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PICTORIAL ESSAY

Sonography of Abdominal Pain

in Children
Appendicitis and Its Common Mimics

Thomas Ray Sanchez, MD, Michael T. Corwin, MD, Andrew Davoodian, BS, Rebecca Stein-Wexler, MD

Abdominal pain is very common in the pediatric population (<18 years of age).
Sonography is a safe modality that can often differentiate the frequently encountered
causes of abdominal pain in children. This pictorial essay will discuss the sonographic
findings of acute appendicitis, including the imaging appearance of a perforated appen-
dicitis. It will also present the sonographic features of the relatively common mimics of
appendicitis, such as mesenteric adenitis/gastroenteritis, intussusception, Meckel diver-
ticulum, and ovarian torsion.
Key Words—abdominal pain; appendicitis; mimics; pediatric ultrasound; sonography

A bdominal pain is very common in the pediatric population

Received April 17, 2015, from the Department of
Radiology, University of California, Davis
Medical Center Children’s Hospital, Sacramento
California USA (T.R.S., R.S.-W.); Department of
Radiology, University of California, Davis Medical
Center, Sacramento, California USA (M.T.C.,
R.S.-W.); and University of California, Davis,
Sacramento, California USA (A.D.). Revision
requested May 19, 2015. Revised manuscript
accepted for publication July 8, 2015.
Address correspondence to Thomas Ray
Sanchez, MD, Department of Radiology, Division
of Pediatric Radiology, University of California,
Davis Medical Center Children’s Hospital, 4860
Y St, Suite 3100 ACC, Sacramento CA 95817
USA.
E-mail: trsanchez@ucdavis.edu
doi:10.7863/ultra.15.04047
(<18 years of age). However, infants and very young chil-
dren are often difficult to examine and can seldom localize
their pain. This challenges clinicians, who must decide whether to
treat patients conservatively or refer them to surgery. In this setting,
sonography is a valuable first-line diagnostic imaging tool. This pic-
torial essay will discuss the sonographic findings of appendicitis and
its relatively common mimics: mesenteric adenitis/gastroenteritis,
intussusception, Meckel diverticulum, and ovarian torsion. It is also
important to consider other conditions that can cause abdominal
pain in children, including urinary tract infections, urinary tract
stones, Crohn disease, and constipation.
Acute Appendicitis
Acute appendicitis is the most common cause of a surgical abdomen
in children. The evaluation of appendicitis using sonography has
been described as early as 1981.1 Graded compression and the use
of high-frequency transducers were introduced in 1986.2 The 6-mm
cutoff size for a normal appendix was suggested soon after.3
Since then, little has changed in the sonographic evaluation of
the appendix. Currently, we identify the normal appendix as a
blind-ending, tubular, and nonperistalsing segment of bowel that
arises from the cecum and measures at most 6 mm in wall-to-wall

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Sanchez—Sonography of Abdominal Pain in Children

transverse diameter; it is compressible and should have no examination performed by the pediatric surgeon was incon-
surrounding mesenteric edema (Figure 1). A dilated clusive, and the patient actually showed substantial improve-
noncompressible appendix is therefore compatible with ment of symptoms after several hours of observation.
appendicitis (Figure 2A). Doppler evaluation may be used The patient was sent home after 24 hours without surgical
to detect inflammation of the appendiceal wall. Since hyper- intervention. In retrospect, the periappendiceal fat was
emia is a marker of inflammation, the addition of color clean, and there were no secondary signs of inflammation.
Doppler imaging can increase the specificity of sonogra- Sonography may also suggest appendiceal perforation,
phy in diagnosing acute appendicitis4 (Figure 2B). with overall sensitivity of 86%.7 Disruption of the echogenic
More recent studies, however, question whether these submucosal layer of the appendix is the most sensitive find-
time-honored criteria remain applicable. For instance, lym- ing that suggests perforation7 (Figure 4). Periappendiceal
phoid hyperplasia and fecal impaction of the appendix may fluid may be seen with or without perforation, but the pres-
increase the size of a normal appendix. In the absence of ence of complex rather than simple fluid may increase the
secondary signs of inflammation, 7 mm may be a more likelihood of perforation. Furthermore, an abscess may be
reasonable maximum diameter of the normal appendix.5 identified as a collection(s) of fluid either adjacent to the
The reliability of graded compression has also been ques- appendix or elsewhere in the abdomen (Figure 5). This sign
tioned; guarding may preclude adequate compression,
and the appendix may slide away from the transducer.
Figure 2. Acute appendicitis. A, The appendix is distended and non-
Operator technique as well as patient obesity may also limit
compressible, and the surrounding mesentery (arrow) is thickened and
adequate application of pressure.6 Furthermore, it is essen- echogenic, secondary to edema. The calipers delineate a shadowing
tial that the sonographer use the transducer that optimally and obstructing appendicolith. B, Doppler sonogram showing shows
images the appendix in a given patient. Although curved hypervascularity of the appendiceal wall due to inflammation.
transducers are useful for obtaining a general overview of
the abdomen, high-frequency linear transducers are usu-
ally necessary to image the appendix—and also to apply
adequate pressure. As a general rule, higher-frequency
linear transducers are especially useful for imaging the
appendix in a thin, young pediatric patient, although lower-
frequency and even curved transducers may be necessary
in larger children.
Periappendiceal inflammation may be the most reliable
indicator of appendicitis.6 This is illustrated in one of our
patients with a proximal appendicolith and mildly dilated
appendix measuring 6.5 mm (Figure 3). The physical

Figure 1. Normal sonogram of an appendix,. The appendix (between

calipers) measures less than 6 mm in diameter. The arrow points to the
cecum as the origin of the appendix.

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Sanchez—Sonography of Abdominal Pain in Children

too is another indicator of perforation. Sometimes the
appendix perforates and then disintegrates to such an extent
that sonography fails to identify an abnormal appendix, but
the presence of complex fluid and perhaps an appendi-
colith may then suggest the diagnosis. Some centers man-
age appendiceal perforation and abscess formation with
percutaneous drainage and delayed appendectomy, so it is
important to establish the presence of perforation.
The skilled sonographer should succeed in identify-
ing a pathologic appendix in greater than 95% of cases, but
the sensitivity of sonographic diagnosis may be as low as
22%.8 However, sonography should still be the initial
modality for attempted diagnosis, since it is quick, inex-
pensive, readily available, and—in capable hands—highly
reliable. The lack of ionizing radiation makes this modality
ideal for the pediatric age group. Furthermore, if appen-
dicitis is excluded, the sonographic examination can be
extended to evaluate common mimics. In addition, sonog-
raphy has a high negative predictive value even if the
appendix is not identified.9
differentiate between these conditions.11 Mesenteric or
right lower quadrant lymphadenopathy is of course often
seen in the setting of appendicitis. However, if a normal
appendix is visualized, or if there are no secondary signs
of appendicitis in a technically adequate study, mesenteric
lymphadenitis is likely.
The definition of pathologic lymphadenopathy does
vary. Some authors suggest using a longest diameter
greater than 10 mm as pathologic,12 whereas some use the
term mesenteric lymphadenitis only when the short-axis
diameter of the enlarged lymph node exceeds 10 mm.13
However, even small lymph nodes less than 5 mm in short-
axis diameter may be symptomatic.14 In our experience,
Figure 4. Two cases of acute appendicitis showing the appearance of
the submucosa without and with perforation. A, Intact submucosa
(arrow) in a distended and inflamed but nonperforated appendix. B,
Submucosal discontinuity (arrows) in a surgically proven perforated
appendicitis. The surrounding echogenicity is consistent with phleg-
monous changes.

Mesenteric Lymphadenitis and Enteritis

The clinical symptoms of appendicitis, including abdomi-

nal pain, anorexia, nausea, vomiting, and fever, are difficult
to differentiate from those of mesenteric lymphadenitis.
The latter condition results from inflammatory lym-
phadenopathy, which in children is often secondary to viral
gastroenteritis. In patients undergoing computed tomog-
raphy for suspected appendicitis, the most common mimic
is mesenteric lymphadenitis.10 Sonography is often able to

Figure 3. Mildly distended appendix and appendicolith without peri-

appendiceal inflammation. An appendicolith (arrow) is evident in the
proximal appendix, and the appendix measured 6.5 mm. Notice that
the adjacent mesentery is not echogenic, and there is no surrounding
fluid. The patient improved without surgical intervention.

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Sanchez—Sonography of Abdominal Pain in Children
multiple mildly enlarged lymph nodes (ranging from 10–15
mm in the long axis) at the root of the mesentery and espe-
cially in the right lower quadrant are most often encoun-
tered with this condition. Doppler imaging is also useful in
showing the hypervascularity of these inflamed lymph
nodes (Figure 6A). However, even asymptomatic children
can have mildly enlarged abdominal lymph nodes, proba-
bly due to a prior inflammatory process. During the sono-
graphic examination, it is also useful to establish whether
these nodes are tender, which can be helpful in diagnosing
mesenteric adenitis. Enlarged mesenteric lymph nodes can
also be seen in giardiasis, Crohn disease, and AIDS. It is also
important to remember that lymph nodes that are matted,
lack a normal hilum, or are massively enlarged, may be
Figure 5. Perforated appendicitis. A, Distended appendix with appendicoliths (arrows). B, Adjacent irregular fluid collection representing an abscess.
C and D, Coronal reformations from computed tomography performed to evaluate the extent of the abscess confirm the sonographic findings (arrow
in C, appendicolith; arrow in D, adjacent abscess).
630
signals of other conditions such as tuberculosis, other
mycobacterium infections, or lymphoma. Since viral gas-
troenteritis may clinically resemble appendicitis or mesen-
teric adenitis, when we routinely evaluate the proximal
jejunum and terminal ileum for the presence of wall thick-
ening, that would suggest enteritis (Figure 6B).
Intussusception
Intussusception is the most common cause of bowel
obstruction in children younger than 5 years. The classic
triad of colicky abdominal pain, a palpable mass, and bloody
stools is present in less than 40% of patients, making imag-
ing diagnosis essential. Radiographs, especially a left lateral
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decubitus film that can aid in the assessment of the cecum
and ascending colon, may show a soft tissue mass or bowel
obstruction, but the appearance is usually nonspecific,
especially in children presenting early in the course of the
disease.
Sonography is currently the imaging modality of choice,
with sensitivity and specificity of about 98%.15 Classic fea-
tures include a “target or pseudokidney sign,” which is
composed of alternating layers of echogenic mucosa,
hypoechoic muscularis, and echogenic serosa. On longi-
tudinal images, a “sandwich sign” can be observed, which
represents the outer intussuscipiens and the inner telescop-
ing intussusceptum. If a soft tissue mass with these features
is identified, it is important to consider its size to differen-
Figure 6. A, Sonogram from a 3-year-old patient with enlarged and ten-
der mesenteric lymph nodes in the right lower quadrant with a long-axis
diameter of 1.5 cm. Doppler imaging also shows hypervascularity of
these lymph nodes. B, Transverse scan of the right lower quadrant in a
9-month-old girl who presented with vomiting and diarrhea. There is dif-
fuse bowel wall thickening consistent with enteritis.
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Sanchez—Sonography of Abdominal Pain in Children
tiate ileocolic from ileoileal (small-bowel) intussusception.
Small-bowel intussusception typically measures 1.5 cm or
less in transverse diameter (outer wall to outer wall),
whereas ileocolic intussusception often will have a trans-
verse diameter greater than 2.5 cm16 (Figure 7). In addition,
the presence of a substantial fatty core and lymph nodes
along with the intussusceptum suggests ileocolic intussus-
ception.16 (Figure 8). This differentiation is critical, since
ileocolic intussusception requires emergent reduction,
whereas most small-bowel intussusceptions resolve spon-
taneously without intervention.
Secondary intussusceptions caused by lead points
such as duplication cysts, an inverted Meckel diverticulum,
vascular malformations, polyps, and submucosal masses
Figure 7. Small-bowel intussusceptions. A, Sonogram from a 2-year-
old patient with a right lower quadrant target sign measuring 1.2 cm.
B, Transverse scan of the right lower quadrant in a 16-month-old patient
with small-bowel intussusception measuring 1.4 cm. Both resolved
spontaneously on follow-up imaging after 12 hours.
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Sanchez—Sonography of Abdominal Pain in Children
may also be evaluated with sonography. If a lead a point is
identified, unnecessary nonsurgical reduction can be avoided,
and the patient can proceed to surgical management to
address the cause of the intussusception. Sonography may
also show diffuse bowel wall thickening, which is encoun-
tered when the intussusception is due to conditions such as
Figure 8. Transverse sonograms of ileocolic intussusceptions. A, Enlarged
lymph nodes (long arrow) are evident within the intussusceptum.
B, Prominent mesenteric fat (long arrow) within the intussusceptum is
also common with ileocolic intussusception. Both ileocolic intussus-
ceptions measure greater than 3 cm in transverse diameter. Short arrows
indicate the outer intussuscipiens.
632
lymphoma and Henoch-Schonlein purpura. Sonography is
also useful in guiding hydrostatic intussusception reduction,
with at least as much success as with fluoroscopic guidance.17
Sonography is therefore useful in both the diagnosis and
management of childhood intussusception, with no radia-
tion burden.18
Meckel Diverticulum
Meckel diverticulum is the most common congenital gas-
trointestinal tract anomaly. It results from failure of
the omphalomesenteric duct to completely involute, and the
vestigial remnant becomes a diverticulum that arises from
the distal ileum. Although most are asymptomatic, a small
percentage contain gastric or pancreatic mucosa that may
cause mucosal erosion and inflammation and result in
Figure 9. A and B, Meckel diverticulum containing a blood clot in a 3-
year old boy with a thickened loop of bowel in the right lower quadrant
containing an irregular echogenic focus. The wall was 6 mm thick, and
the axial diameter of the diverticulum measured 2.8 cm, larger than
typical appendicitis.
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painless, bloody stool. Meckel diverticulum may also act as
a lead point for intussusception. Meckel diverticulitis can
mimic appendicitis, and like appendicitis it can perforate,
mimicking perforated appendicitis. Indeed, patients with
Meckel diverticulitis who present with an acute abdomen
commonly have a initial diagnosis of appendicitis, both clin-
ically and in imaging studies.19
However, several sonographic features suggest Meckel
diverticulitis rather than appendicitis. The inflamed
Meckel diverticulum tends to be larger and more cystlike
in appearance, with thicker and more irregular walls20,21
(Figure 9). Furthermore, unlike the inflamed appendix, it
connects to the small bowel. If imaging remains inconclu-
sive, nuclear medicine Meckel scan results will often be
positive in symptomatic patients, with sensitivity of 81%
and specificity of 96%22 (Figure 10). Surgical resection is
eventually required for both diagnoses.
Ovarian Torsion
In a female child presenting with acute abdominal pain that
suggests appendicitis, ovarian torsion is an important dif-
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Sanchez—Sonography of Abdominal Pain in Children
ferential consideration. Both may present with pain,
nausea, vomiting, and even fever as well as leukocytosis,23
and ovarian torsion is also most common on the right.
Both conditions may present with direct and rebound ten-
derness, and imaging is therefore generally necessary to
resolve this clinical enigma. In the appropriate clinical set-
ting, it is therefore important not only to evaluate the appen-
dix but also to identify the ovaries and establish whether
either is enlarged or shows decreased blood flow on color
Doppler imaging. Ovarian size is the most important factor
in determining the presence of torsion (Figure 11, A and B).
In one retrospective study, all torsed ovaries were signifi-
cantly larger than the normal side, the median volume
being 12 times greater.24 As a general rule, ovarian torsion
is unlikely in ovaries smaller than 5 cm. Although absent or
decreased color on Doppler sonography may confirm tor-
sion (Figure 11, C and D), several studies have found that
Doppler flow is not reliable for diagnosing this condition.25,26
Indeed, 62% of torsed ovaries show either venous or arte-
rial flow on Doppler interrogation.24 The presence of flow
on color Doppler imaging may, however, be helpful in sug-
gesting viability in suspected torsion.27
Figure 10. Meckel diverticulum with gastric mucosa in a 14-year-old
boy. A, A blind-ending loop of bowel (arrow) contains a central enhanc-
ing soft tissue. Adjacent images showed that this loop arose from the
terminal ileum. B, Confirmatory Meckel scan showing increased uptake
just above the bladder, corresponding to the structure evident on the
computed tomographic scan.
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Sanchez—Sonography of Abdominal Pain in Children

Figure 11. Torsion of the right ovary. A and B, Grayscale longitudinal images showing that the right ovary is much larger than the left, with a volume
of 25 mL (versus 8 mL for the left ovary). C and D, Power Doppler images showing absent flow in the right ovary compared to the normal left ovary.

Conclusions References

Acute abdominal pain is a common but nonspecific
manifestation of a variety of diseases in children, ranging
from relatively benign mesenteric lymphadenitis
or gastroenteritis to potentially lethal intussusception or
perforated appendicitis. There is a considerable overlap
in clinical signs and symptoms, and diagnosis often rests
on imaging evaluation. Sonography is a safe modality that
can often differentiate between common causes of abdom-
inal pain in children and thus expedite appropriate clinical
management.
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