Pe d i a t r i c I m a g i n g • O r i g i n a l R e s e a r c h

Blumfield et al.
Ultrasound of Pediatric Appendicitis

Pediatric Imaging
Original Research

JOURNAL CLUB:
Ultrasound for Differentiation
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Between Perforated and

FOCUS ON:

Nonperforated Appendicitis
JOURNA L CLUB in Pediatric Patients
Einat Blumfield1 OBJECTIVE. Acute appendicitis is the most common condition requiring emergency
Gopi Nayak 2 surgery in children. Differentiation of perforated from nonperforated appendicitis is impor-
Ramya Srinivasan1 tant because perforated appendicitis may initially be managed conservatively whereas non-
Matthew Tadashi Muranaka3 perforated appendicitis requires immediate surgical intervention. CT has been proved ef-
Netta M. Blitman 4 fective in identifying appendiceal perforation. The purpose of this study was to determine
whether perforated and nonperforated appendicitis in children can be similarly differentiated
Anthony Blumfield5
with ultrasound.
Terry L. Levin 6 MATERIALS AND METHODS. This retrospective study included 161 consecutively
Blumfield E, Nayak G, Srinivasan R, et al. registered children from two centers who had acute appendicitis and had undergone ultra-
sound and appendectomy. Ultrasound images were reviewed for appendiceal size, appearance
of the appendiceal wall, changes in periappendiceal fat, and presence of free fluid, abscess, or
appendicolith. The surgical report served as the reference standard for determining whether
perforation was present. The specificity and sensitivity of each ultrasound finding were deter-
mined, and binary models were generated.
RESULTS. The patients included were 94 boys and 67 girls (age range, 1–20 years; mean,
11 ± 4.4 [SD] years) The appendiceal perforation rate was significantly higher in children
younger than 8 years (62.5%) compared with older children (29.5%). Sonographic findings
associated with perforation included abscess (sensitivity, 36.2%; specificity, 99%), loss of
Keywords: pediatric, perforated appendicitis, ultrasound the echogenic submucosal layer of the appendix in a child younger than 8 years (sensitivity,
100%; specificity, 72.7%), and presence of an appendicolith in a child younger than 8 years
DOI:10.2214/AJR.12.9801
(sensitivity, 68.4%; specificity, 91.7%).
Received August 17, 2012; accepted after revision CONCLUSION. Ultrasound is effective for differentiation of perforated from nonper-
October 24, 2012. forated appendicitis in children.
1
Department of Radiology, Jacobi Medical Center, Albert

Einstein College of Medicine, 1400 Pelham Pkwy S, Bronx,
NY 10461. Address correspondence to E. Blumfield
(Einat.blumfield@nbhn.net; Einat_blumfield@hotmail.com).
2
Department of Radiology, Montefiore Medical Center,
Albert Einstein College of Medicine, Bronx, NY.
3
Department of Radiology, University of Hawaii,
Honolulu, HI.
4 diate appendectomy for nonperforated appendi-
Department of Radiology, Albany Medical Center,
Albany Medical College, Scarsdale, NY.
5
Radnostics, Scarsdale, NY.
6
Department of Radiology, Children’s Hospital at
Montefiore Medical Center, Albert Einstein College of
Medicine, Bronx, NY.
AJR 2013; 200:957–962
0361–803X/13/2005–957
© American Roentgen Ray Society
A
cute appendicitis is the most com-
mon condition in children that re-
quires emergency surgery and is
one of the most common causes of
hospitalization. Perforation occurs with rates
ranging between 23% and 73% [1]. With the
trend toward conservative management of per-
forated appendicitis [2–4] as opposed to imme-
citis, differentiation between the two conditions
has become increasingly important. Because
clinical differentiation is not always possible,
clinicians often rely on imaging findings [5–8].
CT, although effective in the diagnosis of
acute appendicitis, exposes patients to ion-
izing radiation [9, 10]. CT signs suggesting
perforation include defects within the appen-
diceal wall, abscess, extraluminal air, ileus,
and the presence of an extraluminal appen-
dicolith [6–8]. Ultrasound is also effective in
diagnosing acute appendicitis [11], but there
have been few published reports of the reli-
ability of ultrasound in the diagnosis on ap-
pendiceal perforation [12, 13], and no re-
sults, to our knowledge, are current.
The imaging capabilities of ultrasound
have improved substantially. Although the
site of perforation is typically, over the last
two decades, not identified with ultrasound,
we hypothesized that the size of the appendix,
changes in the appendiceal wall, and findings
of a large amount of inflamed fat around the
appendix are associated with perforation. We
therefore undertook a retrospective study to
assess the effectiveness of ultrasound in di-
agnosing appendiceal perforation in children
and to determine which sonographic findings
or combination of findings would be most
useful in differentiating perforated from non-
perforated appendicitis. We compared the re-

AJR:200, May 2013 957

 Blumfield et al.

TABLE 1: Sonographic Findings

Finding Description
Transverse diameter of appendix Largest diameter, based on longitudinal image of the appendix (Fig. 1)
Appendicolith Present or absent (Fig. 2)
Loss of the echogenic submucosal layer Present or absent (Fig. 3)
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Presence and amount of periappendiceal echogenic fat No echogenic fat, small amount, moderate amount, or large amount (Fig. 4)a
Free fluid No free fluid, free fluid in right lower quadrant or distant free fluid (e.g., in the Morrison pouch or
in the pelvis)
Abscessb Present or absent (Fig. 5)
aSmall amount, small area of echogenic fat seen on one side of the appendix; moderate, echogenic fat surrounding the entire circumference of the appendix; large, large

amount of echogenic fat occupying a large region in the right lower quadrant or extending to the pelvis (Fig. 4).
bCollection of complex material with increased blood flow at its walls and no flow at its center in color Doppler examination.

Fig. 1—3-year-old girl with acute nonperforated
appendicitis. Ultrasound image shows measurement
of appendiceal diameter (calipers) from serosa to
serosa.
sults with results of previous studies in which
ultrasound and CT images were evaluated for
findings of perforation.
Materials and Methods
Patient Data
This retrospective study, approved by our insti-
tutional review board (informed consent waived),
included pediatric patients from two medical cen-
ters: a level 1 trauma center with a pediatric emer-
gency department and a children’s hospital. At
both centers patients were identified in the radi-
ology PACS. The medical charts were then evalu-
ated to determine which patients would be includ-
ed. Inclusion criteria were ultrasound diagnosis of
acute appendicitis, appendectomy, and patholog-
ic review of the appendix. The records of 72 pa-
tients consecutively registered at the trauma cen-
ter between November 2005 and November 2011
and of 91 patients consecutively registered at the
children’s hospital between January 2008 and July
2009 were identified. Two patients were excluded
because it was unclear from the surgical reports
whether appendiceal perforation had occurred.
Clinical data, including age, sex, and findings in sur-
gical and pathologic reports, were collected from
computerized medical charts.
Ultrasound Examinations
Ultrasound examinations were performed with
one of two scanners (HDI 5000 or IU 22, Philips
Healthcare) by certified ultrasound technologists.
The graded compression technique was used. The
diagnostic criteria for appendicitis were based on
previous reports [14, 15].
All ultrasound images were reviewed by one of
two experienced pediatric radiologists blinded to
the surgical and pathologic results. The radiolo-
gists reviewed the imaging findings detailed in Ta-
ble 1, which included transverse diameter of the
appendix (Fig. 1), presence or absence of an ap-
pendicolith (Fig. 2), evaluation of the submucosal
layer of the appendix (Fig. 3), amount of periap-
pendiceal echogenic fat (Fig. 4), and presence or
absence of an abscess (Fig. 5) or free fluid.
The surgical report served as the reference stan-
dard for determining appendiceal perforation. When
the surgical report documented perforation that was
not confirmed in the pathology report, it was as-
sumed that the pathologic specimen did not include
the site of perforation. When the pathology report
documented perforation that was not evident at sur-
gery, it was assumed that the perforation occurred
during surgery or during handling of the specimen
or that it was a microperforation (which for the pur-
pose of management would not be different from
nonperforation). In a subset of five children who
underwent delayed elective appendectomy, the di-
agnosis of perforation was based on imaging find-
ings. In these patients, ultrasound followed by CT
showed appendicitis and periappendicular abscess-
es. The patients were treated conservatively with IV
antibiotics and percutaneous drainage of abscesses.
Statistical Analysis
Data modeling was performed with Eureqa For-
mulize (Nutonian) [16] tuned to seek binary mod-
els to diagnose perforation with high specificity.
Further analysis for specificity and sensitivity of
the models and of isolated variables was performed
with Microsoft Excel software. The Pearson chi-
square test was performed to evaluate the statistical
significance of various sonographic findings and to
determine the statistical significance of the perfora-
tion rate difference between the two age groups re-
sulting from the Eureqa Formulize analysis.
Results
The study included 161 pediatric patients
(94 boys, 67 girls; age range, 1–20 years;
mean, 11 ± 4.4 [SD] years). A final diagnosis
of perforated appendicitis was made in 58 cas-
es (36.0%); 103 patients (64%) had nonperfo-
rated appendicitis. Table 2 details the distribu-
tion of age, sex, and sonographic findings in
the study group. The results of the Eureqa For-
mulize analysis showed that abscess was as-
sociated with perforation and that in children
younger than 8 years, appendicolith and loss
of the echogenic submucosal layer were inde-
pendently associated with perforation.
The sensitivity and specificity of various
sonographic findings and their statistical sig-
Fig. 2—11-year-old girl with acute perforated
appendicitis. Ultrasound image shows shadowing
appendicolith (arrow) in appendiceal lumen.

958 AJR:200, May 2013

 Ultrasound of Pediatric Appendicitis

genic fat had low sensitivity and specificity

(sensitivity, 32.8% and 73.7%; specificity,
54.9% and 45.6%).
When the presence of more than one sono-
graphic finding was evaluated, the combined
specificities and sensitivities were either neg-
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atively affected or not improved substantial-

ly compared with the separate analysis of
each finding. For example, the combination
of age younger than 8 years and appendico-
lith or loss of the echogenic submucosal layer
resulted in sensitivity of 95% and specific-
ity of 75%. The combination of age younger
than 8 years, appendicolith, and loss of the
echogenic submucosal layer resulted in sen-
A B sitivity of 68.8% and specificity of 90.9%.
Fig. 3—Submucosal echogenic layer. The perforation rate in young children was
A, 10-year-old boy with acute nonperforated appendicitis. Ultrasound image shows submucosal echogenic significantly higher than that in older chil-
layer (arrowheads) in inflamed appendix. dren. Perforation was found in 20 of 32 chil-
B, 9-year-old boy with acute perforated appendicitis. Ultrasound image shows region of normal submucosal
layer (black arrowhead) in inflamed appendix but loss of echogenic submucosal layer (white arrowheads) in
dren younger than 8 years (62.5%) while only
distal segment of appendix. 38 of 129 children 8 years and older (29.5%).
This difference was statistically significant
nificance as determined with p values are ever, the sensitivity and specificity of both (p < 0.001) perforated. The sensitivity and
detailed in Table 3. Presence of an abscess, findings increased if the child was younger specificity were 34.5% and 88.3%. Of the 38
presence of an intraluminal appendicolith, than 8 years (sensitivity, 68.4% and 100%; older children with perforation, 17 had an ab-
and loss of the echogenic submucosal layer specificity, 91.7% and 72.7%). scess at presentation (44.7%), while only 4 of
of the appendiceal wall were statistically sig- The finding of free fluid distant from the 20 (20%) younger children with perforation
nificant findings associated with appendiceal appendix (p = 0.12) and the presence of a had an abscess. Most of the patients 8 years
perforation (p < 0.001, p = 0.001, and p = large amount of echogenic fat around the ap- or older without an abscess did not have per-
0.002). Although the presence of an abscess pendix (p = 0.13) were found not to have a foration (91/112, 81.3%).
was highly specific for perforation (specific- statistically significant association with ap-
ity, 99%), the sensitivity was low (36%). The pendiceal perforation. These findings had Discussion
presence of an appendicolith and loss of the moderately high specificities (78.4% and In children with acute appendicitis, the risk
echogenic submucosal layer of the appendix 89.3%). The finding of free fluid in the right of appendiceal perforation ranges from 23% to
were neither sensitive nor specific when the lower quadrant and the presence of a small to 73% [1]. Lee et al. [17] reported that perfora-
entire study population was evaluated; how- moderate amount of periappendiceal echo- tion occurred with greater incidence in children

A B C
Fig. 4—Periappendiceal echogenic fat.
A, 17-year-old boy with acute nonperforated appendicitis. Ultrasound image shows inflamed appendix with small amount of periappendiceal echogenic fat (arrowheads)
on only one side of appendix.
B, 10-year-old girl with acute nonperforated appendicitis. Ultrasound image shows moderate amount of echogenic fat (arrowheads) encircling appendix (calipers).
C, 10-year-old boy (same patient as in Fig. 3A). Ultrasound image shows large amount of periappendiceal echogenic fat (arrowheads) encircling appendix and extending
peripherally.

AJR:200, May 2013 959

 Blumfield et al.

TABLE 2: Distribution of Age, Sex, and Sonographic Findings

Characteristic Perforated Nonperforated
No. of patients 58 103
Age (y) 9.3 ± 4.5 12 ± 4
Sex
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Girls 22 45
Boys 36 58
Appendix diameter (cm) 1.2 ± 0.36 1.1 ± 0.3
Appendicolith 31 (53) 30 (29)
Loss of echogenic submucosal layer 38 (75) 48 (47)
Patients excludeda 7 1
Amount of echogenic fat

Fig. 5—5-year-old girl with acute perforated

None 9 (16) 24 (23)
appendicitis. Ultrasound image shows outline of Small 6 (11) 23 (22)
walled-off fluid collection (calipers), internal echoes,
and foci of gas consistent with abscess. Moderate 31 (54) 45 (44)
Large 11 (19) 11 (11)
younger than 5 years and that abscess forma- Patients excludedb 1
tion at presentation occurred more commonly Free fluid
in children older than 10 years. Our results
None 28 (48) 56 (55)
concur with those in that report. We found a
significantly higher rate of perforation in chil- Right lower quadrant 11 (19) 24 (24)
dren younger than 8 years (62.5%) than in old- Distant 19 (33) 22 (22)
er children (29.5%). Similarly, older children Patients excludedc 1
had a higher incidence of abscess at presenta-
Appendix identified 54 (93) 103 (100)
tion (44.7%) than did younger children (20%).
Once the diagnosis of appendicitis is made, Abscess 21 (36) 1 (1)
differentiation of perforated from nonperfo- Patients excludedc 1
rated appendicitis becomes important. Emer- Note—Except for age and size, values are numbers of patients. Values in parentheses are percentages.
gency surgery is indicated for nonperforated aExcluded because ultrasound images were suboptimal, appendiceal walls were not adequately visualized.
bAppendix and surrounding fat not visualized.
appendicitis, whereas the initial therapy for
cUltrasound study included only images of the appendix; presence of an abscess and distant free fluid could
perforated appendicitis may be nonsurgical
not be determined.
because nonsurgical treatment has a lower
complication rate [2–4]. Thus to avoid delay
of a required surgical procedure, diagnosing statistically significant (p < 0.001, p = 0.001, a 2012 study [18] that showed an increased
perforated appendicitis with high specificity and p = 0.002). The finding of an abscess was incidence of necrosis and perforation of the
is desired. In our study, the findings of an ab- associated with perforation with high speci- appendix when an appendicolith was present.
scess, an intraluminal appendicolith, and loss ficity (99.0%) but low sensitivity (36.2%). Although loss of the echogenic submucosal
of the submucosal echogenic layer of the ap- The finding of an appendicolith in a child layer was found to be highly sensitive for per-
pendix were found to be associated with ap- younger than 8 years also had high specific- foration in young children (100%), the speci-
pendiceal perforation. These associations are ity (91.7%). This concurs with the findings of ficity was low (72.7%). Therefore we do not

TABLE 3: Sensitivity and Specificity of Sonographic Findings

Finding No. of Patients pa Sensitivity (%) Specificity (%)
Abscess 160 < 0.001 36.2 99.0
Loss of echogenic submucosal layer 153 0.001 74.5 52.9
Appendicolith 160 0.002 54.4 70.9
Free fluid distant from the appendix 160 0.12 32.8 78.4
Large amount of echogenic fat around the appendix 160 0.13 19.3 89.3
Loss of the echogenic submucosal layer and age < 8 y 28 < 0.001 100 72.7
Appendicolith and age < 8 y 31 0.14 68.4 91.7
aPearson chi-square test.

960 AJR:200, May 2013


recommend relying solely on this sonographic
finding because it can lead to false diagnosis
of perforation and delay needed surgery. The
findings of a large amount of periappendiceal
echogenic fat and of free fluid distant from the
appendix have limited diagnostic value (sen-
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sitivity, 32.8% and 19.3%; specificity, 78.4%
and 89.3%). Findings with no significant di-
agnostic value include appendix size, presence
of a small or moderate amount of periappendi-
ceal echogenic fat, and free fluid in the right
lower quadrant.
In a 1992 study by Quillin et al. [13], so-
nographic findings of perforated appendici-
tis were evaluated in 71 children. Those in-
vestigators suggested an association between
perforation of the appendix and loss of the
echogenic submucosal layer. However, the
specificity and sensitivity of this finding were
very low, in part because the appendix was not
identified in most of the patients with perfora-
tion. In our study, we identified the appendix
in 54 of 58 patients with perforated appendi-
citis and found that loss of the echogenic sub-
mucosal layer had a higher diagnostic value
in young patients. Similarly, although Quil-
lin et al. reported no association between ap-
pendicolith and perforation, our study showed
that in children younger than 8 years, the pres-
ence of an appendicolith correlated with per-
foration. In 1990, Borushok et al. [12] eval-
uated the sonographic findings of perforated
appendicitis in 100 adults and children. They
found that a combination of pericecal collec-
tions, loss of the echogenic submucosal layer
of the appendix, and prominent pericecal fat
had moderately high sensitivity (86%) but low
specificity (60%) for perforation.
The discrepancies between our study and
the previous studies may be explained by the
technologic advances in sonographic imag-
ing that have occurred since the early 1990s.
In addition, our sample size was larger and
allowed separate analysis of different pedi-
atric age groups.
We compared our results with those of
studies of the effectiveness of CT in diag-
nosing perforated appendicitis [8, 19] and
found that the sensitivities of our sonograph-
ic findings (19–100%) are comparable to
the reported CT sensitivities of various find-
ings (21–64%). Although the specificities of
our sonographic findings, ranging between
72.7% and 99%, are lower than the reported
specificities of CT findings (93–100%), the
finding of an appendicolith in a young child
and the finding of an abscess at any age had
comparable specificities (91.7% and 99%).
AJR:200, May 2013 961
Ultrasound of Pediatric Appendicitis
The limitations of our study included small
sample size of the younger age group (< 8
years, 32 patients) and omission of Doppler
findings due to inconsistent settings in this ret-
rospective study.
CT is currently the modality of choice for
differentiating perforated from nonperfo-
rated appendicitis because this differentia-
tion cannot be made accurately on a clinical
basis. Even in the group of young children
(< 8 years), who tend to experience perfora-
tion more frequently, a substantial number
presented with nonperforated appendicitis
(12/32). Our study showed that ultrasound
of children is effective in diagnosing perfo-
ration of the appendix, thus it has the poten-
tial to replace and thereby reduce the number
of CT examinations commonly performed in
this situation. The diagnosis of perforated
appendicitis can be reliably made when an
abscess is detected with ultrasound. In chil-
dren younger than 8 years, who tend to have
perforation without abscess formation, the
differentiation is more complicated. In that
age group, the findings of an appendicolith,
loss of the appendiceal echogenic submuco-
sal layer, a large amount of periappendiceal
echogenic fat, and free fluid in the Morrison
pouch or pelvis are associated with perfora-
tion in a decreasing order of significance.
Conclusion
In children, ultrasound is useful in the di-
agnosis of perforated appendicitis and should
suffice as the modality of choice whenever the
appendix is identified. The decision to perform
appendectomy or to treat a patient conserva-
tively should be made in association with clin-
ical findings. CT should be reserved for com-
plicated cases in which the appendix is not
identified or the presence or absence of perfo-
ration cannot be determined with ultrasound.
References
1. Sivit CJ. Imaging the child with right lower quad-
rant pain and suspected appendicitis: current con-
cepts. Pediatr Radiol 2004; 34:447–453
2. Oliak D, Yamini D, Udani VM, et al. Nonoperative
management of perforated appendicitis without peri-
appendiceal mass. Am J Surg 2000; 179:177–181
3. Simillis C, Symeonides P, Shorthouse AJ, Tekkis
PP. A meta-analysis comparing conservative treat-
ment versus acute appendectomy for complicated
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ate appendectomy for perforated appendicitis. J
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rated appendicitis be diagnosed preoperatively
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fecalith is associated with early perforation in pe-
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and nonperforated appendicitis: defect in enhanc-
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8. Bixby SD, Lucey BC, Soto JA, Theysohn JM,
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11. Goldin AB, Khanna P, Thapa M, McBroom JA,
Garrison MM, Parisi MT. Revised ultrasound cri-
teria for appendicitis in children improve diagnos-
tic accuracy. Pediatr Radiol 2011; 41:993–999
12. Borushok KF, Jeffrey RB Jr, Laing FC, Townsend
RR. Sonographic diagnosis of perforation in patients
with acute appendicitis. AJR 1990; 154:275–278
13. Quillin SP, Siegel MJ, Coffin CM. Acute appendi-
citis in children: value of sonography in detecting
perforation. AJR 1992; 159:1265–1268
14. Ramarajan N, Krishnamoorthi R, Barth R, et al.
An interdisciplinary initiative to reduce radiation
exposure: evaluation of appendicitis in a pediatric
emergency department with clinical assessment
supported by a staged ultrasound and computed
tomography pathway. Acad Emerg Med 2009;
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15. Kaiser S, Frenckner B, Jorulf HK. Suspected ap-
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randomized study. Radiology 2002; 223:633–638
16. Schmidt M, Lipson H. Distilling free-form natu-
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agement of pediatric appendicitis? J Pediatr Surg
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18. Azok JT, Kim DH, Munoz Del Rio A, et al. Intra-
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 APPENDIX 1: AJR Journal Club

Study Guide
Ultrasound for Differentiation Between Perforated and Nonperforated
Appendicitis in Pediatric Patients
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Alan Mautz, Margaret Mulligan, Joseph J. Budovec*

Medical College of Wisconsin, Milwaukee, WI
amautz@mcw.edu, mmulliga@mcw.edu, jbudovec@mcw.edu

Introduction
1. What is the clinical question being asked? What is the authors’ hypothesis? How would you state the alternative hypothesis?
2. What is the current reference standard for the evaluation of appendicitis in children? How sensitive, specific, and accurate is that test?

Methods
3. What were the inclusion criteria for the study? What were the exclusion criteria?
4. Does the study address potential discrepancies between surgical and pathologic findings related to perforation appropriately?
5. What are the limitations of this study? Are these limitations adequately discussed?
6. Were appropriate statistical tools used to determine the significance of the sensitivities and specificities of the imaging findings in
appendicitis?

Results
7. Were the research questions answered? Were the hypotheses resolved?
8. Was the sample size large enough to draw conclusions on the basis of patient age with respect to rates of appendiceal perforation?
9. What demographic and sonographic findings are associated with increased rates of perforation in appendicitis?

Physics
10. What is the normal sonographic appearance of the appendix? How does graded compression sonography contribute to the diagnostic test?
What is the accuracy of compression sonography in diagnosing appendicitis?

Discussion
11. At your institution, how frequently is ultrasound used as the first-line imaging modality in pediatric patients with right lower quadrant
pain? Do you recommend or plan on recommending ultrasound instead of CT for such situations in the future?
12. What is the average CT dose for pediatric patients undergoing CT for possible appendicitis at your institution? How do CT and ultrasound
compare at your institution for evaluation of appendicitis?
13. What outcomes data might augment the power of this study? Is the study designed well enough and powerful enough to evoke change in
managing pediatric patients for whom appendicitis is a concern?

Background Reading
1. Goldin AB, Khanna P, Thapa M, McBroom JA, Garrison MM, Parisi MT. Revised ultrasound criteria for appendicitis in children improve diagnostic accuracy. Ped
Radiol 2011; 41: 993–999
2. Kaise S, Frenckner B, Jorulf HK. Suspected appendicitis in children: US and CT—a prospective randomized study. Radiology 2002: 223:633–638

*Please note that the authors of the Study Guide are distinct from those of the companion article.

962 AJR:200, May 2013