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7/20/18 Acute appendicitis in children: Diagnostic imaging - UpToDate

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Acute appendicitis in children: Diagnostic imaging

Authors: George A Taylor, MD, David E Wesson, MD Section Editor: Jonathan I Singer, MD Deputy Editor: James F
Wiley, II, MD, MPH

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2018. | This topic last updated: Jul 11, 2018.

INTRODUCTION — This topic will review diagnostic imaging for acute appendicitis in children. The
epidemiology, clinical features, diagnosis, and treatment of appendicitis in children are discussed
separately. (See "Acute appendicitis in children: Clinical manifestations and diagnosis" and "Acute
appendicitis in children: Management".)

IMAGING DECISION — The decision to perform imaging in the diagnostic evaluation of children with
abdominal pain is determined by clinical findings and the setting as follows (algorithm 1):

● Low clinical likelihood of appendicitis – Imaging is not warranted in most children who are unlikely
to have appendicitis based upon the clinical examination and laboratory studies. (See "Acute
appendicitis in children: Clinical manifestations and diagnosis", section on 'Clinical suspicion'.)

● Incomplete or equivocal findings for appendicitis – For children who have atypical or equivocal
findings for appendicitis on physical examination and laboratory testing, imaging may be helpful to
establish or exclude the diagnosis. Imaging may also be needed for patients who have received
antibiotics prior to evaluation. Ultrasonography (US) and computed tomography (CT), separately or in
combination, are the modalities used most frequently although magnetic resonance imaging has similar
diagnostic accuracy as CT. (See 'Imaging approach' below and "Acute appendicitis in children: Clinical
manifestations and diagnosis", section on 'Clinical suspicion'.)

● High clinical likelihood of appendicitis – We suggest that children with a high likelihood of
appendicitis based upon clinical findings undergo evaluation by a surgeon with pediatric expertise prior
to urgent imaging studies. (See "Acute appendicitis in children: Clinical manifestations and diagnosis",
section on 'Clinical suspicion'.)

● Limited pediatric capability – In settings where operative care for children with appendicitis is not
available, resources for appropriate pediatric imaging and interpretation of radiographic findings may
also be lacking [1]. Clinicians managing children with suspected appendicitis in such facilities, whenever
possible, should avoid diagnostic imaging and instead transfer the patient to a center with pediatric
radiology and pediatric general surgery capabilities.

A systematic institutional approach to the choice of imaging is associated with improved outcomes including
increased diagnosis of appendicitis at initial presentation, reduced radiation exposure, decreased negative
appendectomy rate, and no increase in perforation rate. (See 'Clinical protocols' below.)

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7/20/18 Acute appendicitis in children: Diagnostic imaging - UpToDate

Clinical scoring systems have the potential to help with decisions regarding diagnostic imaging and limit the
use of imaging in children with a low risk of appendicitis. (See "Acute appendicitis in children: Clinical
manifestations and diagnosis", section on 'Clinical scoring systems'.)

IMAGING APPROACH — We and the American College of Radiology recommend that imaging in children
with atypical or equivocal clinical findings for appendicitis begin with ultrasonography (US) [2]. If the
appendix is not visualized or the findings on US are otherwise not diagnostic, the patient may either be
observed with serial physical examinations and repeated imaging (US, computed tomography [CT], or
magnetic resonance imaging [MRI]) performed at a later time. If a clinical diagnosis of appendicitis cannot be
made or, if more prompt diagnosis is desired, the patient may directly proceed to contrast-enhanced CT or
MRI. (See 'Techniques' below and 'Magnetic resonance imaging (MRI)' below.)

In patients whose initial ultrasound is equivocal for the diagnosis of appendicitis, repeat physical
examination and a second ultrasound in patients who have persistent findings of appendicitis has good
diagnostic accuracy and can markedly reduce the number of children undergoing CT. As an example, in a
prospective observational study of 294 children undergoing acute evaluation for abdominal pain (38 percent
with appendicitis), a pathway that utilized serial physical examination, surgical consultation, and repeat
ultrasound for patients whose initial ultrasound was equivocal; discharge for patients whose initial
ultrasound showed a normal appendix, and surgical consultation for patients with initial ultrasounds that
were positive for appendicitis achieved a sensitivity of 97 percent and a specificity of 91 percent [3]. CT was
performed in four patients.

Use of MRI instead of CT is limited to pediatric specialty centers because of issues related to cost,
availability, limited experience with interpretation, and the potential need for sedation in younger children.
(See 'Magnetic resonance imaging (MRI)' below.)

Ultrasound for initial diagnostic imaging in obese children may avoid the need for CT in a large proportion of
these patients. As an example, in a small observational study that evaluated outcomes for 76 obese children
undergoing US for suspected appendicitis, appendicitis was confirmed by US alone in 23 of 26 patients and
was excluded in 42 of 50 patients without the use of CT imaging [4]. However, given the technical limitations
of ultrasound in diagnosing appendicitis in very obese children, some clinicians may choose to perform
contrast CT or MRI as the initial imaging strategy in these patients.

If a CT is performed, we use intravenous contrast alone and begin the evaluation with a focused
examination and expand the study to include the entire abdomen if an abnormality is seen on the uppermost
image. When reviewing the images, coronal reformatted images increase the level of confidence in
identification of the normal and abnormal appendix [5]. (See 'Contrast' below and 'Focused CT' below.)

In the United States, increased use of ultrasound alone or ultrasound with CT in children’s hospitals has
been associated with lower rates of negative appendectomy without an increase in appendiceal rupture or
patients returning with a new diagnosis of appendicitis within two weeks of initial emergency department visit
[6-8].

In Israel, increased use of US for diagnosis of acute appendicitis in the emergency department significantly
decreased pediatric hospital admissions without any instance of missed appendicitis [9].

In settings with adequate experience in interpreting MRI for the presence of appendicitis and with the
resources to rapidly obtain and interpret the study, MRI may be preferable to CT. Evidence suggests that
the use of MRI is associated with similar diagnostic accuracy and negative appendectomy rates. (See
'Magnetic resonance imaging (MRI)' below.)

While we encourage radiology departments to develop expertise in US for children, we recognize that the
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respectively. and is safe [10]. longer duration of abdominal pain [22]. (See 'Pitfalls and limitations of US' below.0. in the 469 patients in whom the appendix was clearly seen [13]. and incorporation of specific thresholds for white blood cell count and proportion of polymorphonuclear cells [23] or white blood cell count alone [24]. is relatively inexpensive. primarily false-positive results).17-21]. including studies in which the appendix was not visualized.13-15. 95% CI 1. For example. However. This was demonstrated in a report of 570 consecutive patients referred for suspected appendicitis. followed by scanning of the pelvis through a full urinary bladder.0. scanning of the retrocecal area using a posterolateral approach. 95% CI 1.) Evidence suggests that emergency physicians with proper training and experience in performing bedside ultrasonography for appendicitis can achieve reasonable diagnostic accuracy in children [26]. overall sensitivities of US performed by pediatric ultrasound technicians and/or pediatric radiologists for appendicitis. ULTRASONOGRAPHY (US) — US is available in most institutions.com/contents/acute-appendicitis-in-children-diagnostic-imaging/print?search=ap… 3/28 . the diagnosis of appendicitis cannot be reliably excluded by US unless a normal appendix is seen. In pediatric patients. 13 false-negative findings) [25]. However. and scanning of the right lower quadrant resulted in identification of 68 percent of abnormal appendices [15]. Inaccurate examinations were significantly associated with high body mass index (≥85th percentile.4-4.4. When the appendix is visualized the diagnostic accuracy of ultrasound is equivalent to computed tomography [12]. Among 199 children with appendicitis.uptodate. in addition to the right lower quadrant. However. Test performance — US improves diagnostic accuracy in selected children with suspected appendicitis [11]. Factors that increase the diagnostic accuracy of US in children include operator experience [13]. ● Positional scanning – Scanning in the flank and pelvis. 28 percent of whom were less than 16 years of age [27]. respectively. accuracy depends upon the skill and experience of the sonographer.7/20/18 Acute appendicitis in children: Diagnostic imaging . Visualization of the appendix increased from 85 to 95 percent with posterior manual compression. may be useful. such as torsion or an ovarian cyst. in an observational study of 263 children. Factors that affect this variability primarily include the experience and technique of the sonographer. 4 to 17 years of age. primarily children with a high body mass index or in whom the likelihood of appendicitis based upon clinical findings is low. https://www.UpToDate availability of such expertise may be limited in some locations. with suspected appendicitis. US can result in a significant number of false-positive and false-negative results. It has the added advantage of identifying ovarian pathology. The combination of noncompressive and compressive techniques increased the identification rate to 96 percent. have varied from 74 to 100 percent and specificities have ranged from 88 to 99 percent [11. sensitivity and specificity were 98 and 92 percent. the accuracy of bedside ultrasound for appendicitis in children is operator dependent and requires a rigorous scanning protocol that results in consistent visualization of the appendix and an ongoing quality review process. primarily false-negative results) or low pretest clinical suspicion for appendicitis (odds ratio [OR] 2. In certain situations. As an example.5 and OR 2. Techniques — The following techniques may improve visualization of the appendix and permit more accurate diagnosis of appendicitis: ● Posterior compression – The addition of posterior manual compression to graded compression can help to identify the appendix. US was inaccurate in 101 examinations (88 false-positive findings. as well as the child’s body habitus. Reported visualization rates vary from 22 to 98 percent [14-16]. in a multicenter study of 965 children undergoing abdominal ultrasound for possible appendicitis.1-3.

● Pain and/or anxiety may make sonographic imaging of the abdomen difficult or impossible in some children. ● Fat absorbs and diffuses the ultrasound beam making it more difficult to scan overweight children. Therefore. a negative ultrasound examination in the presence of persistent symptoms is not sufficient to reliably exclude appendicitis. visualization of a normal appendix constitutes a normal US examination. we have seen some false-positive ultrasound reports where the diagnosis of appendicitis was based upon increased appendiceal wall thickness alone.) COMPUTED TOMOGRAPHY (CT) — Enhanced CT is a commonly used imaging modality for testing of children with possible appendicitis who have nondiagnostic findings on ultrasound although magnetic resonance imaging (MRI) is used in some institutions instead of CT in older children (eg. appendicitis. Consequently.UpToDate Pitfalls and limitations of US — There are a number of difficulties with the use of ultrasound for the diagnosis of acute appendicitis. MRI without contrast may be substituted for CT. ● It can be difficult to identify a normal appendix or one that is only focally inflamed ("tip" appendicitis). CT is also useful in establishing alternative diagnoses for abdominal pain. If further imaging is desired. and cystic fibrosis [28]. Further imaging is determined by the requesting clinician. In our practice. ● Many institutions have limited or no access to staff trained to perform ultrasound in children during all hours of operation.com/contents/acute-appendicitis-in-children-diagnostic-imaging/print?search=ap… 4/28 . even with a normal US examination. Crohn's disease. In other institutions.) CT is typically more available and less operator dependent than ultrasonography.uptodate. in one observational study of 125 https://www. clinical correlation and imaging with enhanced computed tomography (CT) or magnetic resonance imaging (MRI) may be required to exclude the diagnosis of appendicitis. How often this occurs is unknown.7/20/18 Acute appendicitis in children: Diagnostic imaging . Diagnoses that can mimic appendicitis on US include lymphoma. When the appendix is not visualized in an otherwise unremarkable pelvic examination. As an example. we typically perform contrast enhanced CT. We recommend caution in utilizing ultrasound reports as the sole criterion for diagnosis of appendicitis without other supportive clinical findings. (See 'Magnetic resonance imaging (MRI)' below. we report the study as showing no evidence of appendicitis. Sonographic findings — Ultrasound findings that support the diagnosis of appendicitis include the following (image 1 and image 2 and table 1): ● Noncompressible tubular structure in right lower quadrant ● Wall thickness of the appendix greater than 2 mm (image 3) ● Overall diameter greater than 6 mm (image 4) ● Free fluid in the right lower quadrant ● Thickening of the mesentery ● Localized tenderness with graded compression ● Presence of a calcified appendicolith (fecalith) (image 4) A small number of children with a normal appendix visualized on ultrasound may have early. or tip. In addition. (See 'Magnetic resonance imaging (MRI)' below. older than six years of age) who can cooperate with the examination.

for girls [OR 0.19.29-31].38].41-43]. respectively.11]) [44]. in 306 children with suspected appendicitis who underwent both unenhanced helical CT of the lower abdomen and intravenous contrast-enhanced CT of the entire abdomen. CT has the disadvantage of exposure to ionizing radiation [32-35]. respectively) [45].39. and careful serial examination for patients with equivocal radiographic and/or clinical findings can achieve lower rates for negative appendectomy and perforation [39. Among boys five years of age and older who underwent appendectomy.40]. and intact or ruptured ovarian cyst [29]. NAR 2 versus 18 percent. mesenteric adenitis. although girls older than 10 years of age had a higher NAR than either boys or girls 5 to 10 years old.33. Enteral contrast (rectal or oral) does not appear to improve diagnostic imaging over the use of intravenous contrast alone. CT had high sensitivity and specificity regardless of the duration of abdominal pain [22]. and delay in surgical treatment [32. Techniques — Techniques to improve the accuracy and safety of CT include the use of intravenous contrast. Contrast — We recommend that children with suspected appendicitis and nondiagnostic findings on ultrasound who proceed directly to CT undergo contrast-enhanced CT with intravenous contrast rather than no contrast. Thus. limiting the examination to a focused CT of the pelvic contents. children younger than five years of age who underwent CT had a clinically significant reduction in the negative appendectomy rate (NAR) when compared to children who did not receive a CT (NAR 5 versus 22 percent. 62 had alternative diagnoses made including ileitis or colitis suggestive of inflammatory bowel disease. [14. Limited evidence suggests that protocols emphasizing early surgical evaluation. Increased utilization of CT and improved accuracy of imaging for acute appendicitis have not contributed substantially to lower rates of negative appendectomy since the mid-1990s. In addition. for boys [OR 0. CT was associated with the greatest reduction in the NAR among young children (<5 years of age). we recommend that children with suspected appendicitis undergo contrast- enhanced CT with intravenous contrast alone rather than intravenous contrast combined with enteral (oral or rectal) contrast. CT. In one large observational study of 1810 children with suspected appendicitis. Test performance — In children. especially on an unenhanced CT [36].18]. This finding has raised concerns regarding increased exposure to ionizing radiation. and adjusting scanning parameters to achieve the lowest radiation dose possible while maintaining diagnostic accuracy. sensitivity for the diagnosis of acute appendicitis by CT ranges between 94 and 100 percent.227 children undergoing appendectomy. As an example.uptodate. respectively. selective imaging that emphasizes ultrasonography. some children have a paucity of mesenteric fat. (See 'Test performance' above.UpToDate children examined with focused CT that was negative for possible appendicitis. and the perforation rate remains as high as 33 percent [37. Diagnostic imaging also did not greatly impact the NAR in girls. respectively) with similar specificity (94 versus 96 percent. In addition. particularly in children under the age of 10 years who generally have limited mesenteric fat. in a multicenter observational study of 55. healthcare costs. which makes visualization of either a normal or an inflamed appendix more difficult.) https://www. (See 'Clinical protocols' below.22.com/contents/acute-appendicitis-in-children-diagnostic-imaging/print?search=ap… 5/28 . Intravenous contrast is helpful in identifying the appendix and adjacent structures. contrast-enhanced CT had a significantly higher pooled sensitivity for appendicitis than unenhanced CT (90 versus 66 percent. or both). Reported specificity is 93 to 100 percent.7/20/18 Acute appendicitis in children: Diagnostic imaging . the NAR was 1 percent and was not significantly different for those boys who had advanced diagnostic imaging (ultrasound.) The benefit of CT for appendicitis in children may also vary according to patient age and gender. For example.

these reactions are rare in children. thus increasing radiation exposure. https://www. All of the abnormal findings leading to a diagnosis of appendicitis were located below the lower pole of the right kidney (RLP). if a child with suspected appendicitis has equivocal or negative findings on an unenhanced CT. Oral contrast delays scanning for approximately two hours. and contraindicated in patients with intestinal perforation. and 53 percent of studies were performed without an adjustment in pitch. observational studies suggest that rectal or oral contrast does not further improve test performance over intravenous contrast CT alone [47-49]. However. iodixanol [Visipaque]) and in children with asthma. there was no difference between the sensitivity and specificity for CT of the entire abdomen compared with CT below the RLP. ensuring control of symptoms before the procedure. does not appear in the terminal ileum in up to 30 percent of patients at the time of CT scan.46].52-55]. difficult to administer in patients with diarrhea. The risk of contrast-induced immediate hypersensitivity can be reduced by using low osmolal contrast material agents (eg. Radiation dose can also be significantly reduced by increasing pitch. such as the tube current setting (in milliamperes) and pitch (table speed). Rectal contrast administration is uncomfortable. and may require nasogastric tube placement for proper administration [48]. Support for this approach was demonstrated in a retrospective review of 93 abdominal CT scans obtained with oral and IV contrast in children with suspected appendicitis [51]. The scan can be expanded to include the upper abdomen if an abnormality is found on the initial uppermost image [50]. One report described the scanning parameters used for body CT examinations that had been obtained at referring hospitals and were then sent to a children's hospital for further review [58].UpToDate In addition. chemotoxicity. CT scanning parameters — CT scanning parameters. (See "Immediate hypersensitivity reactions to radiocontrast media: Clinical manifestations.) Furthermore. Intravenous contrast can cause hypersensitivity reactions. Mean tube current settings exceeded weight-based recommendations in all age groups. and treatment". diagnosis. Important information on opportunities to reduce radiation dose during CT imaging in children can be found on the “Image Gently” website [59]. and renal failure. section on 'Primary prevention of IHRs'.7/20/18 Acute appendicitis in children: Diagnostic imaging .31. However.) Focused CT — A CT scan limited to the lower abdomen may be sufficient to diagnose appendicitis. and treatment". section on 'Epidemiology' and "Immediate hypersensitivity reactions to radiocontrast media: Clinical manifestations. In addition. should be adjusted based upon patient weight or girth to reduce radiation dose [35. while exposing the child to less radiation. iterative reconstruction techniques have been shown to reduce radiation dosage by 45 to 46 percent compared with traditional weight-based protocols while maintaining diagnostic accuracy [57].com/contents/acute-appendicitis-in-children-diagnostic-imaging/print?search=ap… 6/28 . Some experts advocate scanning from the bottom of the third lumbar vertebral body to the pubic ramus. Pitfalls and limitations of CT — There are several limitations to the use of CT for the diagnosis of appendicitis [46]. enteral contrast administration presents several challenges. then frequently the study is repeated with contrast. Awareness of these recommendations may not be widespread. diagnosis. Weight-based reductions in tube current have been recommended [56]. Contrast has also been given enterally (rectal or oral). to opacify and distend the cecum in an attempt to improve visualization of the inflamed appendiceal wall or mesentery [14. (See 'Test performance' above.uptodate. In addition. however.

In another observational study not included in the metaanalysis and retrospectively analyzing 662 children https://www. the appendix is frequently best visualized in the coronal plane [49].com/contents/acute-appendicitis-in-children-diagnostic-imaging/print?search=ap… 7/28 . Findings on CT that support the diagnosis of appendicitis include (image 5 and table 2): ● Wall thickness greater than 2 mm ● Appendicolith (fecalith) (image 6 and image 7) ● Enlargement of the appendix (image 8) ● Concentric thickening of the appendiceal wall (target sign) ● Phlegmon ● Abscess (image 8) ● Free fluid ● Thickening of the mesentery. In three of the studies included in the metaanalysis. total median time from request to radiology report was 123 minutes [62].7/20/18 Acute appendicitis in children: Diagnostic imaging .uptodate. the pooled sensitivity was 96 percent (95% CI: 95 to 97 percent) and the pooled specificity was 96 percent (95% CI: 94 to 98 percent) [60].UpToDate ● Scanning performed in institutions not familiar with pediatric protocols may result in excessive radiation. Reported techniques included MRI without contrast using four sequence axial and coronal T2 and coronal inversion recovery sequences [62] and contrast- enhanced MRI [63]. ● A Meckel's diverticulum can be misinterpreted as an enlarged appendix. imaging time was reported with median or mean imaging times <20 minutes [62-64]. A separate metaanalysis of 11 studies had similar findings [61].) ● A normal appendix is more difficult to visualize in children with less intraperitoneal fat. MAGNETIC RESONANCE IMAGING (MRI) — In settings with adequate experience in interpreting MRI for the presence of appendicitis and with the resources to rapidly obtain and interpret the study. ● Patients with cystic fibrosis may have a markedly enlarged appendix filled with mucus or stool without acute appendicitis. ● A fluid-filled loop of small bowel may be misinterpreted as an inflamed appendix. (See 'CT scanning parameters' above. When multiplanar reformations are performed. MRI may be preferable to computed tomography (CT) when results of abdominal ultrasound are not diagnostic. fat stranding Other pathological processes that involve the appendix and can look like acute appendicitis on imaging studies include the following: ● Crohn's disease and lymphoma may be indistinguishable from appendicitis on CT. ● An appendicolith can be obscured by intestinal contrast. Evidence suggests that MRI without contrast can provide similar diagnostic accuracy as CT without radiation exposure or excessive time delay (image 9). In one of these studies. CT findings — The diagnosis of appendicitis is unlikely if the appendix is not identified as a separate structure on CT and there are no additional signs of inflammation in surrounding structures. For example in a metaanalysis of eight studies that evaluated diagnostic accuracy of MRI for appendicitis in children.

easy-to- read materials. Evidence also suggests a role for magnetic resonance imaging (MRI) in patients who can cooperate with the study [62].5 percent [66].5 percent). SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. such as a fecalith. and they answer the four or five key questions a patient might have about a given condition. However. in two of the above studies. ultrasound as the initial diagnostic imaging test.68]. missed appendicitis after protocol implementation was 0. such as the availability of US. However. Sensitivity and specificity for the diagnosis of appendicitis was high in two of these studies (sensitivity 98. and institutional resources. Of note. PLAIN RADIOGRAPHS — Plain radiographs of the abdomen are primarily indicated in children with suspected appendicitis to confirm a clinical suspicion of bowel obstruction or perforation [65]. more sophisticated.7/20/18 Acute appendicitis in children: Diagnostic imaging .5 percent [41]. Clinicians must apply clinical correlation to imaging results. However.4 to 2. and more detailed. or suggest an alternative diagnosis. Both ultrasonography (US) and computed tomography (CT) are valuable modalities for imaging in children with suspected appendicitis. these studies suggest that MRI with or without contrast may be a suitable alternative to CT in children with suspected appendicitis when it can be obtained in a timely fashion and properly interpreted.com/contents/acute-appendicitis-in-children-diagnostic-imaging/print?search=ap… 8/28 . Time to antibiotics or operation was not different between the groups. or MRI and the expertise of the staff [50]. clinicians may be reluctant to use a protocol that includes modalities that are frequently unavailable or cannot be interpreted with confidence. the time to definitive imaging (CT or MRI) was long for both modalities (7 to 11 hours for CT and 9 to 13 hours for MRI). Observational studies that have evaluated outcomes before and after implementation of imaging protocols show decreased CT utilization of approximately 50 to 60 percent [66-68].68]. In one study. adherence to the protocol ranged from approximately 46 to 57 percent [66. specificity 91 to 94 percent) without an increase in negative appendectomies [66. CLINICAL PROTOCOLS — Institutions should develop imaging protocols that they can utilize effectively. MRI is not always definitive. plain films are of little value and should not be routinely performed. The choice of study in any given clinical situation depends upon patient characteristics.uptodate. (See "Society guideline links: Appendicitis in children".) INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials. Imaging protocols for the diagnosis of appendicitis in children can result in a significant decrease in radiation exposure without sacrificing diagnostic accuracy or clinical outcomes. When MRI was used instead of CT. respectively) with a negative appendectomy rate of 1. Otherwise. at the 5th to 6th grade reading level.UpToDate older than six years of age who were evaluated for abdominal pain before and after the adoption of a new imaging algorithm for appendicitis. such as obesity and gender. "The Basics" and "Beyond the Basics. Plain films may occasionally show secondary signs in acute appendicitis. and/or clinical evaluation by a surgeon to guide patient management decisions. ultrasound (US) followed by MRI for patients with nondiagnostic US results had a sensitivity of 100 percent and a specificity of 99 percent in 397 patients (prevalence of appendicitis 41 percent) which was similar to the findings in the 265 patients who had oral and IV contrast CT as the primary mode of imaging [41]. These protocols emphasize the use of clinical scoring systems. Beyond the Basics patient education pieces are longer. CT. like CT. Taken together. achieving high rates of compliance can be difficult. These articles are written at the 10th to 12th grade reading level and are best for patients who want https://www.6 to 99 percent. Negative appendectomy rates were low in both groups (1. For example. sensitivity and specificity was also high (100 percent and 99 percent." The Basics patient education pieces are written in plain language. even in settings where multidisciplinary protocols have been developed. These articles are best for patients who want a general overview and who prefer short. such as basilar pneumonia (table 3).

we recommend that children undergo contrast-enhanced CT with intravenous contrast rather than no contrast. (See 'Imaging approach' above. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.) ● US is particularly useful in peri.) ● Imaging can assist in the evaluation of children with atypical or equivocal clinical findings for appendicitis (algorithm 1). We suggest that children with a high likelihood of appendicitis based upon clinical findings undergo evaluation by a surgeon with pediatric expertise prior to urgent imaging studies. section on 'Imaging'. (See 'Ultrasonography (US)' above. ● If CT is performed. It is less reliable in obese children because fat absorbs and diffuses the ultrasound beam. transfer of children with possible appendicitis to a center with pediatric radiology and pediatric general surgery capabilities should occur whenever possible.) ● When using CT in children with possible appendicitis. we recommend that radiation doses be adjusted as much as possible without compromising the accuracy of the study. we suggest that these children undergo contrast- enhanced CT with intravenous contrast alone rather than intravenous contrast combined with enteral (oral or rectal) contrast. In settings where pediatric resources to perform and interpret imaging is not available.) ● We and the American College of Radiology recommend that imaging in children with atypical or equivocal clinical findings for appendicitis begin with ultrasonography (US). In addition. contrast-enhanced computed tomography [CT]. options include (see 'Imaging approach' above): • Observation with serial physical examinations and repeated imaging (US. If the appendix is not visualized or the findings on US are otherwise not diagnostic.UpToDate in-depth information and are comfortable with some medical jargon. (See 'Focused CT' above and 'CT scanning parameters' above. • The patient may directly proceed to contrast-enhanced CT or MRI if a more prompt diagnosis is desired.) ● MRI with or without contrast can provide similar diagnostic accuracy as CT without radiation exposure or excessive time delay (image 9) and may be preferred in settings with adequate experience in https://www.) ● A normal appendix must be seen on US in order to reliably exclude appendicitis in a patient with persistent symptoms.and postpubertal females to identify alternative gynecologic diagnoses. (See 'Sonographic findings' above.7/20/18 Acute appendicitis in children: Diagnostic imaging . We encourage you to print or e-mail these topics to your patients.com/contents/acute-appendicitis-in-children-diagnostic-imaging/print?search=ap… 9/28 . (See 'Contrast' above. US findings that support the diagnosis of appendicitis are summarized in the table (table 1 and image 1 and image 2). (See 'Imaging decision' above and "Acute appendicitis in children: Clinical manifestations and diagnosis".) ● Basics topics (see "Patient education: Appendicitis in adults (The Basics)" and "Patient education: Appendicitis in children (The Basics)") SUMMARY AND RECOMMENDATIONS ● Children with clinical findings that do not suggest appendicitis should not undergo imaging. such as ovarian cyst or ovarian torsion. or magnetic resonance imaging [MRI]) performed at a later time if a clinical diagnosis of appendicitis cannot be made.uptodate. Here are the patient education articles that are relevant to this topic.

Advanced radiologic imaging for pediatric appendicitis. JAMA Pediatr 2015. Harris JP.org/~/media/ACR/Documents/AppCriteria/Diagnostic/Ri ghtLowerQuadrantPainSuspectedAppendicitis. 235:879. et al. Dayan PS.7/20/18 Acute appendicitis in children: Diagnostic imaging . Acad Emerg Med 2018. 10. Effect of Reduction in the Use of Computed Tomography on Clinical Outcomes of Appendicitis. Schuh S. Properties of serial ultrasound clinical diagnostic pathway in suspected appendicitis and related computed tomography use. The impact of early sonographic evaluation on hospital admissions of children with suspected acute appendicitis. (See 'Plain radiographs' above. Such protocols have been associated with increased diagnosis of appendicitis at initial presentation. and no increase in perforation rate. Paulson EK.uptodate. Variant 4: Fever. Right lower quadrant pain . Gutermacher M.acr. J Pediatr Surg 2001. reduced radiation exposure. Acute appendicitis: added diagnostic value of coronal reformations from isotropic voxels at multi-detector row CT.UpToDate interpreting MRI for the presence of appendicitis and with the resources to rapidly obtain and interpret the study. 169:755. 160:1034. 13. 18:167. Buklan G. Radiology 2005. http://www. Campaigns Against Ionizing Radiation and Changed Practice Patterns for Imaging Use in Pediatric Appendicitis. 169:720. Economic Analysis of Diagnostic Imaging in Pediatric Patients With Suspected Appendicitis. Pediatr Surg Int 2011. American Academy of Pediatrics. Acad Emerg Med 2013. 20:697. Pediatr Radiol 2017. 5. Pediatrics 2014. Mittal MK. Clinical outcomes in obese and normal-weight children undergoing ultrasound for suspected appendicitis. Langer JC. et al. 6. 8. Dudley NC. Sulowski C. 47:186. et al. plain films are of little value and should not be routinely performed. Langer JC. computed tomography or magnetic resonance imaging - which is preferred for acute appendicitis in children? A Meta-analysis. Monuteaux MC. Acad Emerg Med 2011. Performance of ultrasound in the diagnosis of appendicitis in children in a multicenter cohort. Munden M.com/contents/acute-appendicitis-in-children-diagnostic-imaging/print?search=ap… 10/28 . et al. 9. Acad Emerg Med 2015. American Co llege of Radiology (ACR). Macias CG.suspected appendictis. The impact of ultrasound examinations on the management of children with suspected appendicitis: a 3-year analysis. Kharbanda AB. Bachur RG. Doria AS. Referral to pediatric surgical specialists. leukocytosis. https://www. possible appendiciti s. 7. Vainrib M. Bachur RG. Dilley A. decreased negative appendectomy rate. (See 'Clinical protocols' above. Kotagal M. atypical presentation in children (younger than age 14). et al. Callahan MJ. Hennelly K. 2014). Ultrasound.) ● Institutions should develop imaging protocols that they can utilize effectively. et al.) ● Plain radiographs of the abdomen are primarily indicated in children with suspected appendicitis to confirm a clinical suspicion of bowel obstruction or perforation. et al. JAMA Pediatr 2015. 4. REFERENCES 1. Wesson D. Jaffe TA. 2. Klein MD. Goldin AB. Chan K. J Pediatr 2012. Christensen EW.pdf (Accessed on April 15. Richards MK. 133:350.) Use of UpToDate is subject to the Subscription and License Agreement. et al. Chen J. 22:406. Zhang H. 3. Levy JA. 27:981. 12. 2013. Otherwise. 11. ACR Appropriateness Criteria. et al. Surgical Advisory Panel. Liao M. 2005-2009: trends and outcomes. 36:303. (See 'Magnetic resonance imaging (MRI)' above. Callahan MJ.

https://www. The non-diagnostic ultrasound in appendicitis: is a non-visualized appendix the same as a negative study? J Pediatr Surg 2015. Moineddin R.UpToDate 14. Thapa M. Thapa P. 18. Elliston C. Accuracy of Point-of-care Ultrasonography for Diagnosing Acute Appendicitis: A Systematic Review and Meta-analysis. Cohen B. Davis J. Lebecque P. 29. Schuh S. 23. Brenner D. Penney MW. Development and validation of an ultrasound scoring system for children with suspected acute appendicitis. Jeong YK. J Am Coll Surg 2015.com/contents/acute-appendicitis-in-children-diagnostic-imaging/print?search=ap… 11/28 . 27. J Pediatr Surg 2016. Bachur RG. 178:863. Klig JE. Accuracy of noncompressive sonography of children with appendicitis according to the potential positions of the appendix. Pediatric appendiceal ultrasound: accuracy. AJR Am J Roentgenol 2002. US or CT for Diagnosis of Appendicitis in Children and Adults? A Meta-Analysis. Alsup C. 16. Baldisserotto M. Evaluation of suspected appendicitis in children using limited helical CT and colonic contrast material. et al. 24. Anandalwar SP. Berdon W. Gent R. 220:1010. Estimated risks of radiation-induced fatal cancer from pediatric CT. et al. Outer diameter of the vermiform appendix: not a valid sonographic criterion for acute appendicitis in patients with cystic fibrosis. Bowling J. Pediatr Radiol 2015. Stallion A. Dayan PS. Sivit CJ. Orth RC. AJR Am J Roentgenol 2005. 21. Issues of computerized tomography scans in children and implications for emergency care. 93:405. AJR Am J Roentgenol 2001. 15. 32. 30. Clapuyt P. Unsdorfer KM. et al. et al. Cheng A. Kraus SJ. 50:923. Doria AS. 176:37. 184:1901. et al. Ann Emerg Med 2012. Guillerman RP. Marchiori E. 175:1387. et al. 25. Matthew Fields J. 175:977. Bachur RG. Kircher MF. et al. Garcia Peña BM. Pediatr Radiol 2011. Menten R. determinacy and clinical outcomes. et al. et al. Ryan DP. Mandl KD. Lowe LH. Frauenfelder C. et al. Ann R Coll Surg Engl 2011. Sprigg A. 31. Binkovitz LA. Radiology 2006. Lee JH. et al. 26. Goldin AB. Saint-Martin C. JAMA 1999. 176:31. J Pediatr 2011. et al. AJR Am J Roentgenol 2000. Predictors of non-diagnostic ultrasound scanning in children with suspected appendicitis. 241:83. Lansdale N. et al. Bajaj L. Pediatr Radiol 2015. AJR Am J Roentgenol 2001. Cundy TP. AJR Am J Roentgenol 2001. Acad Emerg Med 2017. 158:112. The effect of abdominal pain duration on the accuracy of diagnostic imaging for pediatric appendicitis. Kellenberger CJ. 45:1934. Midulla P. et al. 41:993. Use of White Blood Cell Count and Polymorphonuclear Leukocyte Differential to Improve the Predictive Value of Ultrasound for Suspected Appendicitis in Children. Man C. Khanna P. Unenhanced limited CT of the abdomen in the diagnosis of appendicitis in children: comparison with sonography.7/20/18 Acute appendicitis in children: Diagnostic imaging . Ultrasonography aids decision-making in children with abdominal pain. AJR Am J Roentgenol 2000. Revised ultrasound criteria for appendicitis in children improve diagnostic accuracy. Graded compression sonography with adjuvant use of a posterior manual compression technique in the sonographic diagnosis of acute appendicitis. 282:1041. et al. Ultrasonography and limited computed tomography in the diagnosis and management of appendicitis in children. 19. 33. 20. Hwang JC. Fallon SC. 60:582. 176:289. Stein SM. Imaging evaluation of suspected appendicitis in a pediatric population: effectiveness of sonography versus CT. Callahan MJ. 17. 45:1945. et al. Mullins ME. 22. Scammell S. Hall E. 51:1939.uptodate. 24:1124. 28. Benchmarking the value of ultrasound for acute appendicitis in children. Applegate KE.

Pediatrics 2007. N Engl J Med 2007. Brody AS. Pediatr Emerg Care 2015. et al. https://www. Frush DP. 44. The influence of advanced radiographic imaging on the treatment of pediatric appendicitis. Aspelund G. 176:497. et al. J Pediatr Surg 2005. Radiology 2001. Pediatrics 2014. Servaes S. Fingeret A. Smith A. 113:29. Pediatrics 2012. Rohrer JE. Minimizing radiation dose for pediatric body applications of single-detector helical CT: strategies at a large Children's Hospital. Jorulf HK. Phillips JD. 45. Taylor GA. Pediatrics 2004. J Am Coll Surg 2006. Pinkney LP. Ultrasonography/MRI versus CT for diagnosing appendicitis. Angel CA. Taylor GA. Suspected appendicitis in children: focused CT technique for evaluation. Eur Radiol 2004. 220:691. 50. et al. et al.com/contents/acute-appendicitis-in-children-diagnostic-imaging/print?search=ap… 12/28 . Radiology 2007. Hall EJ. Monnin P. et al. Grayson DE. Radiation risk to children from computed tomography. CT diagnosis of appendicitis in children: comparison of orthogonal planes and assessment of contrast opacification of the appendix. 129:877. Janik JS. 37. von Allmen D.uptodate. Rodriguez DP. Aguayo P. 35:392. 231:427. Laituri CA. 36. 31:161. York D. AJR Am J Roentgenol 2001. Diagnostic imaging and negative appendectomy rates in children: effects of age and gender. Keesling CA. Swischuk LE. Suspected appendicitis in children: in search of the single best diagnostic test. Love CL. Taylor GA. Roche KJ. 51. Kaiser S. 34. 243:520. Partrick DA. Srinivasan A. The lack of efficacy for oral contrast in the diagnosis of appendicitis by computed tomography. et al. Gross E. 43. Hennelly K. et al. 53. Callahan MJ. Kosloske AM. Kharbanda AB. 231:293. 48. 52. Suspected appendicitis in children: rectal and intravenous contrast-enhanced versus intravenous contrast-enhanced CT. 170:100. et al. Management of patient dose and image noise in routine pediatric CT abdominal examinations. Verdun FR. J Pediatr Surg 2003. 357:2277. J Surg Res 2011. CT of appendicitis in children. Dalrymple NC. Brenner DJ. Lepori D. Radiology 2004. 35. Radiology 2002. Pediatr Radiol 2005. Bachur RG. 46. Suspected appendicitis in children: diagnosis with contrast- enhanced versus nonenhanced Helical CT. Callahan MJ. Caniano DA. 39. 133:586. Rivera L. 49. Increased CT scan utilization does not improve the diagnostic accuracy of appendicitis in children. 40:1908. 176:303. 42. et al. et al. Bachur RG. Appendiceal CT in pediatric patients: relationship of visualization to amount of peritoneal fat. Martin AE. Hernandez JA. Antevil JL. Langenberg BJ. Vollman D. 40. Radiology 2004. AJR Am J Roentgenol 2001. et al. Pena A. Fefferman NR. The diagnosis of appendicitis in children: outcomes of a strategy based on pediatric surgical evaluation.UpToDate Curr Opin Pediatr 2006. et al. 203:849. Finnbogason T. Huda W. 38:659. et al. Adler B. Emery KH. 120:677. 39:886.7/20/18 Acute appendicitis in children: Diagnostic imaging . Imaging of acute appendicitis: US as the primary imaging modality. Wettlaufer JR. CT scans may not reduce the negative appendectomy rate in children. 18:231. Fraser JD. 47. Janik JE. 38. 14:835. Donnelly LF. 224:325. Brody AS. Computed tomography--an increasing source of radiation exposure. J Pediatr Surg 2004. Computed tomography-based clinical diagnostic pathway for acute appendicitis: prospective validation. 41.

29:568. AJR Am J Roentgenol 2016. Arif-Tiwari H. http://spr. Krishnamoorthi R. CT..com/associations/5364/ig/ (Accessed on March 21. 65.affiniscape. Pediatr Radiol 2012. Moore MM. Kulaylat AN. Russell WS. 64. 176:297.UpToDate 54. 68. et al. 58. 57. Vajtai PL. 46:928. et al. et al. Moore MA. 206:508. Frush DP. 59. Pediatr Emerg Care 2013. 194:1611.0 https://www. and number of prior studies. Radiation. 61. Wang NE. Patient size measured on CT images as a function of age at a tertiary care children's hospital. 56. Ultrafast 3-T MRI in the evaluation of children with acute lower abdominal pain for the detection of appendicitis. Pediatr Radiol 2015. Koning JL.uptodate. Ann Surg 2016. Plain abdominal radiographs and acute abdominal pain. Schuh AM. Kruk PG. Duke E. Zurakowski D. Gustas CN. 198:1424. 44:948. Computed Tomography Utilization for the Diagnosis of Acute Appendicitis in Children Decreases With a Diagnostic Algorithm. 55. Choudhary AK. clinical indication. Sinclair KA. Helical CT of the body: are settings adjusted for pediatric patients? AJR Am J Roentgenol 2001. 259:231. et al.com/contents/acute-appendicitis-in-children-diagnostic-imaging/print?search=ap… 13/28 . Paterson A. Ramarajan N.. it's complicated. Theut SB. et al. Br J Surg 1988. 75:554. Moore MM. Iterative reconstruction technique with reduced volume CT dose index: diagnostic accuracy in pediatric acute appendicitis. and children: the simple answer is . 67. Andrews T. Filippi CG. Diagnostic performance of contrast-enhanced MR for acute appendicitis and alternative causes of abdominal pain in children. et al. Radiology 2009. 62. Hill JG. et al. Shah SR. Singh S. Strauss KJ. Johnson AK. 60. 264:474. AJR Am J Roentgenol 2010. et al. Frush DP. et al. 252:200. 42:1056. Donnelly LF. A Systematic Review and Meta-Analysis of Diagnostic Performance of MRI for Evaluation of Acute Appendicitis. Didier RA. Clinical practice guidelines for pediatric appendicitis evaluation can decrease computed tomography utilization while maintaining diagnostic accuracy. 66. 252:4. Hollenbeak CS. Kalb B. AJR Am J Roentgenol 2012. Hopkins KL. Radiology 2009. Magnetic resonance imaging in pediatric appendicitis: a systematic review. Pediatr Radiol 2016. MRI for clinically suspected pediatric appendicitis: an implemented program. Topic 6478 Version 39. 2012). Gunn AA. Radiology 2011. Pediatr Radiol 2014. Effectiveness of a staged US and CT protocol for the diagnosis of pediatric appendicitis: reducing radiation exposure in the age of ALARA. 63. 45:181. Campbell JP. Dose reduction and compliance with pediatric CT protocols adapted to patient size. Naheedy JH. Kalra MK. Kleinman PL.7/20/18 Acute appendicitis in children: Diagnostic imaging .

UpToDate GRAPHICS Diagnostic approach to pediatric appendicitis PAS: Pediatric Appendicitis Score. C RP: C -reative protein. ¶ For components of the pediatric appendicitis score refer to UpToDate graphics on pediatric appendicitis score and to https://www. RLQ: right lower quadrant. * C lassic signs of early appendicitis consist of abdominal pain for less than two days that begins periumbilically and then begins to radiate and localize to the right lower quadrant. and low grade fever.uptodate. WBC : white blood cell count. RLQ tenderness is present on physical examination and the white blood cell count.7/20/18 Acute appendicitis in children: Diagnostic imaging . The pain is associated with anorexia.com/contents/acute-appendicitis-in-children-diagnostic-imaging/print?search=ap… 14/28 . and/or c-reactive protein are elevated. absolute neutrophil count. vomiting. ANC : absolute neutrophil count.

UpToDate the UpToDate topic on clinical manifestations and diagnosis of appendicitis in children. Δ Diagnostic imaging prior to surgical consultation is typically performed for these patients.com/contents/acute-appendicitis-in-children-diagnostic-imaging/print?search=ap… 15/28 . Graphic 96236 Version 3. If local resources are insufficient to adequately perform or interpret pediatric diagnostic imaging or if surgeons with pediatric expertise are not available.7/20/18 Acute appendicitis in children: Diagnostic imaging .uptodate. For specific discussion of which imaging tests to order. refer to UpToDate topics on diagnostic imaging in pediatric appendicitis.0 https://www. the patient should be transferred to a facility with pediatric radiologic and surgical capability and no imaging should be performed at the local institution.

com/contents/acute-appendicitis-in-children-diagnostic-imaging/print?search=ap… 16/28 . Graphic 52767 Version 7. leucocytosis and acute right lower quadrant pain show an enlarged (8 mm).UpToDate Ultrasound of appendicitis in a child Saggital (A) and transverse (B) ultrasound images of the right lower quadrant in a four-year-old boy with fever.uptodate. edematous mesenteric fat (arrows).0 https://www.7/20/18 Acute appendicitis in children: Diagnostic imaging . blind ending tubular structure surrounded by brightly echogenic. Courtesy of George A Taylor. fluid filled. MD.

0 https://www. MD.UpToDate Ultrasound acute appendicitis Acute appendicitis. Diagnosis was surgically confirmed. Graphic 56139 Version 6.uptodate. Image from an abdominal ultrasound with Doppler shows a thickened appendix (calipers) with hypervascular wall. Courtesy of Christoph F Dietrich.7/20/18 Acute appendicitis in children: Diagnostic imaging .com/contents/acute-appendicitis-in-children-diagnostic-imaging/print?search=ap… 17/28 .

uptodate.com/contents/acute-appendicitis-in-children-diagnostic-imaging/print?search=ap… 18/28 .7/20/18 Acute appendicitis in children: Diagnostic imaging .UpToDate Ultrasonographic signs of acute appendicitis Non-compressible tubular structure in the right lower quadrant Wall thickness >2 mm Overall diameter >6 mm Free fluid in the right lower quadrant Thickening of the mesentery Localized tenderness with graded compression Presence of a calcified appendicolith Graphic 61146 Version 2.0 https://www.

MD.7/20/18 Acute appendicitis in children: Diagnostic imaging .com/contents/acute-appendicitis-in-children-diagnostic-imaging/print?search=ap… 19/28 .uptodate. arrow). Transverse US image of the appendix (B) shows a fluid-filled. Sagittal power Doppler US image of the appendix (A) shows a markedly hyperemic appendix.UpToDate Ultrasound of a hyperemic appendix with a thickened wall Acute appendicitis: 17-year-old female with RLQ pain.0 https://www. Note echogenic. appendix with thickened wall (4 mm. Courtesy of George Taylor. surrounding fat consistent with peri-appendiceal inflammation. Graphic 95531 Version 1.

UpToDate Ultrasound of pediatric appendicitis with fecalith Six-year-old girl with RLQ pain. Image A shows a dilated. fluid filled. with a localized peri-appendiceal fluid collection.7/20/18 Acute appendicitis in children: Diagnostic imaging .0 https://www. non-compressible appendix measuring 8 mm in diameter.com/contents/acute-appendicitis-in-children-diagnostic-imaging/print?search=ap… 20/28 . Courtesy of George Taylor.uptodate. Graphic 95529 Version 1. Image B shows a calcified fecalith immediately adjacent to the perforated appendix (cross hatches). MD. The echogenic mucosa is discontinuous (arrow) at the site of perforation.

0 https://www. abnormally enhancing appendix and associated mesenteric inflamation to the left of midline (arrow). fever. Courtesy of George A Taylor.com/contents/acute-appendicitis-in-children-diagnostic-imaging/print?search=ap… 21/28 . MD.uptodate.UpToDate Computed tomography of appendicitis in a child CT of the pelvis following administration of intravenous contrast material in an 8- year-old boy with midline pelvic pain.7/20/18 Acute appendicitis in children: Diagnostic imaging . and leucocytosis shows an enlarged. Graphic 70709 Version 2. fluid filled.

7/20/18 Acute appendicitis in children: Diagnostic imaging .UpToDate Computed tomography signs of acute appendicitis Wall thickness >2 mm Appendicolith Enlargement of the appendix Target sign (concentric thickening of the appendiceal wall) Phlegmon Abscess Free fluid Thickening of the mesentery.uptodate. fat stranding (peri-appendiceal inflammation) Graphic 58384 Version 2.0 https://www.com/contents/acute-appendicitis-in-children-diagnostic-imaging/print?search=ap… 22/28 .

com/contents/acute-appendicitis-in-children-diagnostic-imaging/print?search=ap… 23/28 .UpToDate Abdominal computed tomography showing a peri-appendiceal abscess and fecalith A 13-year-old boy with peri-appendiceal abscess and fecalith. Graphic 95532 Version 1. Contrast-enhanced CT scan through the pelvis shows a large calcified fecalith (arrow) within a large inflammatory mass.0 https://www. MD.uptodate.7/20/18 Acute appendicitis in children: Diagnostic imaging . Courtesy of George Taylor.

Axial (A) and coronal reconstructed (B) CT scans show a large calcified fecalith (arrows) at the base of a dilated.0 https://www.uptodate. C T: computed tomography. Note moderate small bowel dilatation and focal mesenteric edema (dashed arrow).com/contents/acute-appendicitis-in-children-diagnostic-imaging/print?search=ap… 24/28 .7/20/18 Acute appendicitis in children: Diagnostic imaging .UpToDate Appendicitis with fecalith on computed tomography A 17-year-old-male. Courtesy of George Taylor. MD. Graphic 95536 Version 2. fluid filled appendix (arrowhead).

UpToDate Appendicitis on coronal computed tomography (A) Retrocecal appendicitis. Coronal CT reconstruction (A) shows a large.0 https://www. A six-year-old male. Note localized adenopathy (arrowhead).uptodate. Graphic 95534 Version 2. C T: computed tomography. retrocecal location (arrow). Coronal CT reconstruction (B) shows perforated.com/contents/acute-appendicitis-in-children-diagnostic-imaging/print?search=ap… 25/28 . Arrow denotes location of perforation. fluid-filled. fluid-filled appendix in sub-hepatic. appendix with multiloculated pelvic abscess. Courtesy of George Taylor. MD.7/20/18 Acute appendicitis in children: Diagnostic imaging . (B) An 11-year-old female.

These are noncontrast T-2 images obtained from a three Tesla magnet.7/20/18 Acute appendicitis in children: Diagnostic imaging . Courtesy of George A Taylor. MD.UpToDate Axial and coronal magnetic resonance images showing appendicitis in a child The axial (A) and coronal (B) images show an enlarged and inflamed appendix (arrows). Graphic 86410 Version 1.0 https://www.com/contents/acute-appendicitis-in-children-diagnostic-imaging/print?search=ap… 26/28 .uptodate.

0 https://www.uptodate.7/20/18 Acute appendicitis in children: Diagnostic imaging .UpToDate Plain radiographic signs of acute appendicitis Right lower quadrant fecalith Localized ileus with air/fluid levels Paucity of gas in the right lower quadrant Scoliosis concave to the right Loss of the psoas shadow Soft tissue mass Graphic 60537 Version 1.com/contents/acute-appendicitis-in-children-diagnostic-imaging/print?search=ap… 27/28 .

com/contents/acute-appendicitis-in-children-diagnostic-imaging/print?search=ap… 28/28 . MD. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www. these are addressed by vetting through a multi-level review process. MPH Nothing to disclose Contributor disclosures are reviewed for conflicts of interest by the editorial group. II.7/20/18 Acute appendicitis in children: Diagnostic imaging .uptodate. When found.UpToDate Contributor Disclosures George A Taylor. and through requirements for references to be provided to support the content. MD Nothing to disclose Jonathan I Singer. MD Nothing to disclose David E Wesson. MD Nothing to disclose James F Wiley.