arises
from the base of the cecum having a diameter greater
than 6 mms.(Fig.3.) Presence of a fecalith (Fig.4) may
aid in arriving at a positive diagnosis.

Imaging in Acute Appendicitis 527

The ovoid shape15 of appendix in transverse section on
US over the entire appendiceal length reliably rules out
acute appendicitis while in acute inflammation the
appendiceal wall thickening causes an increase of the
outer appendiceal diameter and a rounding of the shape.
In early acute appendicitis (catarrhal stage) five layers
can be identified- (Fig. 5.)
1. central, thin hyperechoic line representing the
collapsed lumen and superficial lining of the mucosa
of the appendix,
2. hypoechoic layer (2-3mms) representing edematous
lamina propria and muscularis mucosa.
3. hyperechoic submucosa (2-3 mms).
4. hypoechoic muscular layer (2-3-mms).
5. outer thin hyperechoic line representing the serosa.
In late (suppurative) stage the lumen of the appendix is
distended with pus/ fluid and there is increased thickening
of the submucosa and muscular wall in the range of 3-6
mms.
Circumferential color in the wall of the inflamed appendix
on color Doppler US images is strongly supportive
evidence of active inflammation (4). (Fig 6.)

Fig.6. Cross-sectional Color Doppler US image obtained

through the base of thick walled appendix in a 74 year old
male presenting with right lower quadrant abdominal pain
shows virtually circumferential flow in the wall of the inflamed
appendix.

Loculated pericecal fluid, phlegmon or abscess,

prominent pericecal fat and circumferential loss of the
submucosal layer of appendix are associated with
appendiceal perforation 16. (Fig 7.)
Fig.5. Classic features of acute appendicitis at US in a 26year-old man with right lower quadrant pain. (a) Long-axis
and (b) cross-sectional US images of the right lower
quadrant obtained with a linear 10-6 MHz transducer show
an 8-mm-diameter, blind-ended, tubular structure with a
laminated wall. The appendix was not compressible and
showed no peristalsis.

A significant disadvantage of sonography is that it is

operator dependent. Difficulties with ultrasonography also
include the fact that a normal appendix must be identified
to rule out acute appendicitis. Visualization of a normal
appendix is more difficult in patients with a large body

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528 RK Jain et al
habitus and when there is an associated ileus, which
produces shadowing secondary to overlying gas-filled
loops of bowel. It may also be not possible on US to
differentiate between appendiceal phlegmon from an
abscess and CT may be helpful in this setting.

IJRI, 16:4, November 2006

of appendiceal perforation.(17,18)
Disadvantages of CT include possible iodinated-contrastmedia allergy, patient discomfort from administration of
contrast media (especially if rectal contrast media is
used), exposure to ionizing radiation, and cost. However,
the cost is considerably less than that of removing a normal
appendix or hospital observation.(8)
Technique- there is no consensus on the ideal CT
technique for studying appendix. There are different CT
protocols depending upon the generation of CT scanners
used as well as varying from center to center. While
nonfocused CT performed for entire abdomen and pelvis
with intravenous and oral contrast material is the most
popular approach(4,17), CT evaluation of appendicitis
without the use of intravenously administered contrast
material is also a growing trend (2,19,21). Opacification
of the terminal ileum and cecum with oral and/or rectal
contrast material alone or in combination has been
advocated4. However lane et al19 do not recommend the
use of any contrast material. Weltman et al20 has shown
that the use of thin-section (5mms) CT significantly
improves the diagnosis of acute appendicitis compared
to 10 mm sections. We at our clinic prefer to opacify the
bowel using oral and / or rectal contrast along with IV
contrast, and use thinner sections.

Fig. 7. Acute appendicitis with perforation in a 17-year-old

boy presenting with right lower quadrant pain and
tenderness. (a) Long-axis and (b) cross sectional US
image, obtained through the right lower quadrant with a
linear 10-6-MHz probe, shows the perforated appendix, with
discontinuity of its wall and surrounded by an abscess.

Computed Tomography
CT has become increasingly popular as an effective crosssectional imaging technique for diagnosing and staging
acute appendicitis. It is a quick and accurate examination
that is operator-independent, is relatively easy to perform
and provides images that are easy to interpret.(4, 17)
Helical CT has reported sensitivities of 90%-100%,
specificities of 91%-99%, accuracies of 94%-98%, positive
predictive values of 92%-98%, and negative predictive
values of 95%-100% for the diagnosis of acute
appendicitis.(4) Its use has decreased the rate of negative
appendectomies and has decreased the number of cases

Image interpretation- the evaluation starts with the

identification of appendix. Since the position of the cecum
and ascending colon is highly variable, identification of
the fatty lips of the ileocecal valve is helpful. Careful
scrutiny of the entire cecum then frequently allows
identification of the appendix as it arises from the
posteromedial border. The appendix is frequently seen
draped over the right external iliac artery and vein. The
right common and external iliac artery and vein are
therefore carefully evaluated from their origins at the
bifurcation of the aorta into the femoral canal to identify
the overlying appendix. This usually helps to avoid the
pitfall of not seeing a pelvic appendix.
Once the appendix is identified, it is evaluated for sign of
acute appendicitis as described to confirm or exclude
the diagnosis of acute appendicitis. Once the appendiceal
region is cleared, the cecum and ascending colon are
carefully examined for potential involvement by cecal
neoplasm (Fig.8), cecal diverticulitis, typhlitis, or
segmental colitis. Diseases that involve primarily the
pericolonic fat, such as primary epiploic appendagitis and
omental infarction, are then excluded.
Focus is then turned to the terminal ileum and its
subtended mesentery. Gastrointestinal diseases to
consider in this anatomic location include acute terminal
ileitis, mesenteric lymphadenitis, Crohn's disease and

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IJRI, 16:4, November 2006
tuberculosis. Genitourinary disease then should be
excluded, including acute pyelonephritis, ureteral
obstruction, complications of ovarian cysts and masses,
and acute postpartum ovarian vein thrombosis. In adult
patients, one must also consider acute cholecystitis
(which may mimic acute appendicitis if the enlarged
gallbladder extends into the right-lower quadrant),
pancreatitis, sigmoid diverticulitis, bowel ischemia, and
bowel obstruction.

Imaging in Acute Appendicitis 529

Imaging findings- the normal appendix appears as a
tubular or ringlike pericecal structure that is either totally
collapsed or partially filled with fluid, contrast material, or
air. The normal appendix has a thickness of 3 mms or
less and a diameter of 6mms or less(14,21). The
periappendiceal fat should appear homogeneous, although
a thin mesoappendix may be present. The finding of a
normal appendix with no fluid in its lumen, normal
periappendiceal fat, and no calcified appendicolith
indicates that the appendix is not inflamed.
The main CT criteria for the diagnosis of acute appendicitis
include identification of a thickened appendix with a twowall diameter greater than 6.0-7.0 mm, periappendiceal
inflammatory
changes,
and
a
calcified
appendicolith(21).(Fig. 9 a). Alobaidi et al(22) has
recommended the use of bone window settings for
detecting appendicoliths when evaluating patients for acute
appendicitis, particularly patients in whom evidence of
appendicitis is equivocal.

Fig. 8. Cecal mass with appendicitis. Coronal reformatted

CT scan shows lobulated heterogenous mass of cecum
with involvement of the base of the appendix.

Fig. 9. Classic CT findings of acute appendicitis in a 48year-old woman who presented with right lower quadrant
pain and tenderness. (a) Transverse CT scan obtained with
oral contrast material and with 5-mm collimation reveals
an obstructing appendicolith within the distended appendix.
(b) Caudal helical CT image reveals periappendiceal
inflammation

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530 RK Jain et al
The size criterion to diagnose appendicitis is especially
important in the absence of periappendiceal inflammation.
Benjaminov et al(21) observed that an upper limit of 6.0
mm for normal appendiceal thickness can be used reliably
at CT only if the luminal content is visualized because in
the absence of periappendiceal inflammatory changes, it
is not possible to differentiate a noncollapsed appendix
filled with fluid of the same attenuation as the wall from a
thick inflamed appendix if the content is not visualized.
They suggested 10.0 mm as the upper limit of normal if
the luminal content is not visualized and extraappendiceal
inflammatory changes are not present. Patients with an
appendiceal thickness of 6.0-10.0 mm should therefore
undergo further examination with rectally or intravenously
administered contrast material or with US to visualize
the wall and thus prevent a false-positive diagnosis of
appendicitis.
In early or mild appendicitis the CT findings are very subtle.
The appendix may appear minimally distended associated
with a hazy, ill-defined increase in CT attenuation in the
fat immediately surrounding the appendix. However most
patients who undergo CT demonstrate greater degrees of
luminal distention and evidence of transmural
inflammation. Circumferential and symmetric wall
thickening is nearly always present and is best
demonstrated on images obtained with intravenous
contrast material enhancement. Periappendiceal
inflammation (Fig. 9b) is present in 98% of patients with
acute appendicitis.

IJRI, 16:4, November 2006

of the appendix(23,24). Inflammatory changes associated
with acute appendicitis can cause focal cecal apical
thickening, which allows contrast material to assume the
configuration of an arrowhead as it funnels at the cecal
apex to the point of the obstructed appendiceal orifice.
Because the sign is formed by the extension of
inflammation from the appendix to the cecum, the
arrowhead sign may allow for placement of patients with
appendicitis into two surgical groups(24): those who likely
will do well with standard ligation (arrowhead sign not
present) and those who may require partial cecectomy
(arrowhead sign present).
Complications- Perforated appendicitis is usually
accompanied by pericecal phlegmon or abscess
formation. Associated findings include extraluminal air,
(Fig. 11) marked ileocecal thickening, localized
lymphadenopathy, peritonitis, and small-bowel
obstruction.

Fig. 10. Transverse CT scan obtained with oral contrast

material and with 5-mm collimation in a 13 year old child
with acute appendicitis demonstrates the arrow head sign
consisting of a triangle-shaped contrast collection between
the thickened cecal apical walls. Surgical exploration
revealed perforated appendicitis.

Other important findings include focal cecal apical

thickening and the arrowhead sign,(Fig. 10) which is seen
as an arrowhead-shaped collection of contrast medium
localized to the upper part of the cecum near the orifice

Fig. 11a and b. Transverse CT scan obtained with oral

contrast material and with 5-mm collimation in a 32 year old
woman with acute appendicitis demonstrates an enlarged
thick-walled appendix with an associated cecal apical
thickening and infiltration of surrounding fat. Extraluminal air
pocket suggests perforation.

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IJRI, 16:4, November 2006
If the abnormal appendix is not seen, a specific diagnosis
of appendicitis can be made by identifying an
appendicolith within a periappendiceal abscess or
phlegmon

Imaging in Acute Appendicitis 531

causing appendiceal wall enhancement to be obscured
by mesenteric fat.

Although a pericecal phlegmon or abscess is strongly

suggestive of appendicitis, these are nonspecific findings
that may be seen with other disease entities. If substantial
inflammation is present within the right lower quadrant, it
may be difficult to differentiate primary appendicitis with
secondary inflammation of the cecum and terminal ileum
from ileocolitis with secondary inflammation of the
appendix.
CT is of considerable value in the treatment of patients
who present with a periappendiceal mass and can be
used to accurately stage the extent of periappendiceal
inflammation and to reliably differentiate periappendiceal
abscess from phlegmon, which is of critical importance
to the surgeon. Many surgeons believe that there is little
value in attempting to drain a nonliquefied phlegmon and
prefer initial nonsurgical treatment with antibiotic therapy
in such cases. Patients with well-defined and welllocalized periappendiceal abscesses typically benefit from
CT-directed percutaneous catheter drainage.(4,17)
Patients with extensive and poorly defined collections
usually require immediate surgical exploration and
abscess drainage.
Magnetic Resonance Imaging
MRI may also be used in the diagnosis of appendicitis in
cases where either CT is contraindicated like in pregnancy
or in children where it is advisable to avoid radiation. T1weighted and T2-weighted turbo spin-echo sequences and
fat-suppressed inversion recovery turbo spin-echo
sequences as well as post contrast T1 weighted
sequences can be used. On T2-weighted images,
inflamed appendix show markedly hyperintense center
and a slightly hyperintense thickened wall with markedly
hyperintense periappendiceal tissue.(Fig. 12) On post
contrast study, intense contrast enhancement of the
inflamed appendiceal wall indicates the presence of
appendicitis. There is also significant enhancement of
surrounding fat on gadolinium-enhanced T1-weighted fatsuppressed spin-echo images. Mild enhancement can
however be seen in the normal appendix and gut. Using
fat-saturation technique, contrast differences between
the inflamed appendix and the surrounding fat is better
appreciated. However, MRI has inherent limitation in
detecting appendicolith.

Fig.12. Axial T2 (a) and T1 (b) weighted images through right

lower quadrant in a 23 year old man presenting with acute
abdomen shows enlarged thick walled inflamed appendix
with periappendiceal inflammation

Fat-suppressed gadolinium enhanced MRI images are

sensitive (97%) and accurate (95%) in the detection of
acute appendicitis25.
Incesu, et al (25) found MR imaging superior to
sonography in revealing appendicitis. Despite some
disadvantage, MR imaging can also be used after
suboptimal or nondiagnostic sonography in cases of
suspected acute appendicitis.
CONCLUSION

Inflammatory diseases of the gut, such as ileal diverticulitis

and Crohn's disease may mimic appendicitis and may
be cause for false-positive diagnosis of acute appendicitis.
False-negative results usually depend on techniquerelated limitations, such as inefficient fat saturation

Although rare in infants, appendicitis is common in human

population. It is one of the most common cause of acute
right lower quadrant abdominal pain and in majority of
cases diagnosis of acute appendicitis can largely be

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532 RK Jain et al
made on the basis of history and physical examination.
Though decreasing, still a large number of appendices at
surgery are found to be normal, leading to a high rate of
negative appendectomies (8- 30%). This is because of
similar signs and symptoms of a wide range of acute
abdominal clinical disorders and nonspecific laboratory
and conventional radiographic findings. In recent years
however with the availability of various cross-sectional
imaging techniques viz. Ultrasonography, Spiral CT and
MRI, false positive diagnosis of acute appendicitis has
reduced therefore also reducing rate of negative
appendectomies. The overall accuracy of cross-sectional
imaging techniques in diagnosing acute appendicitis varies
from 87%-98%.
High resolution sonography is an most common imaging
technique used in diagnosing appendicitis as it is less
expensive, easily available and free from radiation,
however it is operator and subject dependent and requires
lot of experience. MRI can also be used in the setting of
pregnancy, otherwise it expensive, time consuming and
cumbersome. Spiral and recently multislice CT has
therefore emerged as the most effective tool for diagnosing
appendicitis and its complications because of its excellent
resolution. It provides exquisite detailed anatomical images
for review, and is also fast and operator independent.
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Treutner KH, Schumpelick V. Epidemiology of

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RE, and Katz DS. Suspected Acute Appendicitis:
Nonenhanced Helical CT in 300 Consecutive Patients.
Radiology. 1999; 213: 341-346.
3. Schwartz SI. Appendix. In Schwartz SI, Slivers GT, Spences
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