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Commentary

Radiology of Acute Appendicitis
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Although no longer a “hot topic” in the medical litena- although Hatten et al. [10] found an incidence of only 7%
tune, the diagnosis of acute appendicitis still presents a in a review of 300 cases.
challenge. Several modern series indicate that a preop- At least half of acute appendicitis patients with appen-
enative clinical diagnosis of acute appendicitis will be dicoliths have gangrene or perforation of the appendix
incorrect in 15% of cases and that a significant postop- [4, 6]. This potential for advanced disease has prompted
erative complication rate can be expected as a result of surgical zealots to advocate elective appendectomy for
appendectomy performed for such a mistaken impres- asymptomatic patients who have accidental discovery of
sion [1-3]. In many instances the surgeon’s palpating an appendicolith [11].
fingers require d iagnostic reinforcement.
Despite numerous publications on the subject, the Gas in Appendix
inconsistent use of radiography by many clinicians mdi- The radiologic discovery of gas in the appendix is
cates that its role in the diagnosis of appendicitis is still noted in less than 2% of patients with acute appendicitis
poorly appreciated. My own views are formed by expeni- [6-8]. It occurs when the appendix is completely ob-
ence with 291 histologically proven cases oven the past 8 structed and infected with gas-forming bacteria, or when
years at Bridgeport Hospital. the lumen of an inflamed atonic appendix communicates
with the cecum. Gas in the appendix with acute appen-
Plain Film Findings dicitis has been associated with gangrene and perfora-
tion in about 50% of published cases [12].
Appendicoliths
The lumen of a gas-filled inflamed appendix often
An appendicolith originates from a fecal lump inspis- appears dilated throughout its entire length, with a
sated in the appendiceal lumen. The irritating fecal nidus poorly defined air-mucosa interface due to mucosal
provokes secretion and precipitation of mucous rich in edema. There may be a gas-fluid level in the appendix
calcium phosphate. Appendiceal calculi are also known and a surrounding soft tissue mass. All seven Bridgeport
as fecaliths on coproliths, designations corrupted by Hospital cases had accompanying radiographic signs of
frequent application to small nadiolucent fecal lumps acute appendicitis
discovered by barium filling the appendix. An uncalcified For many physicians, gas in the appendix implies the
fecal lump does not have the same potential for lumen diagnosis of acute appendicitis [12]. Samuel [13] first
obstruction and production of acute appendicitis. recognized that air may normally be seen throughout
Radiographi#{231}ally, the typical appendiceal calculus is most of the length of an ascending netnocecal appendix.
0.5-2.0 cm in diameter. In 70% of cases they are solitary Gas filling of appendices occupying other positions in
and in 20%, two are present. The majority are oval and the abdomen has not been so well established as a
laminated [4]. A laminated right lower quadrant appen- normal radiographic finding. Conventional wisdom con-
diceal calculus may be mistaken for an ectopic gallstone, tends that, although gas air enters a normal non retroce-
especially if the patient has dilated small intestinal loops cal appendix, it is not sufficient or constant enough to
suggesting a gallstone ileus. The common differential be identified with certainty on plain abdominal films [12,
diagnosis of a nonlaminated appendicolith includes ure- 13]. Dissenting, Lim [14] presented three cases with
teral calculus, bone island of the ilium, or calcified abdominal complaints and normal gas-filled appendices
mesentenic lymph node [5]. occupying the right lower quadrant of the abdomen. In
Radiographic discovery of an appendicolith in a pa- two cases the cecum was not simultaneously distended
tient with abdominal pain is a highly reliable indicator of with gas.
acute appendicitis. Fagenberg [4] noted that 12 of 100 I analyzed three groups of patients without append ici-
consecutive cases of acute appendicitis had append icol- tis to determine the frequency of air filling of normal
iths demonstrable by plain abdominal films, whereas appendices.
only one of 100 normal cases had such a finding. He 1 . In 100 consecutive ambulatory patients with back
concluded that discovery of an appendicolith in a patient pain, no appendiceal air was observed on a single supine
with abdominal pain indicates at least 90% chance of abdominal film. The study agrees with the series of 200
acute appendicitis. Appendicoliths have been noted in normal subjects studied by Graham and Johnson [7];
7%-12% of cases in large series [6-9]; a 14% incidence none had gas in the appendix.
has been noted in the Bridgeport Hospital review of 291 2. Ninety consecutive hospital cases with abdominal
cases. The frequency of appendicoliths has been ne- complaints, numerous supine abdominal films, and bar-
ported as high as 50% in children with appendicitis, ium studies for confirmation of the shape and position of
1001

so-called appendiceal ileus.23. Graham and Johnson [7] found that sentinel right lower quadrant ileal Abscess loops occurred without air-fluid levels in 19%. The mean seldom dramatic. tance could not be ascertained in nine cases. most anywhere in the abdomen because of the extreme Steinert et al. and sentinel night characteristically in the right lower quadrant or in the lower quadrant air-fluid levels occurred in 2. ileus in the diagnosis of appendicitis [8]. localized increased density oven the night sacroiliac joint with blurring of the joint margins. the colonic contents. Appendiceal air was may not be present in a few normal patients. 15 had a dicitis and those with other abdominal complaints.org by 36. three categories: (1) normal. In 221 cases of appendicitis in which a dilated right lower quadrant bowel loops. a right An appendiceal abscess occurs most frequently and colon air-fluid level occurred in 9%.105 on 07/26/17 from IP address 36. On the were located in the night lower quadrant. Other findings. distended) indicated an abnormal amount of soft tissue. Abscess formation is noted surgically in about 15% A soft tissue mass may be caused by an abscess. All may be reflected only as a bubble appearance. In 100 consecutive hospital patients with either This indicates edema of the cecal wall and/on fluid in excretory urogram or supine abdominal films. the other was in of 104 cases.81.and cases a gasless night colon prevented identification of fluid-filled bowel loops confined to the night lower quad. occasionally contain gas. Such findings as splinting of the night side of the citis. In my own experience there has anywhere along the night flank (with the colon empty on been no significant difference in the frequency of visual.105. tance of 10 mm on more. Hence. and air in a nondilated appendix. are short. such trates and causes edema of the well defined fat stripe. he found Air extending for even a long segment of a nondilated that the soft tissue between the night propenitoneal fat appendix occupying any position of the abdomen may and the night colonic contents usually measures 2-3 mm. An abscess will edema of the mesoappendix. by of large series of appendicitis [1 . absence of the night psoas mar- Even when a left fat stripe is present.9 mm). the pelvis. ination. “cecal-fat distance” greaten than 5 mm. four had the night flank. Appendiceal abscesses have been noted in such unusual sites as the night thigh on the left subphrenic Right Lower Quadrant Soft Tissue Mass area.81. all rights reserved unquestionable air filling of the appendix. Steinert et visualized in six cases. The original large radiographic series of Steinert et al. [9] noted blurring of the right propenitoneal fat in six filling. 1002 COMMENTARY the appendix were then reviewed. The dis- Acute appendicitis may induce atony of the neighbor. For personal use only. 37 had a cecal-fat dis- ceal ileus should prove a useful radiographic finding. then appendi. being noted in 12%-33% of large series [6-9]. and (3) probable . basis of 100 randomly selected supine films. 2. If the term is whereas Casper’s suggestion [15] of 5 mm does not restricted only to those cases with air-fluid levels in seem valid. However. a night fat stripe gin. in 1943 [9] first evaluated the usefulness of the plain Blurring or Loss of Right Properitoneal Fat Stripe abdominal film in acute appendicitis and developed This sign occurs when the inflammatory process infil. dilatation of the small on large bowel. abdomen and loss of the night psoas margin occur in a large number of normal individuals and are of value only Deformity of Cecal Outline as supportive signs [7].or retnopenitoneal dissem- (18. in six ing cecum and terminal ileum causing dilated air. Analyzing a series of 200 normal patients. and/on narrowing of the lumen by lobulated submucosal fluid collections (thumb prints). most unmistakably in a soap filled small bowel loops. such as diffuse Edema deforms the air-filled cecum by causing thick. be normal. if present. on by aggregation of fluid. (2) possibly abnormal.ajronline. In four cases air filling of the appendix occurred on only one of many films and only in a short Separation of Cecal Contents from Right Properitoneal proximal segment. A soft tissue mass is a Other Signs frequent and reliable radiographic finding with appendi.5%. a distance of 10 mm or greaten may be Many authors dispute the reliability of appendiceal regarded as abnormal at the 95% level of confidence. Most series Discussion: Plain Films note this finding in less than 5% of appendicitis cases. measurement was obtainable. right panacolonic gutter. ization of air in the appendix in cases with acute appen. Fat 3. straightening of normally curved and serve only to confuse the diagnosis.3%). and fluid levels. I reviewed films on 172 presumably normal supine Appendiceal Ileus abdomens to substantiate the normal distance. [9] noted cecal air-fluid levels in 40 cases variability in the position of the appendix and the numen- (38. and in three instances the night rant. I cannot offer any criteria to judge early He considered that a measurement of greater than 5 mm degrees of dilatation.5%) and sentinel ileal air fluid levels in 19 cases ous potential routes for intra. Copyright ARRS. the bowel loops are only moderately distance for the 162 remaining cases was 4 mm (SD = dilated. analyzing a series of 104 appendicitis cases. This sentinel ileus is propenitoneal fat line could not be identified. Casper [15] attempted to quantify this Downloaded from www. Of the two with complete al. 2]. it may be found al- panison. In com.23. Of 28 of his cases with acute appendicitis. margins. Three of these observation to increase its diagnostic usefulness. one was a netnocecal appendix. are nonspecific ening of mucosal folds. as cases with scoliosis.

Of 1 1 1 patients with negative studies. Even if positive. nonfilling of the appendix is plain film studies are less frequently positive when the not a helpful diagnostic sign of appendicitis for the appendix is in the retrocecal position. that is obstructed and inflamed distally [21]. . Perhaps to avoid embarrassment. Barium may fill the proximal portion of the appendix rectly diagnosing a cecal deformity. Normally this problem cases of appendicitis. such as the positive abdominal films. All 25 had diagnostic findings with pressure the so called “silent appendix. 3. moid without cecal or ileal abnormalities. 1 Flattening . nal ileum. 121 scess from a netnocecal appendix characteristically (42%) were negative.5%) were merely observed for 48 hr and Deformity of Distended Cecum and/or Superior Medial discharged as presumably normal.e. 30 had positive cecum by edematous peniappendiceal tissue. 32 (11%) had possibly abnormal causes a pressure effect on the ascending colon. Fnei. Downloaded from www. Sakoven and the frequency of radiographic examinations which incon. in 66 (12.81. Lange cecal filling defects usually indicate abscess mained largely unchanged after examination of oven formation. by the appendiceal ileus complex of signs and by incor. obstruction [18]. and 138 (47%) had a positive examination.5%) there without significant abdominal disease. A bibbed cecal filling defect in the expected posi- Steinert et al. 2. which then tapers down to a point of appendicitis. Lumen obstruction is a prerequisite for development graphic examination (62% in the Bridgeport Hospital of appendicitis in most patients [19]. A combination of findings more bladder on night ureter. There were 52 lobes is caused by filling of the most proximal portion of cases (50%) with findings characteristic on suggestive of the appendix. few authors analyze 1 . most com. Demonstra. pected preoperatively.23. Perhaps 20% of patients with Soten [17] presented the first large series of cases of appendicitis present such problems [2]. even though published segment is convex. In suspected ap- make one such false positive diagnosis for every five or pendicitis cases colonic preparation cannot be used.105 on 07/26/17 from IP address 36. Of the 138 positive Bridge. Appendicitis was found in six. [9] classified 24 of 104 cases (23%) as tion of the appendix. positive in less than 50% of appendicitis cases. Fifteen patients with Displacement of Terminal Ileum a negative barium enema were surgically explored for Uncomplicated appendicitis causes cecal deformity by impelling clinical reasons. or when appendicitis is only one of many Discussion: Barium Enema diagnostic possibilities. of the cecum between the expected Many physicians hesitate to order a barium enema for origin of the appendix and ileocecal valve. 18].ajronline. Of cases with acute nongangrenous nonperforative expense and radiation exposure. Barium may not fill a normal appendix. Nonfilling of Appendix on gangrene) are more likely to have a positive radio. Most authors have found that absence of cecal deformity. extension of the inflammation from the base of the an overall false negative frequency of 7%. all rights reserved man-DahI [16] noted that these percentages have ne. However. as does terminal ileal displacement. Of 110 patients cated. gas justifies the specific diagnosis. If an strongly suggests a right lower quandrant inflammatory abscess does not impinge upon the right colon on termi- process than any one alone. while a findings. Copyright ARRS. The indentation between these two normal and 28 as possibly abnormal. 107 (97%) had appendici- Barium Enema Findings tis confirmed at surgery. on spread to remote sites. as are children [7]. Patients with more advanced disease (i. barium enemas with nonfilling of the appendix and monlythe mesoappendix [17. [22] performed 221 barium enemas in evaluation by barium enema examination may be mdi- cases suspected of having appendicitis. pelvic abscess impinges on the netnosigmoid region. perforation . 99 (72%) had two or more radio.105. appendicitis only when the existence of a surgical prob- lem is in doubt.” Since the plain film is changes on the cecum and nonfilling of the appendix. contour abnormalities of the right colon. The surface of this defect may be tion of an appendicolith on night lower quadrant abscess smooth on irregular. Of 40 Bridge- appendix to the cecum (typhlitis) and/or pressure on the port Hospital cases with appendicitis. following reasons. further Rajogopalan et al. Del Fava [20] attempted to fill the appendix by barium in rectly suggest the diagnosis of appendicitis in patients 525 patients without appendicitis. Barium may completely fill an inflamed appendix the straightforward case of acute appendicitis except [17]. Abdominal radiography appendicitis.81. 96 (86.000 patients. I have been betrayed most often further hindering appendiceal filling. An ab- 2. COMMENTARY 1003 appendicitis or suggestive of appendicitis. its appendiceal origin usually remains unsus- port Hospital cases. For personal use only. graphic signs of appendicitis. 20% have no demonstrable lumen obstnuc- is indicated for the evaluation of a patient with suspected tion [19]. Two objections are 2. origin of the appendix. About half of acute appendicitis examined by means of the barium appendicitis patients over 60 have minimal symptoms. abdominal radiographs add little to 3. Two of the 40 Early contour changes characteristic of appendicitis had extrinsic impressions on the rectum and retrosig- include the following. An Most often several signs will be present in cases with abscess may also displace other structures. In a continuation of this same series.23. Of 291 Bridgeport Hospital cases. A single filling defect in the region of the expected raised. with a positive barium enema. evidence indicates its desirability. six times I prove connect. I estimate that I was no visualization of the appendix.org by 36. in the series). enema.

12. Fagenberg D: Fecaliths of the appendix: incidence of sig. 1973 (the same incidence of morbidity encountered in patients 11 . 1963 24.23. Bernhard CM: The roentgenologic diagnosis of Histopathologic study. 1962 Bridgeport. Moynihan PC: Appendicitis reported a 14% morbidity rate in patients undergoing and the abdominal roentgenogram in children. Copyright ARRS. Arch Pathol 57 :279-284. Miller AC. Acta Radiol 57 :469-480. Am tality and increasing morbidity from acute appendicitis. Kennedy M. Thomas. Wilkens EW: pendix. 1974 1 7. . 1977 PostgradMed44:110-114.81. In cases with a questionable Am J Roentgenol 128:209-210. It guides the connect mode of 13. Dietz WW: Fallacy of the roentgenologically negative ap- 2. Such 16. Fisher AG. Shimkin 18. Ill. Surgery 57 :377-384. Arch Surg 1 12 : 531-533. Killen DA: Roentgenographic findings in acute may perforate an inflamed cecum. 5. others have reported diceal calculus. 1971 2. Arch Surg REFERENCES 34:496-526. Del Fava AL: Frequency of visualization of the 1 . Wangensteen OH. especially administered under pressure. Sakover AP. South Med surgery for a mistaken diagnosis of acute appendicitis J 66:803-806. Steinert A. Am J Roentgenol 121 :312-317. Copeland EM. The study is not 100% accurate in comparison with 9. 1974 JSurg 119:681-685. Tex Med 67:89-93. Kay 5: Tissue reaction to barium sulfate contrast medium. dicitis. For personal use only. 1977 acute abdomen. 1954 appendiceal calculi. study with good filling of the appendix offers the surgeon 1970 good justification for a policy of watchful waiting. 1966 8. Hester CL. Graham AD. normal appendix with the barium enema examination. 19:410-415. nal Diseases. Radiographic findings in acute appen- not in cases of appendicitis. Johnson HF: The incidence of radiographic is an accepted procedure with cases of diverticulitis of findings in acute appendicitis compared to 200 normal the sigmoid with its known tendency for perforation. [1] 10.105 on 07/26/17 from IP address 36. Acta Radiol 24 : 13-37. Casper RB: Fluid in the right flank as a roentgenographic prompt indicated surgery for appendicitis. and about the appendix. Roedor WJ. 1970 21 .81. Burgos WF. Clin Radiol attendant expense and morbidity. therapy when appendicitis is only one of several diagnos- 1957 tic possibilities. Radiology 49:178-191 1947 . Brooks DW: Gas filled appendix: a roentgeno- The barium enema deserves widen application in the graphic sign of acute appendicitis. Figiel SJ: Barium examination of the cecum in Bridgeport Hospital appendicitis. Wheelock FC. Surg Gynecol Obstet 130:439-442. Bowers WF: Significance of the obstruc- tive factor in the genesis of acute appendicitis. 1968 Peter M. Aulfs DM. A negative sign of acute appendicitis. all rights reserved nation of acute appendicitis. 1937 20.JAMA 208:1495. appendicitis. Fnimann-Dahl J: Roentgen Examinations in Acute Abdomi- an approach for questionable appendicitis should ob.. Hareide I. Figiel LS.105. 3]. 1968 23. Am J Roentgenol 110:352-354. 1956 nificance. 1004 COMMENTARY 1. 22-24]. This complication is appendicitis.org by 36. Mersheimer WL: Decreasing mor. Mason JH. Soten CS: The use of barium in the diagnosis of acute viate most negative diagnostic laparotomies with their appendiceal disease: a new radiological sign. Barnes BA. Pawlikowski J: Hospital (1937-1959). Felson B. Killen DA. Samuel E: The gas filled appendix. a positive barium enema leads to 15. This argument erroneously as- Downloaded from www. Barium. 1970 occasional postoperative deaths [2. Connecticut 06602 19. 1962 The value of the barium enema in the diagnosis of acute 3. 1969 Treatment of appendicitis at the Massachusetts General 22. 1965 very rare [17. Lim MS: Gas-filled appendix: lack of diagnostic specificity. Kazanian et al. I am puzzled whythe barium enema 7. Chnistiansen T: Aoentgenolic exami- surgical exploration. 6. Rajogopalan AE. Hatten LE. but abdomens. JAMA 180: 122-126. cancer of the night colon.23. Behninger GE. 1965 diagnosis of appendicitis. such as regional entenitis or perforating 14.Am J Clin Pathol 26:155-160. Milit Med 131 :272-276. Am J Roentgenol 89 :752-759. 1943 sumes that surgery is innocuous. Mendeloff J: Granulomatous reaction to barium sulfate in 4. Long JM: Elective appendectomy for appen- with nonperforative appendicitis).ajronline. Ann Surg 161 :474-478. Brooks DW. Johnston DG: Appendicitis: a computer study. Kazanian KK. Br J Radiol 30:27-30. Springfield.